T H E INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. VOL. VII. THE V 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., LL.D. BARTON PROFESSOR OF SURGERY AND PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA ; SURGEON TO THE PENNSYLVANIA HOSPITAL, ETC. ILLUSTRATED WITH CHROMO-LITHOGRAPHS AND WOOD-CUTS IN SEVEN VOLUMES VOL. VII. (SUPPLEMENTARY VOLUME) NEW YORK WILLIAM WOOD & COMPANY 1895 Copyright : WILLIAM WOOD & COMPANY, 1895. PRES8 OF THE PUBLISHERS’ PRINTING COMPANY 132-136 W. FOURTEENTH ST. NEW YORK. PREFACE. The object of this Supplementary Volume is to furnish to the readers of the International Encyclopedia of Surgery a brief but sufficient account of such additions to both Surgical Science and Surgical Art as have been brought forward during the seven years which have elapsed since the revised edition of the original book was published, and as have seemed of sufficient importance to justify their incorporation in a work of this character, which makes no claim to be an ephemeris of theoretic novelties, but rather to be a trustworthy digest of accepted and estab- lished facts. In carrying out the intention to make the volume a Supplement to its predecessors, the authors of the several articles have had constantly in mind the necessity of not unnecessarily repeating what is already in the possession of the reader; and very variable amounts of space have therefore been occupied in the consideration of the several subjects dis- cussed. Some topics were so elaborately presented in the earlier por- tions of the work that, in the absence of any great quantity of new material, they have in the present volume been summarily dealt with; while as regards other subjects the activity of surgeons and surgical writers has been so intense that in some instances more space has been required for the supplementary record than seven years ago was needed for the original article. As an example may be mentioned the subject of Cerebral Surgery, which may almost be said to have come into exist- ence since the revised edition of the Encyclopaedia was published. As with the previous volumes, the editor is responsible for the general arrangement of the work, for those articles, three in number, which bear his own name, and for a very few notes which may be distinguished by their inclusion within brackets [thus]; but for the facts and opinions V VI expressed in the other articles the entire responsibility rests with their respective authors. The illustrations which have been inserted are such as it is believed will really serve to elucidate the text, but none have been included for mere pictorial effect. The thanks of the editor are due to the trustees of the Fiske Prize Fund for permission to use a number of cuts illustra- tive of the Article on Diseases of the Joints. PREFACE. JOHN ASHHURST, Jr. Philadelphia, 2000 West Delancey Place, October, 1895. ALPHABETICAL LIST OF AUTHORS. (VOL. VII.) EDMUND ANDREWS, JOHN ASHHURST, Jk., SAMUEL ASHHURST, ALBERT I. BOUFFLEUR, ALBERT H. BUCK, J. ABBOTT CANTRELL, P. S. CONNER, B. FARQUHAR CURTIS, EDWARD COWLES, GWILYM G. DAY IS, JOHN B. DEAYER, CHARLES W. DULLES, HAROLD C. ERNST, F. FORCHHEIMER, J. McFADDEN GASTON, W. C. GLASGOW, ROBERT P. HARRIS, RICHARD H. HARTE, FRED. KAMMERER, OTTO G. T. KILIANI, WILLIAM W. KEEN, CHARLES B. KELSEY, EDWARD L. KEYES, CHARLES W. KOLLOCK, ROBERT W. LOVETT, HUNTER McGUIRE, J. EWING MEARS, E. M. MOORE, CHARLES B. NANCREDE, THOMAS R. NEILSON, JOHN H. PACKARD, VII VIII ALPHABETICAL LIST OF AUTHORS. THEOPHILUS PARVIN, CHARLES B. PENROSE, JOSEPH RANSOHOFF, MAURICE H. RICHARDSON, JOHN B. ROBERTS, RALPH W. SEISS, J. LEWIS SMITH, LEWIS A. STIMSON, F. R. STURGIS, LOUIS McLANE TIFFANY, W. W. VAN ARSDALE, ALBERT VANDER VEER, ARTHUR VAN HARLINGEN, HENRY R. WHARTON, J. WILLIAM WHITE, DE FOREST WILLARD, JOHN A. WYETH. THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY ARTICLES CONTAINED IN THE SEVENTH VOLUME. Inflammation. By Harold C. Ernst, A.M., M.D., Assistant Professor of Bacteriology in Harvard University; Physician to Out-Patients at the Massachusetts General Hospital. Page 1. Wounds and Wound Treatment. By Fred. Kammerer, M.D., Sur- geon to Saint Francis’s Hospital and to the German Hospital, New York. Page 33. Diseases Complicating Wounds: Erysipelas; Septicaemia and Pyaemia; Hospital Gangrene. By Otto G. T. Kiliani, M.D., Instructor in Clinical Surgery at the New York Post-Graduate Medical School and Hospital; Surgeon to the German Dispensary. Page 75. Gunshot Wounds. By P. S. Conner, M.D., Professor of Surgery in the Medical College of Ohio; Surgeon to the Cincinnati and Good Samaritan * Hospitals, etc. Page 107. Poisoned Wounds. By John H. Packard, M.D., Surgeon to the Penn- sylvania Hospital and to St. Joseph’s Hospital, Philadelphia. Page 117. Hydrophobia. By J. McFadden Gaston, M.D., Professor of the Princi- ples and Practice of Surgery in the Southern Medical College, Atlanta, Ga.; President of the American Academy of Medicine, etc. Page 125. Scrofula and Tuberculosis. By F. Forchheimer, M.D., Professor of Physiology and of Clinical Diseases of Children in the Medical College of Ohio, Cincinnati. Page 139. Rachitis. By J. Lewis Smith, M.D., Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, New York. Page 149. IX X the international encyclopaedia of surgery. Abscesses and Ulcers. By Henry R. Wharton, M.D., Demonstrator of Surgery in the University of Pennsylvania; Surgeon to the Presby- terian, Methodist, and Children’s Hospitals; Assistant Surgeon to the University Hospital, etc. Page 159. Gangrene and Gangrenous Diseases. By E. M. Moore, M.D., Emeritus Professor of Surgery in the University of Buffalo, etc. * Page 171. Anaesthetics and Anaesthesia. By Albert I. Bouffleur, B.S., M.D., Professor of Practical Anatomy in the Northwestern University Woman’s Medical School; Lecturer on Anatomy in the Rush Medical College; Surgeon to Cook County Hospital, Chicago. Page 175. Amputations. By John Ashhurst, Jr., M.D., Barton Professor of Sur- gery and Professor of Clinical Surgery in the University of Pennsyl- vania; Surgeon to the Pennsylvania Hospital, etc. Page 189. Tumors. By B. Farquhar Curtis, M.D., Professor of Surgery in the New York Post-Graduate School; Surgeon to St. Luke’s Hospital and to the New York Hospital. Page 209. Venereal Diseases: Gonorrhcea. By J. William White, M.D., Pro- fessor of Clinical Surgery in the University of Pennsylvania; Surgeon to the University, Philadelphia, and German Hospitals, Philadelphia. Page 305. Venereal Diseases: The Simple Venereal Ulcer or Chancroid. By F. R. Sturgis, M.D., of New York. Page 313. Venereal Diseases: Syphilis. By Arthur Van Harlingen, M.D., Professor of Diseases of the Skin in the Philadelphia Polyclinic; Phy- sician to the Department for Skin Diseases, Howard Hospital, Philadel- phia. Page 321. Surgical Diseases of the Skin and its Appendages. By J. Abbott Cantrell, M.D., Professor of Diseases of the Skin in the Polyclinic Hospital and College for Graduates in Medicine; Physician for Skin Diseases to the Southern Dispensary, Philadelphia. Page 327. Diseases of the Cellular Tissue. By Samuel Ashhurst, M.D., Surgeon to the Children’s Hospital, Philadelphia. Page 341. Injuries of Blood-Vessels and Aneurism. Bv Louis McLane Tif- fany, M.D., Professor of Surgery in the University of Maryland, Bal- timore, Md. Page 347. Surgical Diseases of the Vascular System. By John A. Wyeth, M.D., of New York, Assisted by W. W. Van Arsdale, M.D. Page 353. the international encyclopedia of surgery. XI Injuries and Surgical Diseases of the Lymphatics. By Charles B. Nancrede, A.M., M.D., Professor of Surgery and of Clinical Surgery in the University of Michigan; Emeritus Professor of General and Orthopgedic Surgery in the Philadelphia Polyclinic, etc. Page 365. Injuries and Diseases of Nerves. By John B. Deaver, M.D., Assis- tant Professor of Applied Anatomy in the University of Pennsylvania; Surgeon to the Philadelphia Hospital, to the German Hospital, to St. Agnes’s Hospital, etc., Philadelphia. Page 379. Injuries and Diseases of Bursae. By Charles B. Nancrede, A.M., M.D., Professor of Surgery and of Clinical Surgery in the University of Michigan, Professor Emeritus of General and Orthopaedic Surgery in the Philadelphia Polyclinic, etc. Page 395. Injuries of Bones. By John H. Packard, M.D., Surgeon to the Penn- sylvania Hospital and to St. Joseph's Hospital, Philadelphia. Page 403. Diseases of the Bones. By Charles W. Dulles, M.D., Lecturer on the History of Medicine in the University of Pennsylvania; Surgeon to the Kush Hospital; Surgeon for Out-Patients to the Presbyterian Hos- pital, Philadelphia. Page 439. Injuries of Joints. By Edmund Andrews, M.D., LL.D., Professor of Clinical Surgery in the Chicago Medical College; Surgeon-in-Chief to Mercy Hospital, Chicago. Page 479. Diseases of the Joints. By Robert W. Lovett, M.D., Assistant Sur- geon to the Children’s Hospital; Out-Patient Surgeon to the Boston City Hospital, and Surgeon to the Infants’ Hospital, Boston. Page 489. Excisions and Resections. By John Ashhurst, Jr., M.D., Barton Pro- fessor of Surgery and Professor of Clinical Surgery in the University of Pennsylvania; Surgeon to the Pennsylvania Hospital, etc. Page 527. Orthopaedic Surgery. By De Forest Willard, M.D., Clinical Professor of Orthopaedic Surgery in the Hospital of the University of Pennsyl- vania; Surgeon to the Presbyterian Hospital, Philadelphia. Page 541. Injuries of the Head. By Charles B. Nancrede, A.M., M.D., Pro- fessor of Surgery and of Clinical Surgery in the University of Michigan; Emeritus Professor of General and Orthopaedic Surgery in the Philadel- phia Polyclinic. Page 561. Surgical Diseases of the Head. By W. W. Keen, M.D., LL.D., Professor of the Principles of. Surgery and of Clinical Surgery in the Jefferson Medical College; Surgeon to the Jefferson Medical College XII the international encyclopaedia of surgery. Hospital and to the Orthopaedic Hospital and Infirmary for Nervous Diseases, etc. Page 575. Injuries of the Back. By Lewis A. Stimson, M.D., Professor of Clini- cal Surgery in the University of the City of New York. Page 645. Diseases of the Spine. By De Forest Willard, M.D., Clinical Pro- fessor of Orthopaedic Surgery in the Hospital of the University of Penn- sylvania; Surgeon to the Presbyterian Hospital, Philadelphia. Page 653. Injuries and Diseases of the Eye. By Charles W. Kollock, M.D., Lecturer on Diseases of the Eye and Ear in the Charleston Medical School, and Ophthalmic Surgeon to the Charleston City Hospital and Shirras Dispensary, Charleston, South Carolina. Page 669. Injuries and Diseases of the Ear. By Albert H. Buck, M.D., of New York. Page 703. Diseases and Injuries of the Nose and its Accessory Sinuses. By Ralph W. Seiss, M.D., Professor of Otology in the Philadelphia Polyclinic. Page 713. Injuries and Diseases of the Face, Cheeks, and Lips. By John B. Roberts, A.M., M.D., Professor of Surgery in the Philadelphia Polyclinic and in the Woman’s Medical College of Pennsylvania; Sur- geon to the Methodist Hospital of Philadelphia. Page 727. Injuries and Diseases of the Mouth, Tongue, Fauces, Palate, and Jaws. By J. Ewing Mears, M.D., Professor of Anatomy and Clini- cal Surgery in the Pennsylvania College of Dental Surgery; Gynaecolo- gist to the Jefferson Medical College Hospital; Surgeon to St. Agnes’s Hospital; Ex-President of the American Surgical Association, etc. Page 743. Injuries and Diseases of the Neck. By Joseph Ransohoff, M.D., F.R.C.S. Eng., Professor of Anatomy and Clinical Surgery in the Medical College of Ohio; Surgeon to the Cincinnati Hospital, and to the Good Samaritan Hospital, Cincinnati. Page 751. Injuries and Diseases of the Air-Passages and of the Oesophagus. By W. C. Glasgow, M.D., of St. Louis. Page 783. Intubation of the Larynx. By Henry R. Wharton, M.D., Demon- strator of Surgery in the University of Pennsylvania; Surgeon to the Presbyterian, Methodist, and Children’s Hospitals; Assistant Surgeon to the University Hospital, etc., Philadelphia. Page 799. THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. XIII Injuries and Diseases of the Chest. By Richard H. Harte, M.D., Demonstrator of Osteology in the University of Pennsylvania; Surgeon to the Pennsylvania Hospital and to the Episcopal Hospital; Consulting Surgeon to St. Mary’s Hospital and to St. Timothy’s Hospital, Phila- delphia. Page 809. Diseases of the Breast. By Maurice H. Richardson, M.D., Visiting Surgeon to the Massachusetts General Hospital; Assistant Professor of Anatomy, Harvard Medical School. Page 829. Injuries and Diseases of the Abdomen. By Albert Vander Veer, A.M., M.D., Ph.D., Professor of Didactic, Abdominal, and Clinical Surgery in the Albany Medical College; Surgeon to the Albany Hos- pital, etc. Page 849. Hernia. By John A. Wyeth, M.D., of New York. Page 867. Intestinal Obstruction. By John Ashhurst, Jr., M.D., Barton Pro- fessor of Surgery and Professor of Clinical Surgery in the University of Pennslyvania; Surgeon to the Pennsylvania Hospital, etc. Page 895. Diseases of the Rectum and Anus. By Charles B. Kelsey, A.M., M.D., Professor of Diseases of the Rectum in the New York Post- Graduate Medical School and Hospital; Late Professor of Diseases of the Rectum in the University of Vermont, etc. Page 901. Diseases of the Bladder and Prostate. By Hunter McGuire, M.D., LL.D., of Richmond, Va. ' Page 911. Urinary Calculus. By E. L. Keyes, A.M., M.D., of New York. Page 923. Injuries and Diseases of the Urethra. By Thomas R. Neilson, M.D., Professor of Genito-Urinary Surgery in the Philadelphia Poly- clinic; Surgeon to the Episcopal Hospital and to St. Christopher’s Hos- pital, Philadelphia. Page 939. Injuries and Diseases of the Male Genital Organs. By Gwilym G. Davis, M.D., Univ. Penna. and Gottingen, M.R.C.S. Eng., Sur- geon to the German Hospital and to St. Joseph’s Hospital, Philadelphia. Page 967. Ovarian and Uterine Tumors. By Charles B. Penrose, M.D., Pro- fessor of Gynaecology in the University of Pennsylvania; Surgeon to the Gynaecean Hospital, Philadelphia. Page 1001. The Progress of the Caesarean and Porro-Uesarean Operations, and the Revival of Symphyseotomy. By Robert P. Harris, A.M., M.D., of Philadelphia. Page 1009. XIV THE INTERNATIONAL ENCYCLOPEDIA OF SURGERY. Injuries and Diseases of the Female Genitals. By Theophilus Paryin, M.D., LL.D., Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College, Philadelphia. Page 1017. Construction and Organization of Hospitals. By Edward Cowles, M.D., Superintendent of the McLean Hospital, Waverley, Mass. Page 1039. CONTENTS. PAGE Preface v Alphabetical List op Authors in Vol. VII. ..... vii List of Articles in Vol. VII. ........ ix List of Illustrations ......... xlvii INFLAMMATION. By HAROLD C. ERNST, A.M., M.D., ASSISTANT PROFESSOR OF BACTERIOLOGY IN HARVARD UNIVERSITY, PHYSICIAN TO OUT-PATIENTS AT THE MASSACHUSETTS GENERAL HOSPITAL, ETC. Introductory remarks .......... 1 Changes in the blood-vessels ......... 3 Theories of inflammation ......... 4 Causes of inflammation .......... 5 Immunity and phagocytosis ......... 8 Chemiotaxis of leucocytes and bacterial infection . . . . .16 Muscular phagocytosis and parenchymatous inflammation .... 18 Electricity in phagocytosis ......... 19 Suppuration . . . . . . . . . . . . 23 Action of soluble bacterial products upon inflammation .... 24 Destruction of bacteria by amoeboid cells in inflammation ... 25 Bacteria causing inflammation ........ 28 WOUNDS AND WOUND TREATMENT. By FRED. KAMMERER, M.D., SURGEON TO ST. FRANCIS’S HOSPITAL AND TO THE GERMAN HOSPITAL, NEW YORK. Wounds . 33 Karyokinesis or indirect cell-division ...... 34 Direct cell-division .......... 36 Healing of wounds .......... 37 Healing of wounds in special tissues ...... 38 Healing in epithelium ........ 38 XV XVI CONTENTS. PAGE Healing of wounds in special tissues— Healing in muscles ......... 38 Healing in nervous system ....... 39 Healing in bone and cartilage ....... 41 Wound treatment ........... 42 Disinfection of hands and field of operation ..... 45 Sterilization of instruments ........ 48 Sterilization of sponges and mops ....... 51 Aseptic ligatures and sutures ........ 52 €atgut ........... 53 Silk ........... 56 Dressings ........... 57 Drainage 61 Bandages, aprons, and towels ........ 62 Dressing wounds . . . . . . . ... .62 Tamponade of wounds . . . . . . . .70 DISEASES COMPLICATING WOUNDS: ERYSIPELAS; SEPTICAEMIA AND PYaEMIA; HOSPITAL GAN- GRENE. By OTTO G. T. KILIANI, M.D., INSTRUCTOR IN CLINICAL SURGERY AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL, SURGEON TO THE GERMAN DISPENSARY. Erysipelas ............ 75 History of erysipelas . . .' . . . . . .75 Etiology 77 Symptoms, diagnosis, and prognosis ...... 82 Treatment of erysipelas ......... 86 Internal treatment ......... 86 Local treatment ......... 88 Effect of erysipelas on neoplasms ....... 89 Septicaemia and pyaemia ......... 90 Septicaemia ........... 91 Etiology 91 Morbid anatomy ......... 96 Symptomatology ......... 97 Diagnosis and prognosis ........ 98 Treatment .......... 100 Pyaemia ........... 102 Etiology ........... 102 Morbid anatomy ......... 103 Symptomatology ......... 104 Diagnosis, prognosis, and treatment ...... 105 Hospital gangrene ........... 106 CONTENTS. XVII GUNSHOT WOUNDS. By P. S. CONNER, M.D., PROFESSOR OF SURGERY IN THE MEDICAL COLLEGE OF OHIO, SURGEON TO THE CINCINNATI AND GOOD SAMARITAN HOSPITALS, ETC. PAGE Bullets ............. 107 Wound complications and aseptic and antiseptic wound treatment . . 110 Removal of the ball, etc. . . . . . . . .110 Dressing of the wound . . . . . . . . .111 Wounds of the head .......... Ill Wounds of the abdomen .......... 113 POISONED WOUNDS. By JOHN H. PACKARD, M.D., SURGEON TO THE PENNSYLVANIA HOSPITAL AND TO ST. JOSEPH’S HOSPITAL, PHILADELPHIA. Dissection wounds .......... 117 Other forms of injury allied to dissection wounds .... 117 Insect stings ............ 11S Wounds by poisoned arrows ......... 120 Snake-bites ............ 120 Consequences of snake-bites ........ 121 Treatment of snake-bites . . . . . . . .122 Preventive inoculation ........ 124 Bites of other animals .......... 124 Rat-bites ........... 124 Human-bites ........... 124 HYDROPHOBIA. By J. McPADDEN GASTON, M.D., PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY IN THE SOUTHERN MEDICAL COLLEGE, ATLANTA, GA.; PRESIDENT OF THE AMERICAN ACADEMY OF MEDICINE; EX-PRESIDENT OF THE SOUTHERN SURGICAL AND GYNAECOLOGICAL ASSOCIATION, AND OF THE SECTION OF ANATOMY AND SURGERY IN THE AMERICAN MEDICAL ASSOCIATION. Hydrophobia ............ 125 Pasteur’s method ........... 127 Personal observations .......... 133 XVIII CONTENTS. SCROFULA AND TUBERCULOSIS. By F. FORCHHEIMER, M.D., PROFESSOR OF PHYSIOLOGY AND OF CLINICAL DISEASES OF CHILDREN IN THE MEDICAL COLLEGE OF OHIO, CINCINNATI. PAGE Etiology and pathology of scrofula and tuberculosis .... 139 Treatment of scrofula and tuberculosis ....... 143 RACHITIS. By J. LEWIS SMITH, M.D., CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK. Antiquity and frequency of rachitis ........ 149 Diagnosis of rachitis .......... 151 Age at which rachitis appears ......... 152 Treatment of rachitis . . . . . . . . . .152 Hygienic treatment .......... 152 Medicinal treatment . . . . . . . . .154 ABSCESSES AND ULCERS. By HENRY R. WHARTON, M.D., DEMONSTRATOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE PRESBY- TERIAN, METHODIST, AND CHILDREN’S HOSPITALS; ASSISTANT SURGEON TO THE UNIVERSITY HOSPITAL, ETC., PHILADELPHIA. Abscesses ............ 159 Acute abscess ........... 159 Chronic abscess . . . . . . . . . .160 Treatment of chronic abscess ....... 161 Ulcers ............. 162 Healthy ulcer .......... 162 Inflamed or phlegmonous ulcer ....... 163 Sloughing or phagedgenic ulcer ....... 164 (Edematous ulcer . . . . . . . . . .164 Irritable ulcer . . . . . . . . . .165 Varicose ulcer .......... 165 Warty ulcer of cicatrices ........ 165 Indolent or callous ulcer ......... 166 CONTENTS. XIX PAGE Ulcers— Skin-grafting in ulcers ......... 167 Thiersch’s method . . . . . . . . .168 Transplantation of large skin-flaps ...... 168 Tubercular ulcer .......... 169 Syphilitic ulcer .......... 169 GANGRENE AND GANGRENOUS DISEASES. By E. M. MOORE, M.D., EMERITUS PROFESSOR OF SURGERY IN THE UNIVERSITY OF BUFFALO, ETC. Gangrene ............ 171 Varieties of gangrene . . . . . . . . 171 Treatment of gangrene ......... 171 Amputation in gangrene . . . . . . . . .172 Hospital gangrene .......... 172 Senile gangrene . . . . . . . . . .172 Gangrenous diseases . . . . . . . . . .173 Bed-sores . . . . . . . . . . 173 Noma 173 Symmetrical gangrene . . . . . . . . .173 Diphtheritic gangrene . . . . . . . . .173 Ergotism ............ 173 Embolic gangrene . . . . . . . . . .173 Furuncle ........... 174 Carbuncle . . . . . . . . . . .174 ANAESTHETICS AND ANAESTHESIA. By ALBERT I. BOUFFLEUR, B.S., M.D., PROFESSOR OF PRACTICAL ANATOMY IN THE NORTHWESTERN UNIVERSITY WOMAN’S MEDICAL SCHOOL; LECTURER ON ANATOMY IN THE RUSH MEDICAL COLLEGE; SURGEON TO COOK COUNTY HOSPITAL, CHICAGO. Introductory remarks . . . . . . . . . .175 Administration of anaesthetics ......... 177 Preparation of patient ......... 177 Anaesthetist ........... 177 Ether ............ 177 Chloroform . . . . . . . . . . .178 Nitrous oxide and bromide of ethyl . . . . . . .179 Accidents of anaesthesia ........ . 179 XX CONTENTS. PAGE Accidents of Anaesthesia— Asphyxia ........... 179 Artificial respiration ........ 180 Syncope ............ 180 Epileptic seizures .......... 181 After-effects of anaesthesia ........ 181 Mortality from anaesthetics . . . . . . . • .182 Choice of anaesthetics .......... 183 Ether and chloroform ......... 183 Nitrous oxide and ethyl bromide ....... 184 Selection of anaesthetic for special departments of surgery . . 184 Hypnotism ........... 185 Anaesthetic substances .......... 185 Local anaesthetics ........... 186 Cocaine ............ 186 Ethyl chloride .......... 187 Other local anaesthetics ......... 187 AMPUTATIONS. By JOHN ASHHURST, JR., M.D., BARTON PROFESSOR OF SURGERY AND PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PENNSYLVANIA HOSPITAL, ETC. Operation and dressing of the stump ....... 189 Statistics ............ 192 Special amputations . . • . . . . . . . . 205 Amputation at the shoulder ........ 205 Amputation above the shoulder ....... 205 Amputation of the leg ......... 206 Amputation at the hip-joint ........ 207 TUMORS. By B. FARQUHAR CURTIS, M.D., PROFESSOR OF SURGERY IN THE NEW YORK POST-GRADUATE SCHOOL, SURGEON TO ST. LUKE’S HOS- , PITAL AND TO THE NEW YORK HOSPITAL. Classification of tumors .......... 209 Frequency of occurrence . . . . . . . . .211 Etiology ............ 212 Parasitic origin of malignant growths ...... 214 Geographical distribution ........ 218 Contagion ........... 219 CONTENTS. XXI PAGE Etiology— Connection with syphilis ........ 221 Influence of traumatism ......... 221 Sex and age ........... 224 Heredity 226 Connection with lithsemia, etc. ....... 227 Metamorphosis of tumors ......... 229 Teratomata (dermoid cysts, branchiogenic cysts, odontomata) . . . 232 Branchiogenic cysts ......... 232 Dermoid cysts .......... 233 Teratomata ........... 239 Odontomata ........... 239 Lipoma ............ 240 Fibroma ............ 247 Keloid ............ 250 Chondroma ............ 251 Osteoma ............ 253 Myxoma ............ 254 Myoma ............ 255 Neuroma ............ 257 Angeioma ............ 257 Lymphangeioma ........... 259 Sarcoma ............ 260 Melanotic sarcoma .......... 260 Sarcoma of the bones ......... 261 Sarcoma of the nerves ......... 262 Sarcoma of the breast ......... 263 Sarcoma of the genitals ......... 265 Sarcoma of bladder and prostate ....... 266 Sarcoma of nose, mouth, tonsils, jaws, tongue, and salivary glands . 267 Sarcoma of stomach, intestine, and spleen ..... 268 Sarcoma of kidney .......... 269 Sarcoma of serous and synovial membranes and tendons . . . 269 Sarcoma of the skin ......... 270 Treatment of sarcoma . . . . . . . . . .270 Mixed tumors ........... 271 Endothelioma . . . . . . . • . . . . 272 Adenoma ............ 273 Carcinoma ............ 273 Epithelioma of the skin . . . . . . . . .273 Carcinoma of the lips . . . . . . . . .278 Carcinoma of the mouth, nose, pharynx, palate, and tonsil . . 279 Carcinoma of the tongue ......... 281 Carcinoma of the larynx ......... 283 Carcinoma of the thyroid gland ....... 283 Carcinoma of the oesophagus ........ 284 Carcinoma of the stomach and intestine ...... 284 XXII CONTENTS. PAGE Carcinoma— Carcinoma of the rectum ........ 285 Carcinoma of the breast ......... 286 Carcinoma of the uterus ......... 291 Carcinoma of the vagina . . . . . ' . . . . 293 Carcinoma of the penis ......... 293 Carcinoma of the bladder ........ 294 Carcinoma in unusual situations ....... 294 Results of treatment in carcinoma ........ 296 Bibliography of tumors .......... 309 VENEREAL DISEASES: GONORRHCEA. By J. WILLIAM WHITE, M.D., PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE UNIVERSITY, PHILADELPHIA, AND GERMAN HOSPITALS, PHILADELPHIA. Nature of gonorrhoea .......... 305 Pathology of gonorrhoea ......... 305 Posterior urethritis .......... 306 Abortive treatment of gonorrhoea ........ 306 Antiseptic treatment of gonorrhoea ........ 307 Internal antisepsis .......... 309 Internal remedies for gonorrhoea ........ 309 Treatment of posterior urethritis ........ 311 VENEREAL DISEASES: THE SIMPLE VENEREAL ULCER OR CHANCROID. By F. R. STURGIS, M.D., OF NEW YORK. Varieties of chancroid .......... 313 Inoculability of the chancroid and of chancroidal buboes .... 313 Virulence of chancroidal buboes ........ 315 Treatment of the chancroid ......... 318 Treatment of chancroidal bubo ....... 319 CONTENTS. XXIII VENEREAL DISEASES : SYPHILIS. By ARTHUR VAN HARLINGEN, M.D., PROFESSOR OF DISEASES OF THE SKIN IN THE PHILADELPHIA POLYCLINIC; PHYSICIAN TO THE DEPARTMENT FOR SKIN DISEASES, HOWARD HOSPITAL, PHILADELPHIA. PAGE Chancre ............ 321 Herpetiform and mixed chancres . . ’ . . . . . 321 Relative frequency of chancres in different localities . . . 322 Vaginal chancre .......... 322 Diagnosis of chancre ......... 322 Treatment of chancre ......... 323 Syphilis of the circulatory system ....... 323 Syphilis of the heart ......... 323 Syphilis of the blood-vessels ....... 324 Treatment of syphilis ......... 324 SURGICAL DISEASES OF THE SKIN AND ITS AP- PENDAGES. By J. ABBOTT CANTRELL, M.D., PROFESSOR OF DISEASES OF THE SKIN IN THE POLYCLINIC HOSPITAL AND COLLEGE FOR GRAD- UATES IN MEDICINE ; PHYSICIAN FOR SKIN DISEASES TO THE SOUTHERN DISPENSARY, PHILA- DELPHIA. Affections of the sebaceous glands ........ 327 Milium and molluscum contagiosum ....... 327 Inflammation of the skin ......... 329 Dermatitis venenata ......... 329 Hypertrophies ........... 329 Callosities, clavus, and warts . . . . . . . . 329 Diseases of the nails .......... 330 Onychia syphilitica ......... 330 Treatment of ingrowing nail ........ 331 Diseases of the hair .......... 331 Hirsuties ........... 331 Elephantiasis Arabum .......... 332 Acromegaly ........... 332 Acne hypertrophica .......... 332 Keloid and hypertrophy of cicatrices ....... 332 Fibromata of skin ........... 333 Xanthoma, angeioma, and lymphangeioma ...... 333 Rhinoscleroma 334 XXIV CONTENTS. PAGE Lupus erythematosus and lupus vulgaris ....... 334 Leprosy ............ 335 Connective-tissue cancer .......... 335 Madura foot ............ 335 Parasitic diseases of skin ......... 336 Favus ............ 336 Onychomycosis .......... 337 Tinea tonsurans and tinea versicolor ....... 337 Scabies ............ 338 Pediculosis capitis and pediculosis corporis ..... 338 Pediculosis pubis .......... 339 Psorospermosis .......... 339 DISEASES OF THE CELLULAR TISSUE. By SAMUEL ASHHURST, M.I)., SURGEON TO THE CHILDREN’S HOSPITAL, PHILADELPHIA. Introductory remarks .......... 341 Cellulitis ............ 342 Peri-venous and peri-arthritic cellulitis ...... 343 Ischio-rectal cellulitis ......... 343 Peri-phalangeal and peri-caecal cellulitis ...... 344 Painful hypertrophy of the areolar tissue ...... 345 INJURIES OF BLOOD-VESSELS AND ANEURISM. By LOUIS McLANE TIFF NY, M.D., PROFESSOR OF SURGERY IN THE UNIVERSITY OF MARYLAND, BALTIMORE. Injuries of blood-vessels ......... 347 Aneurism ............ 349 SURGICAL DISEASES OF THE VASCULAR SYSTEM. By JOHN A. WYETH, M.D., OF NEW YORK. ASSISTED BY W. W. VAN ARSDALE, M.D. Phlebitis ............ 353 Arteritis ............ 358 Yarix 362 CONTENTS. XXV INJURIES AND SURGICAL DISEASES OF THE LYM- PHATICS. By CHAELES B. NANCEEDE, A.M., M.D., PROFESSOR OF SURGERY AND OF CLINICAL SURGERY IN THE UNIVERSITY OF MICHIGAN; EMERI- TUS PROFESSOR OF GENERAL AND ORTHOPAEDIC SURGERY IN THE PHILADELPHIA POLY- CLINIC, ETC. PAGE General considerations .......... 365 Traumatic affections of lymphatics ....... 365 Traumatic lymph-cysts ......... 365 Traumatic lymph-fistulae ......... 366 Eupture of the thoracic duct . . .' . . . . 366 Treatment of wounds of large lymphatic trunks .... 367 Lymphangeitis ........... 367 Suppurative lymphangeitis . . . . . . . .370 Uterine lymphangeitis . . . . . . . . .370 Deep lymphangeitis . . . . . . . . .371 Gangrenous lymphangeitis . . . . . . . .371 Tubercular lymphangeitis . . . . . . . .372 Venereal lymphangeitis ......... 373 Treatment of adenitis . . . . . . . . . .373 Lymphangeioma, etc. . . . . . . . . . .374 Chyle cysts ............ 374 Chyle cyst of the neck ......... 374 Chylous cyst of the mesentery . . . . . . .375 Elephantiasis Arabum . . . . . . . . . .375 Craw-craw ........... 377 Chylocele of tunica vaginalis testis . . . . . . .377 INJURIES AND DISEASES OF NERVES. By JOHN B. DEAVEE, M.D., ASSISTANT PROFESSOR OF APPLIED ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE PHILADELPHIA HOSPITAL, TO THE GERMAN HOSPITAL, TO ST. AGNES’S HOSPITAL, ETC., PHILADELPHIA. Traumatic lesions of nerves . . . . . . . . .379 Dislocation of nerves . . . . . . . . .379 Phenomena consecutive to injuries of nerves . . . . . .379 Eegeneration of nerves ......... 379 Inflammatory lesions of nerves; neuritis ...... 380 XXVI CONTENTS. page: Neuralgia ............ 380 Metatarsalgia .......... 381 Tumors of nerves; neuroma ......... 381 Tetanus ............ 381 Traumatic tetanus .......... 381 Prophylaxis and treatment ....... 385 Tetanus hydrophobicus ......... 384 Tetany ............ 384 Bibliography of tetany . . . . . . . 386 Operations upon nerves .......... 386 Nerve-stretching and nerve extraction ...... 386 Nerve suture ........... 386 Nerve-grafting .......... 387 Operations for trifacial neuralgia ....... 387 Kemoval of Gasserian ganglion and intra-cranial neurectomy . . 390 Vaso-motor and trophic nerve changes ....... 393 Angeio-neurotic cedema ......... 393 Acromegaly and Morvan’s disease ....... 393 Raynaud’s disease or symmetrical gangrene ..... 393 Erythromelalgia .......... 394 INJURIES AND DISEASES OF BURSAE. By CHARLES B. NANCREDE, A.M., M.D., PROFESSOR OF SURGERY AND OF CLINICAL SURGERY IN THE UNIVERSITY OF MICHIGAN; PRO- FESSOR EMERITUS OF GENERAL AND ORTHOPAEDIC SURGERY IN THE PHILADELPHIA POLY- CLINIC, ETC. General remarks on the treatment of bursitis ...... 395 Treatment of acute bursitis ........ 395 Treatment of subacute and chronic bursitis ..... 396 Incised and punctured wounds of bursae ....... 396 Treatment of bursae communicating with joints, and of synovial herniae . 397 Hemorrhagic bursitis .......... 397 Kecurrence of chronic bursal enlargements after excision .... 398 Fungous bursitis ........... 398 Caseous bursitis .......... 398 Bursitis with riziform bodies ........ 399 Anomalous bursae ........... 399 Tumors of bursae ........... 409 Exostosis bursata .......... 400 Hygroma proliferans endothelialis ....... 401 Bunion ............ 402 CONTENTS. XXVII INJURIES OF BONES. By JOHN H. PACKARD, M.D., SURGEON TO THE PENNSYLVANIA HOSPITAL AND TO ST. JOSEPH’S HOSPITAL, PHILADELPHIA. PAGE Fragility of the bones .......... 403 Mollities ossium ........... 404 Fractures in persons already diseased ....... 404 Intra-uterine fractures .......... 400 Varieties of fracture .......... 407 Fractures in aged persons ......... 403 Conditions attending and consequent upon fractures .... 408 Tumors developed at the seat of fracture . . . . . . .409 Treatment of fractures .......... 409 Non-union and false joint ......... 410 Fractures of the bones of the face ........ 411 Fractures of the laryngeal apparatus ....... 412 Fractures of the ribs, costal cartilages, and sternum .... 412 Fractures of the clavicle . . . . . . . . . 414 Fractures of the scapula . . . . . . . . .410 Fractures of the pelvis .......... 417 Fractures of the humerus ......... 418 Fractures of the elbow . . . . . . . . . 421 Fractures of the bones of the forearm ....... 421 Fractures of the femur .......... 425 Fractures of the patella .......... 430 Fractures of the bones of the leg ........ 435 Fractures of the bones of the foot ........ 437 DISEASES OF THE BONES. By CHARLES W. DULLES, M.D., LECTURER ON THE HISTORY OF MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE RUSH HOSPITAL; SURGEON FOR OUT-PATIENTS TO THE PRESBYTERIAN HOSPITAL, PHILADELPHIA. Preliminary remarks .......... 439 Disorders of development (deformities) ....... 442 Disorders of nutrition (dystrophies) ....... 443 Deformities from infantile paralysis ....... 443 Osteitis in locomotor ataxia ........ 444 Acromegaly ........... 441 Rachitis 444 XXVIII CONTENTS. PAGE Disorders of nutrition (dystrophies)— Osteomalacia ........... 446 Osteitis deformans (leontiasis, Paget’s disease) .... 447 Rheumatic osteitis .......... 448 Hypertrophy following general diseases ...... 448 Disorders of physiological processes (diseases) . . . . . 448 Osteitis due to traumatism ........ 448 Neurotic osteitis .......... 449 Infective osteitis ........... 449 Infectious osteomyelitis ......... 450 Pathological anatomy of osteomyelitis ...... 453 Symptoms of acute infectious osteomyelitis ..... 455 Diagnosis of acute infectious osteomyelitis ..... 456 Prognosis of acute infectious osteomyelitis ..... 457 Treatment of acute infectious osteomyelitis ..... 458 Tuberculosis of the bones ......... 460 Pathology of tuberculosis of the bones ...... 461 Diagnosis of tuberculosis of the bones ...... 465 Treatment of tuberculosis of the bones ...... 466 Leprosy of the bones .......... 468 Syphilis of the bones .......... 468 Pathology and treatment . . . . . . . .470 Hydatid disease of the bones . . . . . . . . .470 Diagnosis of hydatid bone disease . . . . . . .473 Treatment of hydatid bone disease ....... 474 Actinomycosis of the bones . . . . . . . . .474 Diagnosis, prognosis, and treatment . . . . . .476 Disease of the bones due to disease of the lung ..... 477 Albuminous osteo-periostitis . . . . . . . . .477 INJURIES OF JOINTS. By EDMUND ANDREWS, M.D., LL.D., PROFESSOR OF CLINICAL SURGERY IN THE CHICAGO MEDICAL COLLEGE; SURGEON-IN-CHIEF TO MERCY HOSPITAL, CHICAGO. Dislocations ............ 479 Special dislocations . . . . . . . . . .479 Vertebrae ........... 479 Ribs, sternum, clavicle, and shoulder ...... 480 Elbow ............ 481 Thumb, hip, and knee ......... 482 Patella ............ 483 Gunshot wounds of joints ......... 483 Punctured, incised, and lacerated wounds of joints ..... 486 CONTENTS. XXIX DISEASES OF THE JOINTS. By ROBERT W. LOVETT, M.D., ASSISTANT SURGEON TO THE CHILDREN’S HOSPITAL, OUT-PATIENT SURGEON TO THE BOSTON CITY HOSPITAL, AND SURGEON TO THE INFANTS’ HOSPITAL, BOSTON. PAGE Synovitis ............ 489 Simple acute synovitis ......... 489 Acute purulent synovitis ........ 499 Tuberculosis of bones and joints ........ 491 The presence of bacilli ......... 491 Inoculation experiments ......... 492 Generalization of tuberculosis ........ 493 Presence of tubercle structures ....... 493 Local treatment of tuberculous joint-disease by tuberculin . . 493 Treatment by injection ......... 494 Loose bodies in joints .......... 497 Acute arthritis of young children ........ 497 Diseases of special joints ......... 498 Hip-joint disease .......... 498 Mortality rate .......... 499 Functional results ......... 500 Treatment by recumbency ....... 501 Extension in bed ......... 501 Treatment by ambulatory means ...... 503 Ambulatory treatment by traction ...... 503 Abscesses in hip disease ........ 511 Prevention of hip abscesses ....... 512 Malum coxae senile .......... 512 Congenital dislocation of hip ........ 512 Treatment by traction ........ 513 Operative treatment . . . . . . • .513 Hoff a’s operation ......... 514 Diseases of the knee-joint ........ 515 Treatment ......... • 516 Excision of the knee ........ 519 Arthrectomy or erasion ........ 520 Ankle-joint disease ......... 521 Shoulder-joint disease ......... 524 Chronic sprain of shoulder ....... 524 Tubercular disease of shoulder 525 Disease of the elbow-joint ........ 525 Disease of the wrist-joint and carpus ...... 525 Note 526 XXX CONTENTS. EXCISIONS AND RESECTIONS. By JOHN ASHHURST, Jr., M.D., BARTON PROFESSOR OF SURGERY AND PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE PENNSYLVANIA HOSPITAL, PHILADELPHIA. PAGE Excisions of the upper jaw ......... 527 Excisions of the lower jaw, sternum, and ribs ..... 528 Excisions of the pelvis, clavicle, and scapula ...... 529 Excisions of the shoulder, humerus, and elbow ...... 530 Excisions of the radius and ulna ........ 531 Excisions of the wrist and carpus ........ 532 Excisions of the hip .......... 532 Excisions of the femur and knee ........ 534 Arthrectomy in knee-joint disease ....... 536 Excisions of the patella .......... 536 Excisions of the bones of the leg and of the ankle ..... 537 Excisions of the astragalus ......... 538 Table showing results of excisions ........ 539 ORTHOPAEDIC SURGERY. By DE FOREST WILLARD, M.D., CLINICAL PROFESSOR OF ORTHOPAEDIC SURGERY IN THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE PRESBYTERIAN HOSPITAL, PHILADELPHIA. Club-foot ............ 541 Subcutaneous tenotomy of the tendo Achillis ..... 541 Anatomical changes in congenital varus ...... 542 Treatment of congenital varus ....... 543 Manipulations and mechanical appliances ..... 543 Multiple tenotomies and forcible straightening .... 544 Open incision and tarsotomy ....... 545 Tarsectomy ...... .... 546 Amputation ..... .... 547 Extension in the treatment of club-foot ..... 547 Valgus 547 Flat-foot and calcaneus ......... 548 Deformities of the toes .......... 548 Hammer toe or talon toe ........ 548 Hallux valgus .......... 549 Bow-legs 549 Lateral curvatures of the legs ........ 549 Anterior curves of the tibia and fibula ...... 550 CONTENTS. XXXI PAGE Genu valgum ............ 550 Deformity of the lower extremities from muscular contraction . . . 551 Deformities of the upper extremities ....... 551 Wrist-drop and club-hand ........ 552 Supernumerary or deficient fingers ....... 552 Webbed fingers or syndactylism ....... 552 Writer’s palsy .......... 55^ Dupuytren’s contraction of fingers ....... 553 Lateral curvature of spine . .' . . . . . . 554 Treatment by gymnastics ........ 554 Mechanical appliances ......... 555 Forcible restitution ......... 556 Torticollis ............ 556 Treatment of wry-neck and neurectomy ...... 557 Ligation, stretching, and resection of nerves ..... 558 Congenital malformations of the hip ....... 558 Congenital absence or deficiency of bones ....... 559 INJURIES OF THE HEAD. By CHARLES B. NANCREDE, A.M., M.D., PROFESSOR OF SURGERY AND OF CLINICAL SURGERY IN THE UNIVERSITY OF MICHIGAN; EMERI- TUS PROFESSOR OF GENERAL AND ORTHOPAEDIC SURGERY IN THE PHILADELPHIA POLY- CLINIC, ETC. Treatment of scalp wounds ......... 561 Treatment of phlegmonous erysipelas of the scalp ..... 562 Trephining ............ 562 Preparation for trephining ........ 562 Temporary resection of cranial wall ...... 564 Use of the chisel instead of the trephine ...... 564 Osteoplastic resection of the cranium ...... 565 Mortality after trephining ........ 565 Indications for trephining ........ 565 Trephining in fractures of the base ....... 565 After-treatment of trephining ........ 565 Treatment of contusions of bone ........ 566 Basal fractures ........... 567 Intra-cranial hemorrhage ......... 568 Extra-dural or subcranial hemorrhage ...... 568 Subdural hemorrhage . ....... 570 Diagnosis of head injuries from alcoholic coma and apoplexy . . .570 Eungus cerebri . . . . . . . . . . .570 Wounds of the membranes . . . . . . . . .571 XXXII CONTENTS. PAGFT Cerebral and cerebellar abscesses . . . . . . . .571 Additional methods for determining fissures of Rolando and Sylvius . .572 Fissure of Rolando . . . . . . . . . .573 Fissure of Sylvius . . . . . . . . . .574 Trephining in epilepsy . . . . . . . . .574 SURGICAL DISEASES OF TIIE HEAD. By W. W. KEEN, M.D., LL.D., PROFESSOR OF THE PRINCIPLES OF SURGERY AND OF CLINICAL SURGERY IN THE JEFFERSON MEDICAL COLLEGE; SURGEON TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL AND TO THE ORTHOPAEDIC HOSPITAL AND INFIRMARY FOR NERVOUS DISEASES, ETC. Introductory remarks . . . . . . . . . .575 Technique of cerebral operations . . . . . . . .576 Marking the cerebral fissures . . . . . . . .576 Access to the brain . . . . . . . . .578 Closure of the opening in the ‘skull ....... 582 Secondary operations ......... 584 Transplantation of cerebral tissue ....... 585 Abscess of the brain .......... 586 Causes and pathological anatomy ....... 586 Symptoms ........... 587 Differential diagnosis ......... 588 Treatment of intra-cranial abscess ....... 589 Diseases of the brain arising from suppurative disease of the middle ear . 590 Anatomy ........... 590 Pathology ........... 591 Other cerebral complications ........ 592 Meningitis and subdural abscess ...... 593 Extra-dural abscess ......... 594 Cerebral abscess ......... 595 Mastoid operations ........ 596 Cerebellar abscess . . . . . . * . . 598 Thrombosis of the lateral sinus ...... 598 Tumors of the brain .......... 602 Causes of brain tumors ......... 602 Pathological anatomy of brain tumors ...... 603 Symptoms of brain tumors ........ 605 Diagnosis of brain tumors ........ 608 Tumors of the frontal lobe ....... 608 Tumors of the cerebellum ....... 609 Prognosis of brain tumors ........ 610 Remote prognosis of brain tumors ...... 612 Treatment of brain tumors ........ 612 CONTENTS. XXXIII PAGE Cerebral cysts, including dermoids and hydatids (echinococci) . . . 613 Dermoid cysts .......... 613 Hydatid cysts .......... 614 Actinomycosis of the brain ......... 615 Surgical treatment of epilepsy ........ 616 General or idiopathic epilepsy ....... 617 Eocal epilepsy .......... 617 Jacksonian epilepsy ......... 618 Traumatic epilepsy ......... 619 Conclusions ......... , 621 Trephining for headache ......... 621 Trephining for athetosis ......... 622 Trephining for arrested development ....... 623 Trephining for congenital cerebral palsies ...... 623 Linear craniotomy for microcephalus ....... 624 Trephining for psychoses ......... 626 Traumatic insanity . , . . . . . . . 626 Non-traumatic insanity ......... 628 General paralysis of the insane ....... 630 Trephining in meningitis . . . • . . . . . . 630 Trephining in hemorrhage from pachymeningitis interna hemorrhagica . 631 Operations for meningocele, encephalocele, and hydrencephalocele . . 632 Removal of the Gasserian ganglion for tic douloureux .... 634 Table of operations ......... 638 Surgery of the lateral and fourth ventricles in relation to increased intra- cranial pressure ......... 639 Abscess bursting into the lateral ventricle . . . ... 643 Hemorrhage into the lateral ventricle ...... 644 INJURIES OF THE BACK. By LEWIS A. STIMSON, M.D., PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF THE CITY OF NEW YORK. Dislocations, fractures, and fracture-dislocations of the vertebrae . . 645 Treatment of fractures and fracture-dislocations .... 645 Operative treatment ......... 646 Gunshot wounds of the spine ......... 649 Concussion of the spine and remote effects of spinal injuries.—Railway spine 650 XXXIV CONTENTS. DISEASES OF THE SPINE. By HE FOREST WILLARD, M.D., CLINICAL PROFESSOR OF ORTHOPEDIC SURGERY IN THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE PRESBYTERIAN HOSPITAL, PHILADELPHIA. PAGE Spina bifida ............ 653 Symptoms and diagnosis ........ 654 Treatment of spina bifida ........ 654 Spinal caries ........... 657 Etiology of spinal caries ........ 657 Rare forms of spinal abscess ........ 659 Process of repair after spinal caries ...... 659 The spinal deformity ......... 659 Disturbance of motor nervous system in spinal caries . . . 660 Diagnosis of spinal caries ........ 660 Treatment of spinal caries ........ 661 Operative measures for spinal caries ...... 663 Lamnectomy or trephining of the spine ...... 665 Wiring of the spinous processes ....... 667 Puncture of the spinal canal ........ 667 Congenital sacro-coceygeal tumors ........ 667 Lordosis ............ 667 INJURIES AND DISEASES OF THE EYE. By CHARLES W. KOLLOCK, M.D., LECTURER ON DISEASES OF THE EYE AND EAR IN THE CHARLESTON MEDICAL SCHOOL AND OPHTHALMIC SURGEON TO THE CHARLESTON CITY HOSPITAL AND SHIRRAS DISPENSARY, CHARLESTON, SOUTH CAROLINA. Anaesthetics in eye surgery . . . ... . . . . 669 Asepsis and antisepsis in eye surgery ....... 669 Injuries of the eyeball . . . . . . . . . .670 Foreign bodies in the eye . . . . . . . .670 Wounds of the eyeball . . . . . . . . .672 Injuries and diseases of the eyelids . . . . . . .672 Symblepharon . . . . . . . . . .672 Blepharitis . . . . . . . . . . .673 The lachrymal apparatus . . . . . . . . .673 Inflammation of the lachrymal gland . . . . . .673 Malignant tumors of the lachrymal gland ..... 673 The tear passages . . . . . . . . . .674 CONTENTS. XXXV PAGE Diseases of the conjunctiva . . . . . . . . .675 Conjunctivitis . . . . . . . . . .675 Ophthalmia neonatorum . . . . . . . . .676 Gonorrhoeal ophthalmia . . . . . . . . .676 Trachoma: chronic granular conjunctivitis ..... 677 Phlyctenular ophthalmia . . . . . . . .679 Affections of the cornea .......... 680 Keratitis ........... (580 Conical cornea .......... 682 Tumors of the cornea ......... 683 Pterygium ........... 683 Affections of the iris and ciliary body ....... 684 Iritis and cyclitis .......... 684 Sympathetic irido-cyclitis ....... 685 Secondary iritis and irido-cyclitis ....... 686 Treatment of iritis in general ........ 686 Injuries of the iris .......... 687 Tumors of the iris and ciliary body ....... 687 Pupillary reaction .......... 687 Cataract ............ 688 Glaucoma ............ 691 Hemorrhagic glaucoma ......... 692 Ophthalmoscopic diseases ......... 693 Affections of the vitreous ........ 693 Choroiditis ........... 694 Retinitis ........... 695 Embolism of central retinal artery ....... 696 Detachment of the retina ........ 696 Diseases of the optic nerve . . . . . . . . 696 Tumors of the orbit .......... 699 Strabismus ............ 699 Treatment of eye diseases by subconjunctival injections . . . .701 INJURIES AND DISEASES OF THE EAR. By ALBERT H. BUCK, M.D., OF NEW YORK. Introductory remarks . . . . . . . . . .703 Technique of the mastoid operation . . . . . . . 704 Instruments required . . . . . . . . .704 Preparations for the operation . . . . . * .705 External incision and control of bleeding . . . . . .706 Landmarks for searching for mastoid antrum . . . . .707 Use of chisels and Yolkmann’s spoons . . . . . .707 XXXVI CONTENTS. PAGE Technique of the mastoid operation— Dangers of the operation . . . . . . . .708 Final steps of the operation . . . . . . . .709 After-management of the wound ....... 711 DISEASES AND INJURIES OF THE NOSE AND ITS AC- CESSORY SINUSES. By RALPH W. SEISS, M.D., PROFESSOR OF OTOLOGY IN THE PHILADELPHIA POLYCLINIC. Examination and instruments for general treatment .... 713 Coryza or rhinitis . . . . . . . . . . .714 Acute coryza ........... 714 Idiosyncratic coryza ......... 715 Chronic rhinitis .......... 717 Simple chronic coryza ........ 718 Chronic hypertrophic rhinitis ....... 718 Hypertrophy of pharyngeal tonsil ...... 719 Atrophic rhinitis . . . . . . . . . .720 Tumors of the nose .......... 721 Nasal neuroses ........... 722 Diseases of accessory sinuses of nose . . . . . . .722 Frontal sinus ........... 722 Diseases of ethmoidal sinus . . . . . . . .723 Purulent and myxomatous diseases of sphenoidal sinus . . . 723 Purulent inflammation of maxillary sinus . . . . .724 INJURIES AND DISEASES OF THE FACE, CHEEKS AND LIPS. By JOHN B. ROBERTS, A.M., M.D., PROFESSOR OF SURGERY IN THE PHILADELPHIA POLYCLINIC AND IN THE WOMAN’S MEDICAL COLLEGE OF PENNSYLVANIA; SURGEON TO THE METHODIST HOSPITAL OF PHILADELPHIA. Anatomical and surgical peculiarities . . . . . . .727 Wounds of the face .......... 729 Cicatricial deformities and deformed scars . . . . . .730 Fistulae upon the surface of the face . . . . . . .732 Facial spasm ........... 734 Trigeminal neuralgia . . . . . . . . . .735 Harelip ............. 741 CONTENTS. XXXVII INJURIES AND DISEASES OF THE MOUTH, TONGUE, FAUCES, PALATE AND JAWS. By J. EWING HEARS, M.D., PROFESSOR OF ANATOMY AND CLINICAL SURGERY IN THE PENNSYLVANIA COLLEGE OF DENTAL SURGERY ; GYNECOLOGIST TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL ; SURGEON TO ST. AGNES’S HOSPITAL ; EX-PRESIDENT OF THE AMERICAN SURGICAL ASSOCIATION, ETC. PAGE Affections of the tongue . . . . . . . . .743 Wounds of the tongue . . . . . . . . .743 Conditions affecting the frsenum . . . . . . .743 Ranula . . . . . . . . . . . .744 Cysts of the tongue ......... 744 Carcinoma of the tongue . . . . . . . .744 Malformations and diseases of the palate . . . . . .745 Cleft palate . . . . . . . . . . .745 Affections of the pharynx ......... 746 Wounds of the pharynx . . . . . . . . .746 Tonsillitis ........... 746 Pharyngitis ........... 746 Tumors of the pharynx ......... 747 Retropharyngeal tumors . . . . . . . . .747 Affections of the jaws .......... 747 Alveolar abscess . . . . . . . . . .747 Necrosis of the jaws .......... 748 Closure of the jaws .......... 748 INJURIES AND DISEASES OF THE NECK. By JOSEPH RANSOHOEF, M.D., F.R.C.S. Eng., PROFESSOR OF ANATOMY AND CLINICAL SURGERY IN THE MEDICAL COLLEGE OF OHIO ; SURGEON TO THE CINCINNATI HOSPITAL AND TO THE GOOD SAMARITAN HOSPITAL, CINCINNATI. Abscess of the neck .......... 751 Actinomycosis . . . . . . . . . . .753 Tuberculosis of the neck . . . . . . . . .754 Leukaemia and pseudo-leukaemia . . . . . . . .757 Lympho-sarcoma of the neck . . . . . . . .758 Carcinoma of the neck . ... . . . . . . .759 Cysts of the neck . . . . . . . . . . .761 Hygroma . . . . . . . . . . .761 Branchial cysts . . . . . . . . . .762 Lymphatic cysts . . . . . . . . . .765 XXXVIII CONTENTS. PAGE Cysts of the neck— Sanguineous cysts . . . . . . . . . .766 Hydatid cysts . . . . . . . . . .768 Surgical affections of the thyroid gland . . . . . . .768 Thyroiditis . . . . . . . . . . .768 Goitre ............ 771 Follicular goitre . . . . . . . . .771 Fibrous goitre .......... 772 Vascular goitre ......... 772 Colloid and cystic goitre . . . . . . . .773 Myxoedema; cachexia thyreopriva ...... 777 Myxoedema operativa . . . . . . . . 778 Operations for goitre . . . . . . . .779 Malignant goitre . . . . . . . . .781 Exophthalmic goitre . . . . . . . .782 INJURIES AND DISEASES OF THE AIR-PASSAGES AND OF THE (ESOPHAGUS. By W. C. GLASGOW, M.D., OF ST. LOUIS. CEdema of the larynx . . . . . . . . . .783 Acute inflammatory oedema ........ 783 Chronic inflammatory oedema . . . . . . . .784 Simple serous oedema . . . . . . . . .784 Angeio-neurotic oedema . . . . . . . . .785 Solid or septic oedema; influenza oedema . . . . . .786 Treatment of oedema of the larynx . . . . . .788 Lymphoid hypertrophy of vault of pharynx . . . . . .789 Symptoms ........... 791 Diagnosis ........... 793 Treatment ........... 794 Retro-pharyngeal abscess . . . . . . . . .795 Symptoms and diagnosis . . . . . . . .793 Prognosis and treatment . . . . . . . . .797 INTUBATION OF THE LARYNX. By HENRY R. WHARTON, M.D., DEMONSTRATOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PRESBYTERIAN, METHODIST, AND CHILDREN’S HOSPITALS; ASSISTANT SURGEON TO THE UNIVERSITY HOSPITAL, ETC., PHILADELPHIA. Prognosis of intubation of the larynx ....... 799 Instruments required for intubation ....... 800 CONTENTS. XXXIX PAGE Preparations for intubation ......... 800 Position of patient for intubation ........ 801 Operation of intubation .......... 801 Accidents during and after intubation ....... 803 After-treatment in cases of intubation 804 Deeding of patients after intubation ....... 804 Removal of intubation-tube ......... 805 Intubation in chronic stenosis of larynx ....... 806 INJURIES AND DISEASES OF THE CHEST. By RICHARD H. HARTE, M.D., DEMONSTRATOR OF OSTEOLOGY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PENNSYL- VANIA HOSPITAL AND TO THE EPISCOPAL HOSPITAL, CONSULTING SURGEON TO ST. MARY’S HOS- PITAL AND TO ST. TIMOTHY’S HOSPITAL, PHILADELPHIA. Contusions of the chest .......... 809 Contusions of the thoracic wall ....... 809 Contusions involving thoracic viscera ...... 810 Wounds of the chest .......... 811 Non-penetrating wounds of the chest ...... 811 Penetrating wounds of the chest ....... 811 Complications of chest wounds ....... 814 Tumors of the chest .......... 815 Parietal tumors .......... 815 Mediastinal tumors ......... 815 Mediastinal abscess .......... 816 Operations on the lungs . . . . . . . . .817 Hydatid cysts of lungs ......... 819 Surgical treatment of pleuritic effusions . . . . . . 819 Paracentesis thoracis ......... 821 Drainage of pleural cavity ........ 822 Thoracoplasty; Estlander’s operation ...... 824 Paracentesis pericardii .......... 826 DISEASES OF THE BREAST. By MAURICE H. RICHARDSON, M.D. VISITING SURGEON TO THE MASSACHUSETTS GENERAL HOSPITAL; ASSISTANT PROFESSOR OF ANATOMY. HARVARD MEDICAL SCHOOL. Anatomy of the breast .......... 829 Inflammation of the breast ......... 832 Osteochondro-sarcoma of the breast ....... 832 CONTENTS. XL PAGE Tuberculosis of the breast ......... 832 Malignant degeneration of benign tumors ...... 833 Sarcomata of the breast ......... 834 Carcinoma of the breast ......... 836 Operation for cancer of the breast ........ 842 Incision for removal of mammary cancer ...... 843 Treatment of malignant tumors of breast by local applications . . . 845 INJURIES AND DISEASES OF THE ABDOMEN By ALBERT VANDER VEER, A.M., M.D., PH.D., PROFESSOR OF DIDACTIC, ABDOMINAL, AND CLINICAL SURGERY IN THE ALBANY MEDICAL COLLEGE; SURGEON TO THE ALBANY HOSPITAL, ETC. Introductory remarks .......... 849 Peritonitis ............ 850 Pathology of peritonitis ......... 851 Symptoms of peritonitis ......... 852 Diagnosis, prognosis, and treatment of peritonitis .... 853 Appendicitis ............ 856 Symptoms and morbid anatomy. . . . . . . 857 Diagnosis of appendicitis ......... 859 Treatment of appendicitis . . . . . . . . 860 Cholecystotomy ........... 861 Pylorectomy and gastro-enterostomy ....... 861 Retroperitoneal tumors .......... 862 Anatomical relations and pathology ....... 862 Diagnosis, prognosis, and treatment ....... 863 Intestinal sutures and anastomosis ........ 864 HERNIA. By JOHN A. WYETH, M.D., OF NEW YORK. Classification of herniae .......... 867 Structure of herniae .......... 868 Special herniae ........... 868 Inguinal hernia .......... 868 Femoral, umbilical, and ventral herniae ...... 870 Rarer forms of hernia . . . . . . . . .871 Symptoms, diagnosis, and treatment of hernia ...... 871 Symptoms and diagnosis of inguinal hernia ..... 871 Treatment of inguinal hernia ........ 874 CONTENTS. XLI p - PAGE Symptoms, diagnosis and treatment of hernia— Treatment of strangulated inguinal hernia ..... 877 Resection of bowel ......... 880 Diagnosis and treatment of femoral hernia ..... 888 Umbilical hernia .......... 890 Other forms of hernia ......... 891 Hernia in children .......... 892 INTESTINAL OBSTRUCTION. By JOHN ASHHURST, Jr., M.D., BARTON PROFESSOR OF SURGERY AND PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF - PENNSYLVANIA J SURGEON TO THE PENNSYLVANIA HOSPITAL, ETC. Intussusception ........... 895 Enterotomy for acute obstruction ........ 896 Laparotomy ............ 897 Colotomy ............ 898 Enterectomy and colectomy ......... 898 Circular enterorrhaphy and lateral anastomosis ..... 899 DISEASES OF THE RECTUM AND ANUS. By CHARLES B. KELSEY, A.M., M.D., PROFESSOR OF DISEASES OF THE RECTUM IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL ; LATE PROFESSOR OF DISEASES OF THE RECTUM IN THE UNIVERSITY OF VERMONT, ETC. Colotomy ............ 901 Inguinal colotomy .... ...... 902 Excision or extirpation of the rectum ....... 906 Resection of the rectum .......... 907 Comparison of operative methods ........ 908 DISEASES OF THE BLADDER AND PROSTATE. By HUNTER McGUIRE, M.D., LL.D., OF RICHMOND, VA. Cystitis .............. 911 Use of the cystoscope .......... 914 Hypertrophy of the prostate ......... 915 XLII CONTENTS. URINARY CALCULUS By E. L. KEYES, A.M., M.D., OF NEW YORK. PA Off Introductory remarks .......... 923- Symptoms and diagnosis of urinary calculus ...... 924 Preventive treatment .......... 926 Selection of a mode of cure ......... 926 Relapse ............. 927 Selection of a method of radical treatment ...... 928 Preparation of the patient for operation ....... 932 Operative details ........... 935 Speed in operating .......... 937 Lithotomy ............ 937 The suprapubic operation ......... 938 After-treatment .......... 938- INJURIES AND DISEASES OF THE URETHA. By THOMAS R. NEILSOX, M.D., PROFESSOR OF GENITO-URINARY SURGERY IN THE PHILADELPHIA POLYCLINIC; SURGEON TO THE' EPISCOPAL HOSPITAL AND TO ST. CHRISTOPHER’S HOSPITAL, PHILADELPHIA. Exploration of the urethra and bladder ....... 939 Endoscopy ........... 939 Electric endoscopy .......... 942 Aero-urethroscope .......... 944 Employment of the urethroscope ....... 944 Endoscopic appearance of the normal urethra ..... 945 Uses of the urethroscope ......... 946 Cystoscopy ........... 947 Leiter’s cystoscope ......... 947 Employment of the cystoscope ........ 948 Immediate suture of the ruptured urethra ...... 950 Stricture of the urethra .......... 951 Exploration of the urethra ........ 951 Metallic bulbous explorer ........ 952 Calibre of the urethra ......... 952 Urethroscope in diagnosis and treatment of stricture .... 953 Internal urethrotomy ......... 953 Suture of the urethra after external urethrotomy . . . .. 955 Suprapubic cystotomy and retrograde catheterization .... 956 CONTENTS. XLIII PAGE Stricture of the urethra—■ Combined internal and external urethrotomy ..... 956 Resection of the urethra (urethrectomy) . ..... 957 Urethroplasty ........... 958 Cutaneous flaps ......... 958 Transplantation of mucous membrane ..... 959 Treatment of stricture of the urethra by electrolysis .... 959 Urethral neoplasms .......... 961 Urinary fever ........... 962 Pathogenesis of urinary fever ........ 962 Treatment of urinary fever ........ 964 INJURIES AND DISEASES OF THE MALE GENITAL ORGANS. By GWILYM G. DAVIS, M.D., Univ. Penna. and Gottingen, M.R.C.S. Eng., SURGEON TO THE GERMAN HOSPITAL AND TO ST. JOSEPH’S HOSPITAL, PHILADELPHIA. Injuries and diseases of the penis ........ 967 Luxation of the penis ......... 967 Fracture of the penis ......... 968 Preputial calculi .......... 968 Balano-posthitis .......... 969 Herpes progenitalis .......... 969 Phimosis . . . . . . . . . . .970 Horny growths of the penis . . . . . . . .971 Tuberculosis of the penis ......... 972 Pruritus of the genitals . . . . . . . . .973 Affections of the scrotum '. . . . . . . . .973 Contusions and wounds . . . . . . . . .973 Sloughing of the scrotum . . . . . . . .974 Elephantiasis of the scrotum . . . . . . . . 974 Epithelioma of the scrotum ........ 975 Amputation of the penis . . . . . . . . . .975 Diseases of the testicle and tunica vaginalis . . . . . .978 Hydrocele . . . . . . . . . . .978 Congenital hydrocele ......... 980 Varicocele ........... 981 Anomalies of the testicle ......... 983 Undescended or misplaced testicle ...... 983 Inflammation of the seminal vesicles ...... 985 Spermatocele and spermatic fistula ....... 985 Neuralgia of the testis ......... 986 Strangulation of the testicle from twist of the cord .... 986 Benign fungus of the testicle ........ 987 XLIV CONTENTS. PAGE Diseases of the testicle— Tuberculous disease of the testis ....... 987 Tumors of the testicle ......... 990 Adenoma and cystic disease ....... 991 Dermoid cysts of the testicle ....... 992 Chondroma of the testis ........ 993 Fibrous tumor and lipoma ........ 994 Malignant diseases of the testicle ....... 995 Scirrhous carcinoma ........ 995 Sarcoma of the testis ........ 995 Lympho-sarcoma and myo-sarcoma of the testis .... 998 Epithelioma of the testis ........ 998 Excision of the testis ......... 999 Spermatorrhoea ........... 999 OVARIAN AND UTERINE TUMORS. By CHARLES B. PENROSE, M.D., PROFESSOR OF GYNAECOLOGY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE GYNAECEAN HOSPITAL, PHILADELPHIA. Abdominal ovariotomy .......... 1001 Preparation and care of woman in eoeliotomy ..... 1002 Drainage of peritoneum ......... 1003 Uterine fibroids ........... 1005 Removal of tubes and ovaries ........ 1006 Supra-vaginal hysterectomy ........ 1007 Cancer of the uterus . . . . . . * . . . . 1008 THE PROGRESS OF THE CAESAREAN AND PORRO- OPERATIONS AND THE RENEWAL OF SYMPHYSEOTOMY. By ROBERT P. HARRIS, A.M., M.D., OF PHILADELPHIA. The Caesarean operation; puerperal coelio-hysterotomy .... 1009 The Porro-Caesarean operation; puerperal coelio-hysterectomy . . . 1012 Symphyseotomy; division of the symphysis pubis ..... 1012 Italian operation as now performed ....... 1014 CONTENTS. XLV INJURIES AND DISEASES OF THE FEMALE GENITALS. By THEOPHILUS PARVIN, M.D., LL.D., PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA. PAGE Lawson Tait’s operation for partial rupture of the perineum . . . 1017 Anterior colporrhaphia .......... 1019 Winckel’s posterior colporrhaphia ........ 1020 Martin’s elytrorrhaphia and perineauxesis ...... 1022 Sanger’s method of flap-splitting perineorrhaphy ..... 1024 Sanger’s operation applied to deep perineal laceration .... 1027 Plap-splitting repair of recto-vaginal fistula ...... 1028 Perineotomy ............ 1029 Sanger’s substitute for Emmet’s operation for lacerated cervix, and amputa- tion of the uterine lips ......... 1031 Vaginal hysterectomy . . . . . . . . . 1032 Para-sacral and sacro-coccygeal extirpation of the uterus .... 1030 CONSTRUCTION AND ORGANIZATION OF HOSPITALS. By EDWARD COWLES, M.D., SUPERINTENDENT OF THE MCLEAN HOSPITAL, WAVERLEY, MASS. Introductory remarks .......... 1039 Hospital improvements to promote aseptic surgery ..... 1040 Small hospitals ........... 1048 Hospitals for infectious diseases ........ 1054 INDEX 1061 LIST OF ILLUSTRATIONS. CHROMOLITHOGRAPH. PLATE PAGE XXXVI. Carcinoma of the Brest ........ 288 WOODCUTS. FIG. 1537-1555. Karyokinetic cell-division (Ziegler) ..... 35 1556. Union of incised wound after suture (Ziegler) .... 36 1557. Formation of blood-vessels from granulation tissue (Ziegler) . . 37 1558. Phagocytosis. Embryonic cells containing leucocytes, etc. . . 38 1559. Regeneration in striated muscle tissue (Ziegler) .... 39 1560. Rotter’s portable sterilizer for instruments ..... 50 1561. Schimmelbusch’s sterilizer for instruments ..... 50 1562. Dowd’s sterilizer .......... 55 1563. Braatz’s box for sterilizing catgut ....... 56 1564. Schimmelbusch’s sterilizing apparatus for dressings, etc. . . 60 1565. Sorel’s sterilizer for dressings ....... 61 1566-1571. Buried sutures (after Neuber) ...... 66 1572-1575. Application of sutures (Neuber) ...... 67 1576, 1577. Suture after excision of breast (Neuber) .... 68 1578. Suture after excision of breast (Neuber) ..... 69 1579. a. Streptococcus erysipelatis; b. Pus with streptococcus . . 78 1580. Culture of streptococcus erysipelatis . . . . . .78 1581. Streptococci erysipelatis. Section through a lymphatic duct of the skin (Fluegge) . . . . . . . . . .79 1582. Chains of cocci, a. Cocci of erysipelas; b. Cocci of phlegmonous inflammation after (Rosenbach) ....... 83 1583. Fever curves of erysipelas ........ 83 1584. Bacilli of septicsemia in diaphragmatic vein of septicsemic mouse. Leucocytes partly containing bacilli, partly changed into heaps of bacilli (R. Koch) ......... 93 1585. Blood of septicsemic mouse ........ 94 1586. Streptococcus of progressive gangrene in mice. a. Cells of the aural cartilage; b. Streptococci (R. Koch) ..... 94 1587. Streptococci between muscular fibres ...... 94 1588. Fever-curves of septicsemia ........ 97 1589. Blood-vessel from cortical substance of kidney of pyaemic rabbit (R. Koch) 103 XLVII XLVIII LIST OF ILLUSTRATIONS. FIG. PAGE 1590. Preparation from liver of soldier dead with pyaemia (Klebs) . .104 1591. a. Thrombus attached to valve of vein; b. Suppurative thrombus of vein ............ 104 1592. Eever curve in pyaemia ......... 104 1593. Warty ulcer of leg ......... 165 1594. Esmarch’s inhaler . . . . . . . . . .178 1595. Recovery after triple amputation ....... 191 1596. Lipoma of back .......... 243 1597. Subcutaneous fibro-lipoma of linger ...... 245 1598. Sarcoma of tibia .......... 261 1599. Sarcoma of ectopic testicle ........ 266 1600. Epithelioma of hand ......... 274 1601. Epithelioma of hand in cicatrix ....... 275 1602. Melanotic epithelioma of mamma ....... 277 1603. Epithelioma of skin of lower lip . . . ... . . 278 1604. Atrophic scirrhus .......... 289 1605. Carcinoma of mamma in man ........ 290 1606. Normal rapid blood-current (Eberth and Schimmelbusch) . . 354 1607. Marginal portion of white blood-corpuscles (Eberth and Schimmel- busch) ........... 354 1608. Slower current; blood plates in plasmatic zone (Eberth and Schim- melbusch) .......... 354 1609. Stagnation of blood-current (Eberth and Schimmelbusch) . . 355 1610. Blood-plate thrombus (Eberth and Schimmelbusch) . . . 356 1611. Tuberculous arteritis (Ziegler) ....... 361 1612. Longitudinal section of decalcified humerus of foetal sheep (Quain) . 440 1613. Infantile paralysis; locomotion on all fours (Willard) . . . 443 1614. Excessive lateral curvature with rotation (Willard) . . . 443 1615. Cancellation (osteoporosis) of compact tissue in rachitis (Lanne- longue, Comby) ......... 446 1616. Cancellation and curvation of rachitic tibia (Lannelongue, Comby) . 446 1617. Culture of streptobacillus tuberculosis of Dor (Arloing) . . . 460 1618. Culture of bacillus tuberculosis of Courmont (Arloing) . . . 461 1619. Latent circumscribed tubercle of femur (Gangolphe) . . . 461 1620. 1621. Eburnated sequestrum of condyles of femur (Ollier) . . 462 1622. Ossifluent abscess of tibia (Gangolphe) ...... 464 1623. Tuberculous osteitis of vertebrae (Lannelongue) .... 464 1624. Section of first phalanx of thumb of leper (Sawtschenko) . . 468 1625. 1626. Gummatous osteomyelitis of tibia (Gangolphe) . . . 469 1627. Taenia echinococcus from dog (Payne) ...... 470 1628. Human echinococci (Payne) ........ 471 1629. Human humerus fractured (Targett) . . . . . .472 1630. Cyst from humerus of ox (Targett) ...... 472 1631. Ischium of ox (Targett) ........ 472 1632. Cyst in human tibia (Targett) ....... 472 1633. Human tibia (Targett) . . . . . . . . .473 1634. Human femur, tibia, and fibula (Targett) ..... 473 LIST OF ILLUSTRATIONS. XLIX FIG- PAGE 1635. Large hydatid of pelvis (Gangolphe) ...... 473 1636. Actinomyces, unstained (von Jaksch) . . . . . . 475 1637. Actinomycosis of vertebrae (Gangolphe) ...... 475 1638. Actinomycosis granule (von Jaksch) ...... 476 1639. 1640. Perforation of bone by modern bullet ..... 483 1641. Comminution of bone by modern bullet ...... 483 1642. Laceration of soft parts in gunshot fracture by modern bullet . . 484 1643. Bradford’s bed-frame ......... 501 1644. Weight and pulley apparatus for bed-traction ..... 502 1645. Bed-traction in flexion and abduction ...... 503 1646. Traction splint applied during recumbency ..... 503 1647. Head and neck of femur without traction ..... 506 1648. Head and neck of femur after traction ...... 506 1649. Splint with curved pelvic band ....... 506 1650. Splint with straight pelvic band ....... 506 1651. Splint with straight pelvic band ....... 507 1652. Splint with open space over trochanter ...... 507 1653. Straight two-band liip-splint applied ...... 507 1654. Curved two-band hip-splint applied ...... 507 1655. Gas-pipe hip-splint ......... 508 1656. Windlass and extension for long splint ...... 508 1657. Judson’s perineal crutch ........ 508 1658. 1659. Phelps’s hip-splint ........ 509 1660. Lovett’s long splint ......... 509 1661, 1662, 1663. Phelps’s fixation bed ....... 510 1664, 1665. Convalescent splint ........ 511 1666. Convalescent splint applied ........ 511 1667. Plaster-of-Paris bandage applied to knee . . . . .516 1668. Thomas’s knee-splint ......... 516 1669. Modified Thomas’s knee-splint . . . . . . * . 517 1670. Goldthwait’s apparatus for straightening knee . . . , .517 1671. Billroth’s knee-splint ......... 518 1672. Traction splint for disease of knee-joint ...... 518 1673. Cerebral localization; points for trephining ..... 569 1674. Chiene’s method of finding fissure of Rolando ..... 573 1675. Horsley’s cyrtometer modified by Lewis . . . . .576 1676. Horsley’s later cyrtometer . . . . . . . .576 1677. Horsley’s later cyrtometer applied ....... 577 1678. Buchanan’s cyrtometer ......... 577 1679. Chiene’s method of fixing fissure of Rolando ..... 577 1680. Luer’s double rongeur forceps . . . . . . .578 1681. Hopkins’s rongeur forceps modified by Weir ..... 578 1682. Horsley’s dural separator ........ 580 1683. Keen’s double brain electrode ....... 581 1684. Bulging of scalp after removal of dura and brain substance . . 585 1685. 1686. Anatomy of mastoid process ...... 590 1687. Necrosis of petrous bone ........ 594 LIST OF ILLUSTRATIONS. L PIG. PAGE 1688. Surface guides for sigmoid sinus and supra-meatal triangle (Macewen) 596 1689. Landmarks for incision for abscess of brain (Barker) . . . 597 1690. Lateral aspect of skull showing relation of lateral sinus to outer wall, etc. (Ballance) . . . . . . . . . .601 1691. Keen’s rongeur forceps ......... 626 1692. Excision of meningocele (Lea) ....... 633 1693. Excision of encephalocele (Lea) ....... 633 1694. Hartley’s operation for removal of Gasserion ganglion; separating the Hap ........... 636 1695. The same; hap turned down ........ 637 1696. Successful removal of Gasserion ganglion by Hartley’s method . 639 1697. Puncture of lateral ventricles by lateral method .... 640 1698. Vertical section of base of skull; a, basal subarachnoid cavity; b, fourth ventricle; c, site of trephine opening (Parkins) . . 643 1699. Noyes’s trachoma forceps . . . . . . . .678 1699. bis. Knapp’s roller forceps for trachoma . . . . . .678 1700. Volkmann’s spoons . . . . . . . . .705 1701. Mastoid hook guide ......... 705 1702. Retractor . . . . . . . . . . .705 1703. Mode of applying chisel to mastoid . . . . . .708 1704. Kramer’s dilator . . . . . . . . . .713 1705. White’s palate hook ......... 713 1706. Wright’s nasal snare ......... 719 1707. Bardenheuer’s method for prevention of cicatricial closure of jaw . 731 1708. Nerve changes in trigeminal neuralgia (Rose) .... 735 1709. Diagram showing dissection necessary to expose second division of fifth nerve, according to Braun-Lossen method (Rose) . .739 1710. Side view of lower jaw showing position of trephine opening in operation for deepening sigmoid notch (Rose) .... 739 1711. Aggravated harelip; fissure extending into eye and cranium (Wyeth) 741 1712. Congenital fissure of lower lip and jaw (Bryant) . . . .741 1713. Congenital fissure of lip with deficiency of intermaxillary bones (Bryant) ........... 742 1714. Diagram of operation for harelip . . . . . . .742 1715. Malignant lymphoma in a man of seventy . . . . .757 1716. 1717. Carcinoma of neck . . . . . . . .760 1718. Branchial cysts . . . . , . . . . .763 1719. Sanguineous cyst of the neck . . . . . . .766 1720. Sanguineous cyst of the neck . . . . . . .767 1721. Inguinal hernia .......... 869 1722. Congenital inguinal hernia ........ 869 1723. Infantile inguinal hernia . . . . . . . .870 1724. Femoral hernia . . . . . . . . . .870 1725. Direct inguinal hernia (Bryant) . . . . . . .872 1726. Indirect or oblique inguinal hernia (Bryant) ..... 872 1727. Femoral hernia (Bryant) ........ 872 1728. 1729, 1730. Bassini’s operation for radical cure of inguinal hernia 876 LIST OF ILLUSTRATIONS. LI ™, PAGE 1733. Resection of intestine ......... 881 1732. Resection of intestine; the suturing completed .... 882 1733, 1734. Czerny and Lembert sutures ...... 882 1735. Relative positions of Czerny and Lembert sutures .... 883 1736. Murphy’s button for intestinal anastomosis .... 885 1737. Mode of passing suture to secure the Murphy button . . . 885 1738. Bowel puckered around the Murphy button ..... 886 1739. Femoral hernia; relation to obturator artery, etc. .... 889 1740. Operation for making artificial urethra ...... 921 1741. Obturator for use after formation of artificial urethra . . . 922 1742. Thompson’s searcher for stone ....... 925 1743. Chismore’s lithotrite ......... 936 1744. Evacuating tube with hard-rubber obturator ..... 936 1745. Chismore’s washing-bottle ........ 936 1746. Desormeaux’s endoscope ........ 939 1747. Griinfeld’s endoscopic tube ........ 940 1748. Steurer’s endoscopic tube ........ 940 1749. Klotz’s urethroscopic tube ........ 940 1750. Auspitz’s bivalve endoscope ........ 941 1751. F. Tilden Brown’s wire urethral speculum ..... 941 1752. F. Tilden Brown’s solid bivalve urethral speculum .... 942 1753. Leiter’s urethroscope ......... 943 1754. W. K. Otis’s “ perfected urethroscope” ...... 943 1755. Fenwick’s aero-urethroscope ........ 944 1756. Leiter’s cystoscope ......... 948 1757. Otis’s metallic bulbous explorer ....... 952 1758. Otis’s dilating urethrotome ........ 954 1759. Gerster’s dilating urethrotome ....... 954 1760. Deaver’s circular urethral curette ....... 961 1761. Incision in Tait’s operation for lacerated perineum (Macnaughton Jones) ............ 1017 1762. Tait’s operation for lacerated perineum, showing points of entrance and emergence of sutures (Macnaughton Jones) .... 1018 1763. 1764. Tait’s operation for lacerated perineum (Pozzi) . . .* 1019 1765, 1766. Anterior colporrhaphy (Winckel) ..... 1020 1767, 1768, 1769, 1770. Posterior colporrhaphy (Winckel) . . . 1021 1771. Posterior colporrhaphia (A. Martin) ...... 1023 1772, 1773. Perineauxesis (Martin) ....... 1023 1774. Sanger’s perineorrhaphy ........ 1024 1775, 1776. Sanger’s perineorrhaphy ....... 1025 1777. Sanger’s perineorrhaphy ........ 1026 1778. Schematic figure showing faulty repair of lacerated perineum (Sonntag) .......... 1026 1779. 1780, 1781. Sanger’s posterior colporrhaphy 1027 1782. Sanger’s posterior colporrhaphy ....... 1028 1783. Sanger’s method of closing recto-vaginal fistula .... 1028 1784. Diagram of Zuckerkandl’s perineotomy ...... 1029 LIST OF ILLUSTRATIONS. LII PIG. PAGE- 1785. Hegar and Sanger’s lateral perineotomy ..... 1030 1786. Willems’s transverse perineotomy ....... 1030 1787. Traction forceps, bident, trident, and quadrident (Bonnet et Petit) . 1032 1788. Doyen’s retractor (Bonnet et Petit) ...... 1033 1789. Pean’s “ valve en truelle” (Bonnet et Petit) ..... 1033 1790. Segond’s retractor with movable angle (Bonnet et Petit) . . . 103J 1791. Straight and long retractor (Bonnet et Petit) ..... 1033 1792. Vaginal extirpation of uterus; Douglas’s pouch opened (Martin) . 1034 1793. Vaginal extirpation of uterus; introduction of lateral sutures (Martin) 1035 1794. Vaginal hysterectomy (Bonnet et Petit) ...... 1035 1795. Bradlee ward and theatre ........ 1041 1796. Surgical ward and operating theatre, Bradlee Memorial Ward . . 1041 1797. Gynaecological operating room, Johns Hopkins Hospital . . . 1042 1798. Operating pavilion, Presbyterian Hospital, New York . . . 1043 1799. William J. Syms operating theatre, Boosevelt Hospital . . . 1044 1800. Memorial pavilions, Pennsylvania Hospital ..... 1046 1801. Memorial wards, Pennsylvania Hospital ..... 1047 1802. Middle pavilion, second floor, memorial ward, Pennsylvania Hospital 1048 1803. City Hospital, Quincy, Mass. ....... 1049 1804. Mary Hitchcock Memorial Hospital, Hanover, N. H. . . 1050 1805. Arnot-Ogden Memorial Hospital, Elmira, N. Y. . . . 1052 1806. Watts Hospital, Durham, N. C. . . . . . . 1053 1807. Twelve-bed pavilion, Warrington Hospital ..... 1054 1808. Warrington Hospital, block plan ....... 1055 1809. City of Glasgow Hospital ........ 1056 1810. Contagious disease ward, Cambridge Hospital .... 1057 1811. Isolation ward, Massachusetts General Hospital .... 1057 THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY INFLAMMATION. BY HAROLD C. ERNST, A.M., M.D., ASSISTANT PROFESSOR OF BACTERIOLOGY IN HARVARD UNIVERSITY ; PHYSICIAN TO OUT-PATIENTS AT THE MASSACHUSETTS GENERAL HOSPITAL, ETC. Both the pathology of inflammation and its clinical aspects have been so fully treated of in the two articles already devoted to these sub- jects in the first volume of this work, that a reconsideration of the topics there discussed at length would be an undesirable filling of space to no good end. There remains to speak of the recent advances in the knowledge of the subject, which seem likely to revolutionize at least a part of the theories held in regard to the changes seen, and which have not been fully touched upon in the articles spoken of. These advances lie in the increase of our observations upon the etiol- ogy of the processes commonly grouped under the heading of inflam- mation, and depend largely and especially upon the work of one indi- vidual, whose researches are as epoch-making as those of Virchow or of Cohnheim. The researches spoken of are those of Metchnikoff and his followers, and these, taken together with the general increase of knowledge of etiology in the last few years, enable a new point of view to be taken in regard to inflammation, which it now seems necessary to look upon as a symptom of some disturbance of the tissues, and not in any sense as a disease by itself. This is the position that will be taken in regard to it—that it is a symptom of irritation of some sort—and this being well understood, the keynote of what follows will easily be found. The recent advances in our knowledge of bacteria have completely changed our ideas in regard to the process. Up to the time of these advances, it had been taught that inflammation was the result of a local irritant, producing an excessive flowing of blood to the part, with 1 2 INFLAMMATION. vascular paralysis and exudation; that it might be produced by a for- eign body, such as a splinter of wood, or that it might be due to a poi- son in the blood, and the activity of the bacteria in producing the con- dition was not only ignored, but was unknown. With the advance of our knowledge, has gradually come the belief that practically all forms of true inflammation are the result of the activity of bacteria, and this belief has gone so far as to permit Gerster1 to make the assertion, which, however, is not quite correct, that bacteria are necessary for the production of all inflammations. His position is stated as follows:— “ An injury of some kind has devitalized the tissues of a certain region, and these become a living pabulum for micrococci. The living tissues around still form a decided resistance to the invasion of the microbe. Bacteria cannot thrive on the products of decomposition. They need for their sustenance dead, but undecomposed, albuminoid substances. As soon as the supply of dead animal tissue is exhausted, the micro organisms starve and perish, while the spores are left behind dormant. We will suppose the injury resulting in the inflammation to have been a wound. This has destroyed the vitality of those cells that lie in the direct path of the cutting implement. The blood and lymph exuded from the vessels have coagulated, and also the dead matter. If a number of micro- cocci are implanted in the bottom of the wound, they are at once multiplied, using the blood clot and its extensions into the blood-vessels, together with the adjacent dead or devitalized tissues, as welcome soil for their development. This fermentative decomposition produces, from the very beginning, certain poisonous alkaloids—ptomaines—that are very diffusible. These have a toxic influence on the adjacent vaso-motor nerves, causing their paralytic dilatation, hence the active hyperaemia, the rubor. The blood passing through the adja- cent arterioles and capillaries seems also to become altered, the red corpuscles become packed, and finally stagnate in the smaller vessels. The walls of these vessels, including the veins, lose their impermeability, and there is emigration of the leucocytes, and even of the red corpuscles, into the surrounding tissues, hence the swelling, turgor. Chiefly as a consequence of the increased blood supply, a marked increase of the local temperature is observed, calor. Direct pressure, caused by the dense inflammation, and the actual destruction of the nerve tissue, perhaps also in some measure the immediate influence of the ptomaines on the sensory nerve filaments of the part, give rise to pain, the dolor. Stagnation and dense infiltration finally produce a very high degree of tension, leading to com- pression of large afferent vessels. The inflamed portions, devitalized by sup- pression of the animal circulation, readily succumb to the inroads of the millions of micro-organisms, and actual necrosis rapidly follows. The last stage of tex- tural destruction is the final liquefaction of the tissues and infiltrating leucocytes, aided by the exudation of large quantities of lymph serum from the adjacent unobstructed blood-vessels, and thus we have the formation of an abscess, or a cavity, filled with lymph serum, dead leucocytes (pus cells), and shreds of necrosed tissue. The veins also participate in the disturbance, and give actually of their contents; thrombosis takes place, and adds to the existing stagnation.” Here we have stated very briefly the usual processes seen in what is called inflammation, together with the old cardinal points that have always been considered as going to make up the clinical picture to which the name is given. A better statement even than this, and per- haps the best in any of the recent monographs upon the subject, is that which is to be found in “An American Text-Book of Surgery’’ (Philadelphia, 1892), in which it is stated that “inflammation is a dis- 1 Aseptic and Antiseptic Surgery, 1888. CHANGES IN THE BLOOD-VESSELS. 3 turbance of the mechanism of nutrition, and affects the structures con- cerned in this function.” From the point of view of this article, as will be seen, this is not quite the idea that it is desired to convey, and instead of saying that inflammation is “the response of living tissue to injury,” we are in- clined to say that it is the response of living tissue to irritation, as a result of the disturbances occurring in connection with this irritation, of whatever kind it may be. Various changes give rise to the five cardinal symptoms of inflammation, pain, heat, redness, swelling, and impaired function (dolor, color, rubor, tumor, functio Icesa). Changes in the Blood-Vessels. The changes to he seen in the blood-vessels are the first that attract attention, and our knowledge of these changes is very largely due to the work of Cohnheim in 1867. Recklinghausen was the first to show that many connective-tissue cells possess a power of motion and mi- grate into the inflamed part, forming a portion of the great number of cells found there, and Cohnheim identified the cells of inflamed tissue with the white blood corpuscles or leucocytes. The beginning of an inflammatory process is marked by a greatly increased rapidity of the flow of blood in the part, producing hypercemia, and this is followed by a slowing of the current. A great accumulation of white corpuscles takes place on the interior of the vessel wall, and this is followed by an emigration of these leucocytes from the interior of the veins, pro- ducing diapeclesis.1 The leucocytes escape through the walls by send- ing out little prolongations (pseudopodia) that extend through the wall of the vessel, and the remainder of the corpuscle follows, but the question of the existence of actual spaces, or holes, in the wall of the vessel, through which the cells may pass, is as yet a disputed one. No such process of migration has been seen occurring through the walls of arteries, nor, excepting to a limited extent, through the walls of the capillaries. The changes thus seen in the circulation in inflammation explain two of the main symptoms, the heat and the redness. The swelling is to be accounted for by the alteration of the tissues of the part, which are found distended with an abundant exudation, escaping through the walls of the dilated blood-vessels, consisting not only of leucocytes, but also of a certain amount of fluid closely resembling the liquor sanguinis. It was at first supposed by Cohnheim that all the cells found in the part came from the white blood corpuscles, but later investigations have shown that the fixed connective-tissue corpuscles and other cells in the tissues of the body are capable of division, and by the latest views the multinuclear leucocytes appear to be taken up and destroyed by the proliferating connective-tissue cells, the leucocytes ap- parently serving simply as nutrition for these. The function of leuco- cytes has been widely argued. Cohnheim considered them to be active agents during repair, and Metchnikoff has advanced the important theory of phagocytosis, to which much space is given in this article. The pain felt in inflammation is due to pressure or tension produced by the swelling upon the terminal branches of the nerves, and it may also 1 See Strieker’s article on Inflammation, in Vol. I 4 INFLAMMATION. be due to increased sensibility from hypersemia, and to the chemical irritation resulting from the presence of ptomaines. The fifth symptom of inflammation, the disturbance of function, manifests itself in vari- ous ways according to the part affected. It is now a well acknowl- edged fact that inflammation does not begin spontaneously, and the idiopathic . form of inflammation recognized by older writers is now not believed to occur. Theories of Inflammation. The pathology of inflammation from one point of view is also very well summarized in an editorial in the Boston Medical and Surgical Journal (1892), in which the views of Cohnheim are especially empha- sized. He considers, in his lectures on General Pathology, the numer- ous theories that have been adopted to explain inflammation. The neuro-humoral theory has had many advocates, being presented in two modified forms, an ischaemic and a paralytic. According to the former, it is to the contraction of the afferent vessels of a part, reflexly called forth by the excitation of sensory nerves, that the slow- ing of the capillary stream is due. According to the second, it is a reflex relaxation and dilatation of the arteries that occasions the inflammatory hypersemia. Narrowing of the arteries, according to Cohnheim, can only produce anaemia, or extreme necrosis, and active hypersemia can only exceptionally produce exudation. It has been shown, besides, that parts unconnected with the remainder of the body, except by means of their principal vessels, may undergo inflammation, as in the frog the tongue may become inflamed, even when the brain and medulla oblongata are completely destroyed. The cellular theory of inflammation presupposes an attraction of the tissues, or tissue cells, and the vessels and their contents. The tissue cells swell and enlarge, and give birth to new cells, the pus cells; an influence that Cohnheim thinks could only relate to fluids. But how the tissue cells can bring colorless or red corpuscles out of the vessels is not easily to be understood, and it can also be shown in many in- stances that not only a very marked hypersemia is present, but also very considerable transudation before the slightest change has occurred in the tissue cells. If then inflammation begins neither in the nerve cells nor in the anatomical elements of the part, it seems to bring us to the funda- mental conception of inflammation according to Cohnheim, that it is the excitation and consequence of a molecular alteration in the vessel walls. By this alteration, adhesion between the vessel wall and the blood, and by consequence friction, is increased, the result being the retardation of the blood stream in the inflamed district, while the permeability, the porousness of the walls, is augmented by the molec- ular change, and this results in an increase of transudation of the albuminous contents, as well as in the admixture of colorless and red corpuscles with the transuded fluid. He does not consider that the exit of the leucocytes depends upon spontaneous movements, but that it is a mere process of mechanical filtration. He considers the causes of inflammation to be every agency by which the chemical construe- CAUSES OF INFLAMMATION. 5 tion of the vessel walls is at all altered, and which, on the other hand, is not so powerful as to bring about the death of the vessels, and these causes may be classed under three principal heads as traumatic, toxic, and infective. The point that especially distinguishes inflammation from active or passive hypersemia is certainly the exudation. What is especially owed to Cohnheim is the demonstration that it is only the vessel wall which is responsible for the whole series of events in in- flammation. He considers it evident that this is not due to an action on the blood, because the blood is constantly in motion, and can never be more than momentarily exposed to the local action; and the vaso- motor nerves may also be excluded, since the fact that the vessels are wont under the influence of various agents to dilate very much more than is ever the case in paralysis of the vaso-constrictors, or in hyper- sesthesia of the vaso-dilators, seems to weigh against their taking part in the process. Besides, all the described effects set in in pre- cisely the same way, and with equal prominence, in parts deprived of all connection with the central system. Finally, it is not an action or reaction of the tissues surrounding the vessels, for no alterations are observed in the latter, except at most such as are of a deleterious char- acter, as for example, coagulation or rupture of the muscle fibres. “ We are therefore compelled by exclusion to come back'to the vessel walls, as the central originating focus. According to this view, there- fore, we have had to deal with a molecular change of the vessel walls, whose highest degree involves the death of the latter, but whose slighter degrees, on the other hand, call forth a certain typical series of abnormal events in connection with the motion of the blood and the transudation. The sum total of these events, together with their consequences, have been for ages comprised and known under the name of inflammation.” Causes of Inflammation. Notwithstanding the fact that in Prof. Van Buren’s article in Vol. I., the causes and definitions of inflammation, as they are usually thought of, are very fully considered; and also notwithstanding the fact that in the present article inflammation is considered from a differ- ent point of view from the usual one, a brief summary of the com- monly described causes will not be out of place here. Considering inflammation, therefore, as merely a symptom of the effect of some preceding agent, its causes may be looked, upon as arising from (1) mechanical violence; (2) irritant or destructive chemical action; (3) poisonous infection, including, besides bacterial action, such things as venom of serpents, etc. There are, of course, both predis- posing and exciting causes aiding the appearance of inflammation, and among the first, we may include a defective nerve supply, the period of life, and the habit of body and climate. Among the second, the ex- citing causes, there is, as Van Buren says, strictly speaking but one cause, and that is an irritation of the living tissues by some agent that is called an irritant. But these irritants are necessarily very numer- ous, and among them must be included cold, or sudden chilling of the body (although it is doubtful by the light of our newer knowledge whether this is not one of the predisposing causes, and not a true ex- 6 INFLAMMATION. citing cause), incised wounds, punctured wounds with rough instru- ments, the presence of foreign bodies in wounds, mechanical violence, contusion of living tissues, the presence of a clot of blood in a wound, slight persistent mechanical irritation, the effects of heat and certain minerals, the poisonous action of secretions of animals, and last, hut most important, the action of bacteria or their products. It is one result of the later experimental science that there appears to be ground for the belief in the possibility that most of these exciting causes, cer- tainly as their results are seen in practice, are not true exciting causes at all, hut must be placed among the predisposing causes; as, for example, ii such a case as is quoted by Van Buren, as follows:1— “A gentleman of 28, in full health, stripped himself entirely on returning home from business on an exceptionally hot day, and threw himself on a lounge before an open window, to cool off before dressing for dinner. He fell asleep, heedless of a thunder-storm accompanied by a decided fall in the temperature, and awoke thoroughly chilled. On the same night he was seized with a rigor, which proved to be the initial symptom of an acute geueral peritonitis which terminated fatally within a week.” In such a case as this, it is hardly fair to ascribe the inflammation to the effect of cold, pure and simple, for if its etiology he the same as in all other cases of peritonitis that have been investigated by proper bac- teriological methods, the peritonitis was produced by the activity of a definite form of bacterium, and the chilling acted merely as a predis- posing cause, probably diminishing the chemiotactic power of the cor- puscles of the body. The mass of evidence that has been collected of late years, favoring the belief that active forms of inflammation and suppuration are due to bacterial activity, hardly warrants the conclusion reached by Sternberg,2 that the inference that no pus formation can occur in the absence of micro-organisms of this class (those found in acute abscess) is a mistaken one, and that certain chemical substances introduced be- neath the skin give rise to pus formation quite independently of bac- teria. It is true that among the substances tested, which have given a positive result, are nitrate of silver, oil of turpentine, strong liquor ammonise, cadaverine, etc., and that the demonstration has always been made, apparently, that cultures of pus cocci when sterilized by heat still give rise to pus formation, when injected subcutaneously. In regard to this subject I must hold to the position expressed some years ago, when, in a discussion upon the conditions underly- ing the infection of wounds,3 I made the following statements, first quoting the conclusions of an article read before the American Sur- gical Association several years before:— As far as the experiments go, they tend to show that no form of the suppu- rative process in man is unattended by the presence of bacteria. . . . This conclusion, that of the dependence of the suppurative process upon bacteria, is very strongly supported by the most recent evidence of the best-equipped workers in the field of bacteriological research. This assertion indeed does not need to be very considerably modified even now, although, in the face of such work as can be quoted, it cannot be said that actually no suppuration, or at 1 Yol. I., page 78. 2 Manual of Bacteriology, page 263. 3 Transactions of the Congress of American Physicians and Surgeons, vol. ii., page 71, 1891. CAUSES OF INFLAMMATION. 7 least a process answering all the histological requirements of that expression, occurs without the action of bacteria. The experiments spoken of make it im- possible to doubt that such processes as they speak of may occur, although it is not yet proved that these processes should be included under the head of true suppuration. It is an experimental suppuration, perhaps, but as far as is apparent it differs entirely from the processes observed in man. Experimental suppuration produced by chemical action is localized, and never spreads from the place of origin; there is never any metastasis, the amount is directly in pro- portion to the amount of the irritating agent made use of, and the products of this form of suppuration never produce new activity when introduced into other animals—characteristics differing very markedly from what is known of true bacterial, or, as may be said, of human suppuration. If one were obliged to sum up the present position of affairs, it would be something like this: notwith- standing the laboratory experiments to show the possible occurrence of chemical suppuration, it still remains to be demonstrated that the infection of wounds as seen in practice occurs without the influence of bacterial activity. The num- bers and varieties of bacteria thus occurring are well shown by the summaries of Zuckermann and Karlinsky. This being true, such researches as those of Ullmann and Welch, showing where these bacteria are most commonly found, are of special value. The most important lessons yet taught to us are those which warn us that our pupilage is not yet over, and that we are but entering upon the first stage of our knowledge of the processes spoken of here to-day. This position in regard to the effect of bacteria upon wounds may be held and defended in regard to most forms of inflammation that come under observation. The processes that must he excluded from those produced by bacteria form a class by themselves, and should be consid- ered under a separate group, and here it is interesting to quote some of the conclusions of Park 1 upon wound infection. In closing, he says that the particular features to which he would especially invite atten- tion may be epitomized in the following conclusions:— Sepsis may arise from circumstances and conditions other than those pertain- ing to the wound itself, although hitherto practitioners have been too prone to scan solely this field in searching for its cause. Sepsis and infection are combated in more than one way by natural agencies and by inherent properties of cells and fluids, totally aside from the measures which the surgeon institutes. A recogni- tion of the power of chemiotaxis possessed by organized and unorganized ma- terials in such varying degree, can be utilized to great advantage, as soon as it can be reasonably clearly defined. Welch also may be quoted in the same direction from his article upon “Conditions Underlying the Infection of Wounds,”2 in which some of the conclusions reached are as follows:— “ The number of different species of bacteria, particularly of bacilli, revealed by the systematic study of traumatic infections, is much greater than was for- merly supposed; the pyogenic staphylococci and streptococci, however, are by far the most common causes of suppurative affections of wounds. A coccus, which may appropriately be called the Staphylococcus Epidermidis Aldus, is a nearly, if not quite, constant inhabitant of the epidermis, lying both superfi- cially and also deeper than can be reached by present methods of disinfection of the skin. ... It is the most common cause of stitch abscesses in wounds treated antiseptically or aseptically. The pathogenic bacteria set iq:> suppuration by means of chemical substances produced by them, and entering into their com- 1 Transactions of the Congress of American Physicians and Surgeons, vol. ii., page 49. 2 Ibid., page 27. 8 INFLAMMATION. position. The studies of chemiotaxis have shed much light upon the mode of action of these substances. The tissues of the wound should be handled so as to interfere as little as possible with their vital capacity to overcome bacteria.” In the preceding passages and quotations, I have endeavored to state as clearly as possible such modifications of and additions to the views in regard to inflammation taken in the articles by Strieker and Van Buren, as seemed to be necessary in the light of the newer re- searches upon the subject. Immunity and Phagocytosis. Closely allied is the doctrine of immunity and phagocytosis, as fur- nishing a possible explanation of many of the phenomena seen in the processes under discussion, and without a somewhat full explanation of the present position of pathology in regard to these, it will not be possible to understand their full significance. I am convinced that the doctrine of phagocytosis and the work of Metchnikoff in connection with it, have not received the recognition that they really deserve, and even if the doctrine be not so wide-sweeping in its applicability as this author feels, nevertheless its value is very great. William Hunter,1 speaking of phagocytosis and immunity, comes to the following conclusions as expressing the chief grounds upon which he considers that the doctrine claims a greater credence than has been given to it by the school which has Klein at its head:— He is disposed to claim for it, that in revealing the power possessed by the cells of themselves opposing the attacks of virulent bacteria, it lias not only added much that is new, but is also valuable and important as explaining the means by which infectious disease is combated; and that our knowledge of the bactericidal properties of blood serum, to which so much importance is attached by the opponents of the phagocytic theory, is itself the direct outcome of the atten- tion drawn by Metchnikoff to the action of cells. So far from being antago- nistic, the two doctrines, the phagocytic and the humoral, mutually supplement and support each other. Both theories recognize the existence of antitoxic and antibiotic substances in blood serum and blood plasma, but it is, in Hunter’s opinion, the peculiar merit of the phagocytic as opposed to the humoral doc- trine, that it subordinates their interest and importance to the action of the cells from which they admittedly derive their origin. He is disposed to claim for the phagocytic theory, that, while it does not profess, as its opponents assert, to be in any way a complete or satisfactory explanation of the phenomena of im- munity, yet as a working hypothesis, and it is that which we must first look for, it is in all respects more logical, more tenable, more in consonance with the teachings of cellular pathology, and almost more biological, than that which ascribes to the fluids of the body the first role in protecting it against infectious disease. Considered apart from the teachings of phagocytosis, the humoral doctrine has as its chief characteristic, in Hunter’s opinion, a self-satisfying sufficiency, for which there is no real basis. It appears to explain, without explaining. It speaks much of antibiotic and antitoxic substances in the fluids of the body, and is apparently content to rest there. It does not ignore their origin from cells, indeed cannot possibly do so, but, unlike the doctrine of phagocytosis, it does not encourage further inquiry into the nature of the changes of cells 1 British Medical Journal, 1892. IMMUNITY AND PHAGOCYTOSIS. 9 which lead to the production of these substances, or into the conditions which determine the precise reaction in the cells necessary for their formation. In the first instance, on both views, the final nature of the change, whether in cell or in product, is unknown; but as the change in the cell must necessarily precede that in the product, and as the doctrine of phagocytosis directs most attention to the cells, that doctrine has claims on our support out of proportion greater than any teaching that may temporarily draw our attention away from the cell to the product in which it lies, and thus exalt the product at the expense of the pro- ducer; and lastly it is claimed for the phagocytic theory that in attaching spe- cial importance to the action of certain cells—leucocytes of the blood, cells of the spleen, and lymphocytes generally—it draws attention to facts of wide physi- ological importance, namely, that it is precisely these cells that govern in a spe- cial degree the constitution of the plasma and blood serum; and that therefore, whether acquired immunity be due to a direct phagocytic action of these cells, or to antibiotic or antitoxic properties of the plasma of the blood, the cells must be specially affected by the preceding changes. This is a very fair statement of the position that must reasonably be taken in regard to the subject; but for a clear knowledge of what it is, recourse must be had to the work of Metchnikoff himself, and this is nowhere so well stated as in his Lectures upon the Comparative Pathology of Inflammation, delivered at the “ Institut Pasteur” in April and May, 1891 (Paris, 1892). In this volume he details the most important and remarkable studies upon inflammation which have appeared since the publication of Virchow’s Cellular Pathology and Cohnheim’s great work upon the Inflammatory Processes. “His the- ories of inflammation,” says Steven, “differ from all others with which we are acquainted, and this being so, they must be subjected to the most searching criticism before they can be accepted in whole or in part. They are founded upon an exhaustive and conscientious inves- tigation of biological phenomena, in so far as these bear upon this most interesting and complicated pathological process.” 1 Toward the end of the first lecture, the basis of all modern ideas in regard to inflammation is stated, when it is said that instead of plac- ing the phenomena of inflammation in two fundamentally distinct categories, regeneration and degeneration, injury and repair, they must all of them be regarded as a healthful reaction against some sort of disturbing cause. Metchnikoff shows that comparative pathology, by taking recognition of the phenomena seen in the lower invertebrates, may give information that research in the vertebrates cannot supply, on account of the presence in these latter of disturbing elements. Indeed, heretofore, it has only been possible under experimentation to eliminate one of the factors of inflammation—that of a rise of temperature— and this has been done in the frog because it is a cold-blooded animal and incapable of producing heat in any appreciable quantity. We must employ invertebrate animals in order still further to eliminate cer ■ tain of the factors present in the process, and it is in this way only that we can ever look to be able to answer the following questions: Can the factors of traumatism, or infection, that produce inflammatory changes in the higher animals, produce anything analogous in the inferior ver- tebrates, such as the amphioxus; or in the invertebrates is the presence of a circulatory system indispensable to the production of inflamma- 1 Glasgow Medical Journal, Sept. 1, 1892. 10 INFLAMMATION. tion; or can it also be 'produced in animals which have no blood-vessels? What is the part played by the nervous system? In regard to the production of inflammation, is it necessary that an animal should pos- sess a series of differentiated organs, or is it sufficient that it should he composed of an accumulation of lion-differentiated corpuscles? Can any- thing analogous to inflammation be found in the vegetable kingdom ? Do unicellular organisms present inflammatory phenomena? These are the questions that Metclmikoff has endeavored to answer in the lectures which detail the methods that he lias pursued in arriving at his conclusions. Steven 1 pursues the argument about as follows: Starting with the general principle that the most marked characteristics, both of plant and animal organisms, are those adapting them either for aggression or defence, and that active aggression is easily transformed into infec- tion, and that defence from this point of view is equivalent to the salu- tary reaction of the organism against infection, all the phenomena observed by Metchnikoff or others in the invertebrates and lower verte- brates, which have any bearings upon the explanation of the inflam- matory process, are described. We are told that the amoebae and the infusoria react to traumatism or infection, and that amoebae are liable to epidemics of infectious disease communicated by other minute or- ganisms attacking them. We are shown the effects produced upon bacteria when taken into the bodies of amoebae. They absorb vesuvine there, although it has no effect upon them outside, and these results are said to be produced by the digestive action of the amoebae called forth for their self-defence. In the case of paramoecium, organisms capable of thriving vigorously are digested and rejected in the proto- plasm of the organism itself. Going on to the polycellular organisms, the phenomena observed that affect large protoplasmic masses, to which the term “plasmode” is applied, are first of all described in de- tail. It is shown that the currents observed in this undifferentiated living mass may flow toward, or be directed away from, external agents, according as they are beneficial to or destructive of the proto- plasm. The effect of traumatic, physical, and chemical irritation are considered in detail, and the significance of the property of chemio- taxis, positive if protoplasm be attracted, negative if it be repelled by the external agent, is indicated, especially as regards the important bearing it has in explaining the behavior of corpuscles in the higher animals during the inflammatory process. It has been shown that the chemiotaxy of these inferior beings obeys Weber’s law for the sensitive perceptions of mankind, and it also appears that they can become acclimatized to their surroundings. The production of cicatrices in plants, as the result of traumatism, and the bearing of this upon Virchow’s theory of inflammation as a nutritive and formative hyperplasia of the inflamed tissues, are dis- cussed. Metchnikoff does not consider that this phenomenon lends any great support to Virchow’s opinion, for the reason that no account is taken of the phenomena, even more characteristic of inflammation, which are exhibited by organisms intermediate between plants and higher animals. Plants are protected from the attacks of bacteria by the thick resisting cell membranes, but, on the other hand, they are 1 Loc. cit. IMMUNITY AND PHAGOCYTOSIS. 11 especially liable to invasion by moulds, which possess a great power of growth, and secrete a diastase which dissolves the cellular membrane of the plant. If the mould obtains entrance, it absorbs the cell contents without hindrance, and the cells invaded perish, or, if they survive, undergo hypertrophy, often giving rise to the formation of special tumors or “galls,” and sometimes even to a hypertrophy of the whole organism. As in the cure of wounds, infections in plants are accom- panied by regenerative phenomena, due to the abundant multiplication of corpuscles not directly attacked, without presenting a process com- parable to the essential conditions of inflammation. To arrive at these, it is necessary to examine the conditions met with in the animal kingdom. In thus drawing a hard and fast distinction between proliferative or regenerative phenomena and the “essential acts of inflammation,” the author is promulgating an opinion 1 which is not unlikely to call forth a good deal of adverse criticism. Calling attention to the fact that we do not know how polycellular animals are derived from the protozoa, that this gap must be filled by theories based on embryological observa- tions, and indicating the subject of his own theory upon this question, to which he has given the name of phagocytella—the stage phagocy- tella being easily transformed into the stage gastrula—an account is next given of the experiments upon sponges. He points out the differ- ent parts played by the contractile and sensitive cells of the ectoderm, and by the mobile amoeboid corpuscles (phagocytes) of the mesoderm, in the protection of the organism from noxious external agencies. The flagellate cells of the entoderm are also endowed with the powers of phagocytes, ag they surround small granules carried to them by the currents of water passing into the sponge, but the chief power in this way is located in the mesodermic cells and the contractile cells of the ectoderm, while the power of preventing to a certain extent the pas- sage of noxious matters is effected also by closing the superficial spores. In similar detail, the phenomena bearing on the inflammatory process in the higher members of the invertebrate group, such as the coelen- terates, worms, molluscs, etc., are described. In the case of those species supplied with a vascular system, it is shown that the blood-ves- sels take no part in the reactionary process (phagocytosis) that Metch- nikoff believes to be the essential element in inflammatory action. As we ascend higher in the scale of animal existence, it is interest- ing to note how the phagocytes become specialized and located in different parts of the economy. In the case of worms, it is shown that the mesodermic phagocytes are represented by the cells suspended in the perivisceral liquid, or by the endothelial cells of the peritoneum, and in this case, the struggle between the parasite and the phagocytes goes on; while the blood-vessels developed to a high degree in the annelida remain completely inactive, presenting neither visible changes of volume nor secretion of the reddish colored plasma. Among the invertebrates are found leucocytes with phagocytic properties pre- senting different characters—some granular, some hyaline, all pos- sessing a large, oval, non-lobulated nucleus. In invertebrate animals whose vascular system is not entirely shut off from the general body cavity, we do not find polynuclear leucocytes (arthropodes and mol- 1 Steven, loc. cit. 12 INFLAMMATION. luscs). Inflammatory reaction may be induced, and abundant leucocyte accumulation accompanied by giant-cell formation take place, without any question of diapedesis, for the simple reason that the vascular system is not completely closed, and is in communication with the body cavity. There are recorded a number of observations of inflammatory infec- tions in some of the lowest vertebrates and their embryos, and it is shown that it is possible for these to be excited without the interference of the vascular system. Metchnikoff recapitulates the whole series of phe- nomena observed, and their details, in the first seven lectures, pointing out that in the vegetable kingdom, although there may be lesions such as primary necrosis and regeneration, yet there is no inflammation. This process appears only in the animal kingdom, commencing in those organisms that are endowed with a mesoderm. There is given a de- tailed description of the different varieties of leucocytes, of which there are four principal kinds: first, the small lymphatic corpuscles (lympho- cytes) formed by the lymphatic glands, containing one nucleus sur- rounded by a thin layer of protoplasm; second, mononuclear leucocytes, having a single oval or rounded nucleus, and bearing a slight re- semblance to certain fixed elements of the connective tissue; third, Ehrlich's eosinophilic corpuscles, which contain often lobulated and variously shaped nuclei, and which stain best with acid aniline colors; and fourth, multinucleated corpuscles, which, in reality possessing only a single nucleus, often have the appearance of a clover leaf or a daisy, the different lobes being united by thin filaments. The first two varie- ties of leucocyte merge the one into the other, and the fourth variety is often denominated a u leucocyte neutrophile,” because it is only possible to stain both the nucleus and the protoplasm by a mixture of acid and basic aniline colors. These corpuscles develop in the lymphatic glands, the spleen, the bone marrow, and the blood, the last named being the part in which the ordinary polynuclear corpuscles chiefly originate. All the varieties are amoeboid, but the lymphocytes and the eosinophilic bodies have no power of phagocytosis, a property that especially charac- terizes the mononuclear and polynuclear or neutrophilic bodies. Certain organisms, such as the streptococcus of erysipelas and the gonococcus, are never taken up by mononuclear corpuscles, while they are easily absorbed by the polynuclear. On the other hand, the bacillus of leprosy is never absorbed by the polynuclear corpuscles, while it is readily taken up by the mononuclear, and this difference in the reaction of the two classes of leucocytes is ascribed to “ chemiotaxis. ” There are next brought forward a large number of observations illus- trating the chemiotactic and digestive properties of leucocytes, and it is admitted that, while it is a fact that leucocytes can digest bacteria, the agent by which this is accomplished, whether a digestive diastase or something else, is not yet known, and it is also affirmed that because in the higher animals the peptic and tryptic ferments do not destroy bacteria, there is no reason for affirming that there are not in them other ferments possessed of a bactericidal action. As regards the mul- tiplication of leucocytes, Metchnikoff shows that while polynuclear corpuscles most often divide directly, they are also capable of reproduc- tion by nuclear division (karyokinesis), a fact that has been shown by Flemming in the leucocytes of the salamander, and by Spronck in the leucocytes of the blood of the rabbit. IMMUNITY AND PHAGOCYTOSIS. 13 By means of observations on the tin of the tadpole, artificially in- flamed, Metchnikoff has observed that in these animals polynuclear leucocytes can transform themselves by fusion of the nuclei into those of the mononuclear variety, and can indeed become veritable fixed cells of the connective tissue. On these grounds, he considers that the opinion accepted by the Berlin Congress of 1890, that leucocytes, that is, emigrated corpuscles, can play no active part in the formation of tissue, is no longer to be sustained. It is not the naw view of Ziegler, but his old one of 1S75 and 1876, that is correct, and in support of this assertion Metchnikoff brings forward the facts observed by himself and his pupils, that in rabbits inoculated with tubercle, epithelioid and giant cells are formed in the interior of the vessels at the expense of the mononuclear leucocytes. In this summing up of observations upon leucocytes, it is shown that the two classes of corpuscles that play the principal part in inflamma- tion are the mononuclear leucocytes and the “ neutrophilic” cells. These are the elements endowed with a chemiotactic and pliysiotactic sensi- bility that are capable of amoeboid movements, and that are able to surround and digest foreign bodies, notably the living bacteria. It is certain that, at least in amphibians, polynuclear leucocytes can trans- form themselves into mononuclear corpuscles, and become fixed cells of the connective tissue. In vertebrates in general, mononuclear leuco- cytes can be transformed into epithelioid and giant cells; and all that has been said on the subject of leucocytes applies with equal force to the different varieties of migratory corpuscles. Metchnikoff next goes on to discuss in detail the part played by the endothelial cells of the blood-vessels, and shows that they are contractile, and that this property has much to do with the stomata that are formed in the process of diapedesis. It is also asserted that the endothelial cells can, under certain morbid conditions, quit the vessel wall in virtue of their amoeboid movements, and form a kind of adventitious mem- brane in the interior of the vessel; and that they are also capable of taking up foreign granules and bacteria. It is admitted that the con- nective-tissue elements play some part in the inflammatory process, chiefly in the production of cicatricial tissue. The plasma cells of the connective tissue are leucocytes that have become immobile, and that can resume their migratory character under the stimulus of inflam- mation ; and the “ Mastzellen” of Ehrlich that abound in inflammatory products are regarded as a kind of scavengers for clearing away the detritus of other elements. The emigration of the leucocytes is con- sidered to be determined by the chemiotactic state of the corpuscles, in- duced by the poisonous microbic agency employed, rather than by any condition of the vessel wall or circulating blood. The axial and the peripheral arrangement of the blood corpuscles is not looked upon as in any way due to mechanical causes, and it is asserted that Cohnheim overlooked the influence of the nervous system in the causation of in- flammatory hypersemia and diapedesis. Metchnikoff considers that the sensibility of the leucocytes plays the most weighty part in inflamma- tory maladies, although this does not mean that in the vertebrates en- dothelial sensibility, nervous influences, and other functions may not also take part in the process. In acute inflammation, there is a vascular dilatation, an active state 14 IXFLAMMATIOX. of the vascular endothelium, and an exudation with diapedesis, three phenomena which result in an afflux of phagocytes toward the inflamed area. Are the same phenomena present in chronic inflammations, in which the principal role has hitherto been attributed to local changes in the tissues without any notable influence of sanguineous and vascular elements? As illustrating this question, there are studied in detail the processes involved in the formation of a miliary tubercle, as a type of chronic inflammatory change. The view of Baumgarten, which is that generally accepted, that tubercle is the product of a proliferation of fixed local elements due to the presence of the bacillus of tubercu- losis, is rejected. According to this view, the leucocytes and phagocytic corpuscles play only a secondary part in the formation of tubercle; but after describing in detail the development of artificially induced tuber- culosis in the liver of a rabbit, Metchnikoff’s own view of the origin of tubercle is formulated as follows: “A tubercle is made up of a massing together of phagocytes of a mesodermic origin, that crowd toward the points where the bacilli are found, and englobe them, The phagocytes taking part in the formation of a tubercle are of a mononuclear char- acter. Polynuclear phagocytes take up the bacilli very easily, but soon perish, and with their contained bacteria are destroyed by different varieties of mononuclear phagocytes that are called macrophages.” The calcification of tubercle is looked upon as the result of an active secre- tion on the part of giant cells, not as a degenerative process; and in support of this view are offered the details of the effects of inoculation of the gerbille, a rodent of Algeria, which is very resistant to tuberculosis, and which defends itself in this way. It is admitted, however, that fre- quently the tubercular phagocytes themselves perish and become caseous. This theory of the action of the giant cell in the tubercular process is directly opposed to that supported by Koch and by Weigert, who regard the tubercular giant cell as presenting a state of partial necrosis, which view of the process is one that has been very generally accepted, and seems to be up to the present time that which is best sup- ported. With regard to serous inflammations, it is shown that generally the serous exudation contains very few phagocytes, and that in this respect it differs from the ordinary varieties of acute and chronic inflammatory processes. Some varieties of serous inflammation are due to the fact that there is a “negative sensibility” of the leucocytes preventing their passing along with the fluid through the inflamed vessel walls. The exuded fluid in these cases, however, contains a considerable number of bacteria that multiply without hindrance. In another class of cases, as for example diphtheria, serous exudations take place in areas more or less distant from the collections of bacteria, and in these exudations there are no bacteria. The question then arises as to the object of the serous exudation. Some experimenters look upon the process as a means of ridding the organism of its enemies, and believe that the serum possesses a bactericidal power. Metchnikoff objects very vigor- ously to this view, and details a number of experiments in support of his opinions. Phagocytes alone are, he thinks, the agents provided in the organism for the destruction of pathogenic bacteria, but at the same time the fact of the occurrence of serous inflammation has been diffi- cult for him to explain, a difficulty which he meets by saying that at IMMUNITY AND PITAGOCYTOSIS. 15 present we are only incompletely acquainted with the phenomena of serous inflammation, and that from whatever point of view we look at it, it appears always as an occurrence of much less importance than true inflammation, that is to say, that which is accompanied by an accumulation of phagocytes in the inflamed area. Also from the point of view of comparative pathology, serous inflammation is regarded as of much more recent date genealogically than this “ inflammation par excellence” which is accompanied by a “leucocytic reaction.” In the last lecture, the theories of Virchow and Cohnheim are criti- cised in detail. The nutritive-attraction theory of Virchow is sum- marily dismissed as untenable, and many facts both experimental and natural are brought forward in regard to the injured-wall theory of Cohnheim to show that it also must be rejected. Metchnikoff lays great stress upon the different effects resulting from inflammatory causes introduced into the blood stream, and from those applied outside the vascular system. In these arguments, however, he applies the term inflammation in a way that Cohnheim, and probably also most living pathologists, would not accept. It is certainly something quite new to think of an intravascular inflammation. Quoting the phenomena of recurrent fever as an illustration of this, appears to be arguing in a way that Cohnheim would never have recognized. For what we ordi- narily understand by recurrent fever, and the poisoning of the blood that takes place in consequence of the presence there of the organisms which cause it, is something very different from inflammation as ordi- narily understood by the morbid anatomist and the clinician. If Metch- nikoff’s views of inflammation are accepted, then we must start afresh, and include in our definition of the process phenomena that have never been so included before. By his experiments, he attempts to show that the primal cause of inflammation is a digestive reaction of the protoplasm against a noxious agent. Examples of intravascular inflammation without diapedesis, as illustrated by recurrent fever and the formation of intravascular tubercles, have, so far as we know, never before been included in what is ordinarily understood by inflammation; but a very tenable case is made out by Metchnikoff in support of his opinion, and it is not surprising that he should define inflammation as follows: “Inflammation in its entirety should then be regarded as a phagocytic reaction of the organism against irritant agencies, a reac- tion which is sometimes accomplished by mobile phagocytes alone, but occasionally with the concurrence of vascular phagocytes, or with that of the nervous system.” Inflammation then is not a process for the regeneration of tissue, nor a provision for the absorption of, and conse- quent riddance of the organism from, dead and useless material, but it is a battle against noxious agencies, especially virulent bacteria. “ Even if all his views are not accepted, facts and arguments have here been laid before the scientific world that demand the most careful ex- amination and consideration, but the feeling may well be held that the author has limited himself too much to one aspect of his subject, al- though this is prepared for in his preface, by his pointing out that several sides of the inflammatory process have been intentionally omitted.” 1 Steven concludes his review of Metchnikoff’s work as follows: “We 1 Steven, loc. cit. 16 INFLAMMATION. finish our careful study of the work with the conviction that although it is a great one, and likely to be a lasting one, it is the work of a bio- logist pure and simple, and cannot possibly be that of a practical physi- cian or pathologist;” which is a dismissal of the subject that is hardly in consonance with its importance. It is only by such work as this— coming from the experimental laboratory—that the views of either pathologist or clinician are ever to be enlarged or modified. Chemiotaxis of Leucocytes and *Bactekial Infection. A very important branch of the subject that occupies us at present has received attention in the study of the chemiotactic powers of the and their relation to bacterial infection. Massart and Bordet1 have studied it very thoroughly. After a number of considerations upon the progress of our knowledge of bacteria, and having spoken of the experiments upon animals in order to make them resistant to the invasion of bacteria, instancing the fact that phagocytosis and the bacterial condition of the fluids play the principal part in this result, they raise the point that a species of ani- mal which is ordinarily refractory to a bacterium may, under the in- fluence of various causes, become susceptible to its attacks, and that this modification constitutes the x>redisposition to infections disease. Among the causes that weaken natural or acquired immunity are (1) the introduction of products secreted by the species of bacterium in- oculated, (2) the introduction of products secreted by a different micro- organism, (3) exposing the animal to conditions unfavorable to its ex- istence, or the production of traumatic lesions, (4) the introduction of certain definite chemical substances, (5) the introduction of anesthetics. The numberless facts cited permit the following conclusions: That the injection of bacterial products and of certain definite chemical sub- stances, exposing the animal to abnormal conditions of life, as well as the employment of anesthetics, diminishes the resistance of the econ- omy to an invasion of bacteria. It follows, therefore, that it is necessary to discover by what means the different factors just spoken of act upon the mechanism of infection. Bouchard, to explain this influence, has suggested two theories which will be spoken of hereafter, but first it is necessary to consider the chemiotactic power of the leuco- cytes, for it has been very definitely shown that this kind of irritability of the white corpuscles plays a special part in diminishing immunity. For many years it has been known that certain substances contained in bacterial cultures produce purulent collections at the points where they are injected, and the different experiments upon the subject show dis- tinctly that certain bacterial products have the power of attracting the leucocytes, which are thus brought in contact with the bacteria that attempt to invade the economy, and may destroy them at once, before they have time to secrete great quantities of poison. Metchnikoff’s studies make it more and more probable that immunity rests in great part upon phagocytosis, and in order that this shall take place effectively, the white globules, which are among the most active phagocytes, must collect at the threatened parts of the economy; and ' Annales de 1’ Institxit Pasteur, Juillet, 1891. CHEMIOTAXIS OF LEUCOCYTES AND BACTERIAL INFECTION. 17 Bouchard’s1 results, as well as those of Massart and Bordet, show dis- tinctly that in animals in which the immunity has been enfeebled by one of the predisposing causes, the leucocytes lose the faculty of collect- ing in front of the bacteria. In regard to what produces this loss of chemiotactic power in the leucocytes, Bouchard concludes that the bac- terial products exercise a stupefying action upon them. When a steri- lized culture of bacteria is introduced into the circulation, the white globules appear paralyzed and no longer collect in the neighborhood of the virulent bacteria; but the observations of Massart and Bordet, and of Metchnikoff,2 show that this loss of power does not result from paralysis of the leucocytes, because they move in their ordinary way, and also englobe small foreign bodies as well as bacteria other than the in- vading ones; and Bouchard, in his later essay upon the Theory of In- fection, insists upon a second hypothesis, maintaining that pathogenic bacteria, or at least those he has worked upon, secrete a substance that paralyzes the vaso-dilator centre, and that the vaso-dilator paralysis thus produced prevents the inflammatory phenomena, especially vas- cular dilatation, exudation, and diapedesis, from occurring in the in- jured part. In this way the bacteria are relieved of one of the destroy- ing causes, phagocytosis, and can develop, flourish, and produce their secretions in perfect freedom; but Massart and Bordet object to the methods employed to prove this, that it has not been demonstrated that the desiccation of the nerve, or its having undergone several times and at intervals the action of induced currents, does not play a principal part in the results mentioned by Charran and Gamaleia,3 and by Char- ran and Agley.4 To accept the conclusions of these authors, it must be admitted that successive and supposed identical irritations have given reflexes of depression equal among themselves, which is a point not yet determined. The method adopted by Massart and Bordet was employed upon white rabbits and guinea-pigs. They inoculated into the animals, subcuta- neously, a very small quantity of the bacilli of blue pus, and at the same time made an intra-peritoneal or subcutaneous injection of a ster- ilized culture of the same bacillus, or of the bacillus prodigiosus. Im- mediately after this operation, the middle of one of the ears was very lightly cauterized, and it was easy to determine whether this procedure produced vascular dilatation, which their experiments showed that it did. Even if the doses were made so large as to produce death by direct toxic effect, they were not capable of interfering with vascular dilatation. These observers have attempted to discover for themselves what are the predisposing causes of infection, studying the method of action of four—the injection of bacterial products, varnishing, anaesthe- sia, and the presence of lactic acid—and have reached the conclusion that the increase of receptivity is dependent upon various causes, of which the following are some: First, the leucocytes float in fluids charged with products secreted either by bacteria or by altered cells. 1 Action of Products Secreted by the Pathogenic Bacteria, Paris, 1889; and also, Upon a Tiieory of Infection. Proceedings of the 10th international Medical Congress, Berlin, 1890. 2 On the Struggle of the Cells of the Organism against the Invasion of Bacteria. Annales de l’lnstitut Pasteur, 25 Juillet, 1887. 3 On Inflammation. Comptes Rendus dela Societe de Biologie, 5 Juillet, 1890. 4 Experimental Research upon an Action of Products secreted by the Bacillus Pyocyaneus on the Vaso-motor Nerve System. Arch, de Physiol. Norm, et Pathol., Octobre, 1890. 18 INFLAMMATION. These products attract the phagocytes, retaining them in the tissues, and prevent their migration toward the menaced points, while, in a normal condition, the phagocytes travel toward these points by reason of their chemiotactic power; second, the leucocytes are repulsed from the regions invaded by the pathogenic bacteria, by reason of the presence of products that exercise upon them a negative chemiotactic power; and third, anaesthetics facilitate or aggravate infection by suppressing the irritability of the phagocytes. Muscular Phagocytosis and Parenchymatous Inflammation. Another and very important contribution to the subject of inflam- mation in general is made by Metchnikoff and Soudakewitch 1 in the result of their work upon Muscular Phagocytosis, which is a partial study of Parenchymatous Inflammation. In this discussion they raise the question at the very first: Are the leucocytes the sole agents capable of producing phagocytosis? Even if their role does preponderate when the destruction of bacteria introduced into the organism is concerned, it does not follow that they alone in every case have the power of producing the disappearance of certain elements that are foreign, or have become useless to the econ- omy. Metchnikoff has studied the mechanism by which the tails of tadpoles are thrown off when they become adults. Looss and Bataillon had already gone over the problem, and had concluded that the muscu- lar fibres were dissolved in the ambient fluid, and that the leucocytes had nothing to do with it. These results would of course weaken very seriously the phagocytic theory, provided that they were exact; hut according to Metchnikoff they are very far from being entirely so. He recognizes, it is true, that the white corpuscles take no part in the dis- appearance of the contractile substance, but this latter does not dissolve purely and simply in the intercellular fluid, and other elements than the leucocytes are concerned in englobing and digesting it. In a mus- cular fibre there is a peripheral part that is non-striated, made up of amorphous and very finely granular protoplasm. It is usually found in the shape of a band or layer placed immediately within the myo- lemma about the nuclei. This protoplasm, to which is given the special name of sarcoplasm, is possessed of very great vitality, and is also pos- sessed of very marked amoeboid movements, and it is to this substance that is ascribed the part of absorbing the striated material near which it is placed, and of producing its dissolution. Some time before the metamorphosis of the animal (the tadpole), the nuclei multiply and produce, within the sarcoplasm, special cells. The muscular phagocytes which send amoeboid prolongations between the different bundles sep- arate them and break up the fibrillae; by their action, these are also broken into fragments which are more and more separated and end by being absorbed. Therefore, although the results of Looss and Bataillon are exact as far as the non-intervention of the white globules is con- cerned, they are not exact as to denying the existence of phagocytic phenomena. These last are, on the contrary, very active, hut their 1 Ann. de l’lnst. Past., Janv., 1892. ELECTRICITY IN PHAGOCYTOSIS. 19 study shows us that phagocytes and leucocytes are two things which must not be confounded. Some work of Soudakewitch on the modification of muscular fibres in trichinosis confirms that of Metchnikoff. When a trichina is in- stalled in a muscle, it is the same elements, the same “muscular pha- gocytes,” that are formed, and that tend to produce the resorption of the fibrillae that have already been destroyed by the parasite. The latter by its movements ends by destroying all the living cells, and there is therefore left only a mass of degenerated elements. At this moment alone, new leucocytes are introduced into the bundle to break it up, and englobe the debris. These two pieces of work are of great value, as showing how far phagocytosis is of importance in varying cases, and as showing also that it can be carried on not only by leuco- cytes, but also by elements of a different nature and conformation. Electricity in Phagocytosis. As a part of the study of phagocytosis, and, from one point of view, of inflammation, the action of various agencies upon the phagocytes is of importance, and among these agencies none are so subtle and in- structive as electricity. The subject has been worked out by a num- ber of experimenters, notably Kuhne,1 Engelmann,2 and especially Verworn.3 A summary of the conclusions of the latter is as follows: In one chapter, he studies the excitation of rhizopods by the galvanic current, and he uses for this purpose electrodes that he considers unpolarizable, employing a battery of twelve elements, in bichromate, as the generator of his electricity. As the result of the first series of experiments, he concludes, first, that the law of contractions hitherto considered appli- cable to all contractile organisms is not so applicable, and that there exists a series of elements that are not governed by it; and, second, that there is not a common law of contraction for the three species upon which he experimented. The second part of his work consists of ex- periments upon the ciliated infusoria, to show the influence exerted by electricity upon their orientation and their displacement. He experi- mented upon the Paramoecium aurelia, the Halteria grandinella, the Stentor coerulea, the Stent’or polymorphus, the Colpoda cucullus, the Coleps hirtus, etc. He found that all these animals, when watched in a drop of water through which an electric current was passed, moved toward the negative pole, with undulations more feeble as the current was less. If the current was broken, they all took their freedom again, and became disseminated throughout the drop of water. As soon as the circuit was closed, they arranged themselves in such a way as to present their anterior extremities toward the negative pole, and directed themselves toward it. They followed therefore the direction of the electric current, passing from the positive to the negative pole. This phenomenon might be attributed to a cataphoric action, and, in fact, it is known that inert particles which are very small, and are held in suspension by a fluid traversed by a current, are mechanically trans- 1 Researches upon Protoplasm and Contractility, Leipsic, 1864. 2 Pfliiger’'. Archiv, Bd. ii., 1869. 3 Ibid., Bd. xlv., 1889. 20 INFLAMMATION. ported by it in the direction in which it is travelling, and therefore come, as do the infusoria spoken of above, from the positive to the negative pole; but Verworn thinks that in this case the corpuscles travel in a straight line, that they do not arrange themselves so that their antero- posterior axis is in the direction of the current, and that their progress is slow. On the other hand, if the infusoria be ansesthetized by chloro- form or ether, the same current that before produced a manifest gal- vanotropic effect no longer does so, and it is therefore evident that the rapid movement of orientation observed is a manifestation of sensibility. Dineur 1 repeated the latter experiment upon a number of infusoria, and observed the existence of the galvanotropic effect, notably in the paramoecium, and especially in the rassula, but found that he was obliged to use a current with sufficient electromotive force to produce a rapid and very apparent electrolysis. If the current was not sufficiently energetic to develop bubbles of gas, the galvanotropism was not mani- fest, and he therefore considers that Verworn must have employed cur- rents sufficiently strong to decompose the fluids containing the infusoria, and able therefore to influence them chemically. In such a problem, it is difficult to separate the part played by true galvanotropism from that produced by chemiotaxis. It is known that the inferior organisms react to changes in the chemical constituents of the fluid in which they move, and this kind of sensibility, studied by Pfeffer 2and Massart,3 has received the name of positive or negative chemiotaxis, according as the infusoria observed are attracted or repelled. The only point that it is desired to make here is that in order to be considered due exclusively to galvanotropism, the orientation and displacement of the infusoria toward the negative pole observed by Verworn must be also produced by non-electrolytic currents. New experiments, with a more feeble electromotive force, must be made to illustrate this point.4 The fact that leucocytes, considered as free cells or as independent organ- isms, possess an irritability analogous to that of monocellular beings, has been completely demonstrated, especially so far as concerns their tactile sensibility, or chemiotactic power. The tactile sensibility of the leucocytes described by Ranvier5 has been recently experimented upon by Massart and Bordet,6 their method of procedure being as follows: A drop of lymph is placed on a large cover- ing-glass, and this is inverted and placed over a cell in a piece of heavy plate glass covered with water, so that the fluid is entirely prevented from evaporating. At the end of a little time, the leucocytes are mostly collected on the lower surface of the cover-glass, and on the free surface of the suspended drop, some only remaining in the middle of the drop. According to the situation that they occupy the leucocytes have different forms; the cells that are in contact with the glass have peculiar shapes, presenting certain fine prolongations by means of which they fasten themselves to the lower surface of the glass, as if with tentacles. They have been seen spread out in such a way on the lower surface of the glass as to disappear almost completely, so that they could no longer be detected except by the eyes of the expeiimenter which had followed 1 Ann. de la Soc. Roy. des Sciences Med. de Bruxelles, t. i. No. 1, 1892. 2 Arb. a. d. bot. Inst. z. Tubingen, Bd. i. S. 363; Unters. a. d. bot. Inst. z. Tubingen, Bd. ii., 1888. 3 Archives de Biologie, 1889. 4 Dineur. loc. cit. 5 Treatise upon Histology. 6 Journal de la Societe Royale de Medecine de Bruxelles, 1890. ELECTRICITY IX PHAGOCYTOSIS. 21 them during their transformation, and then only by means of the special refrangibility of the edge of the protoplasmic layer thus formed on the lower surface of the cover-glass. The floating cells are still round, but all (at the surface of the drop) have one or two needle-shaped prolongations. They thus show that every resisting surface coming in contact with the leucocyte produces a reaction on its part, manifested by throwing out and extension of the pseudopodia; the globule reacts by placing itself in contact with the excitant by the largest possible surface. This tactile sensibility explains the penetration of leucocytes into porous bodies, such as elder pith, and it is also this peculiarity that accounts for the diversity of the shapes of the leucocytes contained in a drop of lymph examined under the microscope. Suspended under a cover-glass, these shapes vary, in fact, according as the cell is in con- tact with the glass or with the surface of the drop, where superficial tension acts as the resisting surface, or on the borders of the drop where the two causes act at the same time. The same authors, Verworn and Dineur, have also studied the chemio- tactic powers of the leucocytes, and have established a fact of the greatest interest in pathology, that the chemical sensibility of the leuco- cytes is excited by the products of bacteria (the staphylococcus pyogenes albus, bacillus cholerse gallinarum, bacillus typhi, bacillus anthracis), the ptomaine of the first showing the most active attraction. The prod- ucts of disintegration of the injured cells possessed the same property, as well as certain products of oxidation of the albuminoids, like leucin. These experiments upon chemiotaxis were undertaken by Gabrit- chewsky,1 who applied the method of Massart and Bordet to a long series of substances, which he divided into, first, substances possessed of negative chemiotaxis that repelled the white corpuscles (concentrated solutions of the salts of sodium and of potassium, lactic acid from one- tenth per cent, to ten per cent., etc.); second, substances of indifferent cl^emiotactic power (distilled water, medium and weak solutions of the salts of sodium, one-tenth per cent, to one per cent., antipyrin one per cent., peptone one per cent.); and third, substances of positive chemio- tactic power (papayotin in one-per-cent, solution, and different pto- maines). The method employed was that of Pfeffer, of placing in the peritoneal cavity, or under the skin in the cellular tissue of the animal, capillary tubes of glass, closed at one end and previously filled with the solution to be used for study. As a result, the conclusion may be drawn, that in a cold-blooded animal leucocytes are sensitive to the chemical composition of the medium in which they live, and that the modifica- tions of this medium are of a nature to influence the direction of their movements. Dineur2 has proposed to find out whether the leucocytes are equally en- dowed with chemiotactic powers, choosing for his source of electricity a single Daniell cell. He employs capillary tubes of glass, placed much as in the experiments of Massart and Bordet, upon an ebonite plate, measuring one centimetre by four. He fixes, by means of a drop of sealing wax, three glass capillary tubes of the same apparent diameter, placed so that their extremities extend about two centimetres beyond the edge of the ebonite plate. These ends should be broken square across, and so placed as to converge toward each other. They are 1 Arm. del’Inst. Past., 1890. 2 Loc. cit. 22 INFLAMMATION. filled with the physiological solution of chloride of sodium (six-tenths per cent.) exactly neutral in reaction; being tilled, there is passed into each tube a very fine platinum wire to the end of the tube, extending over the edge of the ebonite plate, care being taken that no bubble of air shall enter at the same time; the entire absence of any bubble of gas must be ascertained by means of a lens, and if any is present it must be removed with the greatest possible care; then the ends of the tubes through which the wire has been introduced (and out of which it ex- tends a little way) are closed by a drop of sealing-wax, which must be done with the other ends placed in a watch-glass of the chloride of sodium. The animal to be experimented upon is thoroughly fixed upon the board, and an incision exactly long enough for the introduction of the tubes is made in the abdominal wall. The incision must be made with the greatest possible care—with a bistoury heated to a cherry red— and absolutely all hemorrhage must be avoided. Finally, the tubes are placed in the cavity in such a way as neither to bruise nor to wound the intestinal folds, and great care must be taken not to raise the edges of the wound, in order that no air may enter the peritoneum; for if this were done, it might happen that the extremities of the wires, instead of being bathed in the serum which should join them and complete the circuit, would terminate in a gaseous bubble which would break the current and make the experiment negative. In order to avoid this, some cubic centimetres of the physiological solution of chloride of sodium may be injected into the cavity, but if the peritoneal serum is sufficient to moisten the tubes well, this procedure is unnecessary. Everything being thus prepared, the current is passed through two of these electrodes, the third acting as a control. If the intensity of the current is to be diminished, a resistance is introduced at some point of the circuit, although the distance of the two extremities of the wires produces so considerable a resistance that a galvanometer must be used at the beginning of the experiment, in order to be sure that the current is passing through. This also is the reason why the extremities of tlie tubes must be placed as close together as possible. The animal is covered over, and the whole apparatus placed in a moist chamber. At the end of some time, often exceeding twenty-four hours, the micro- scopic examination is to be proceeded with, and here again the galvan- ometer must be employed, in order to be certain that the current is still passing. Then the capillary tubes are removed with very great care, in order to avoid disturbing the little fibrinous collections that may be gathered over the end of one or the other of the tubes, which could easily be destroyed if the removal was effected carelessly. The whole is then placed on a slide, the free ends of the tubes are covered with a cover-glass, and a few drops of the solution of chloride of sodium are introduced under it. In this way the capillary tubes can be very easily observed under the microscope, and the evaporation of their contents is not to be feared. If, in spite of all precautions, a bubble of gas has entered the tubes, or if they are in any way obstructed, the result, of course, is not valuable, any more than when, as often happens, an end of one of the tubes has broken some of the small vessels; and it is easy to see that it is only after having repeated the same experiment many times that one can secure a sufficient number of observations, free from any source of error. In Dineur’s experiments he has obtained the SUPPURATION. 23 same result in every case in which he could exclude sources of error, and as a result of a long series he has discovered certain interesting properties of the white corpuscles, which he summarizes as follows: ‘‘ First, the leucocyte is endowed with a special sensibility to electricity. I propose to give to this property the name of galvanotaxism. Second, the galvanotaxism of the normal leucocyte guides it with a marked preference toward the positive pole (positive galvanotaxism). Third, the galvanotaxism of the leucocyte in inflammation directs it, on the contrary, toward the negative pole (negative galvanotaxism).” These experiments are of the greatest value and interest, as tending to show the relationship of the action of the leucocytes and phagocytes (for we have seen they are not necessarily the same thing) toward ex- citation of various kinds, and also as tending to uphold that theory of inflammation which forms the keynote of this paper. Suppuration. Suppuration being but a part of the same process of inflammation, but carried further, may next claim some attention; and in the same way as inflammation, must this process be considered from a new point of view, as is well illustrated by Shattock1 in his remarks before the London Pathological Society, in which he claims that the time has ar- rived for a revolution in the terms at present in use, as applied to sup- puration. The terms suppuration and pus are purely anatomical, and include things quite different in their etiology. Setting aside larger questions, the process of acute suppuration can be etiologically distinguished from other forms, and is as specific in its nature as tuberculosis or syphilis, as is now well established by experiment. Koch’s four postulates can all be fulfilled in this case, and the doctrine can be confirmed by the control experiment of introducing aseptic chemical irritants beneath the skin of animals, which, if the animals are healthy, produces in- flammation, but not suppuration. A strict parallel can be drawn be- tween tuberculosis in its different manifestations and acute suppuration, which is given in tabular form thus: Tuberculosis. Local. Glandular. General. Pyosis. Local. Secondary Glandular Abscess. General. Acute Circumscribed Abscess. Diffuse Suppuration. In order to bring out these facts, Shattock suggested the term, Pyosis.” Generalized Pyosis will then be what is named Pyaemia; Glandular Pyosis will denote the secondary glandular infections; and the acute abscess or acute suppuration of a bowel will be Pyosis in a local form. Shattock also speaks of certain observations on the presence of peptone in the pus of acute abscess. This can best be demonstrated by shaking 1 Brit. Med. Journ., Feb. 6, 1892. 24 INFLAMMATION. the pus with half its bulk, or less, of a saturated solution of ammonium sulphate, then adding crystals of the same salt to saturation, and fil- tering. If a drop of copper sulphate solution is then added to the clear filtrate, no precipitation is produced, for the ammonium has precipi- tated all the proteids except peptone, and on adding an excess of solution of caustic potassa, a dense white precipitate of potassium sulphate is thrown down. On this subsiding, the pink coloration of the clear supernatant fluid can be seen. Shattock has been able, by dialyzing pus, to show the same with the biuret reaction. For the separation of the albumoses, Dr. Sidney Martin’s method was necessary. The pres- ence of albumose and peptone in pus is not peculiar to the action of pyogenic bacteria. Dr. Martin had shown both in the alkaline albumin in which he had grown the bacillus of anthrax. The peptone in all the specimens tried was very small, being indeed a mere trace, and the amount of albumose was much larger. The summary of this work of Shattock’s leads naturally to a men- tion of other experiments of the same nature (upon soluble products of bacteria), but of a very different and more important class. Action of Soluble Bacterial Products upon Inflammation. Charran and Gamaleia1 thus summarize the results of their investiga- tions upon the action of soluble bacterial products upon inflammation:— Buchner and Bouchard have established that the intensity of a local bacterial lesion is most often proportionate to the resistance of the inoc- ulated animal. It has also been demonstrated that this local lesion is always rich in leucocytes, except in cases of absolute vaccination, a direct result of this resistance of the animal. In order to explain the presence or absence of these leucocytes according to the condition of immunity, or of receptivity, certain authors have considered that in the first case the white corpuscles are attracted by the bacterial secretions, or at least become accustomed to their action, which in the second case produces an effect of repulsion, or of paralysis. Bouchard has placed beyond doubt, by his experiments, the property possessed by the soluble products of preventing the appearance of the leucocytes. He has, in fact, shown that the diapedesis can be arrested if certain sterilized cultures be injected, and the authors quoted above bring forward new facts to support this observation. If one rubs croton oil, according to Samuel's method, upon the ears of rabbits, there appear at the end of fpur hours redness and swelling, and in about eight hours an exudation which is very abundant, and which is sometimes accompanied by the formation of blisters; but if after having subjected an animal to the same treatment with croton oil. there are injected into the veins (four or six times every two hours) 5 to 8 cubic centimetres per kilogram of the sterilized culture of the bacillus pyo- cyaneus, none of the foregoing phenomena occur. The alterations only appear on the following day, if through fear of poisoning the injections are stopped. As a result, therefore, it appears that the secretions of certain pathogenic agents can act upon inflammation as a whole, pre- venting congestion and transudation of plasma, as well as diapedesis. 1 Comptes Rendus, t. 110, p. 1154. DESTRUCTION OF BACTERIA BY AMCEBOID CELLS IN INFLAMMATION. 25 The question as to whether these soluble products act directly upon the vessels or through the medium of the nerves is not yet settled, and further work is to be carried out by these authors to discover if possible what other substances, and in what degree, can produce the same effects. Destruction of Bacteria by Amoeboid Cells in Inflammation. Again, and in a very important measure supplementing the work of Metchnikoff, comes that of Armand Buffer1 on the destruction of bac- teria by the amoeboid cells in inflammation. In a memoir published in the British Medical Journal for May 24, 1890, upon the same subject, Buffer was led to the following conclu- sions : First, the inflammatory phenomena following the introduction of the bacilli of symptomatic anthrax under the skin of the guinea-pig have a protective and useful character; second, the destruction of bac- teria at the point of inoculation is produced entirely by the amoeboid cells contained in the inflammatory exudation. He based these conclusions upon the effects seen in guinea-pigs, but he has also studied the action of the same virus (of symptomatic an- thrax) upon rabbits—animals that were considered refractory to this disease by Arloing, Cornevin and Thomas, Boux and Nocard, and many others. He has carried on his experiments with the bacillus Chauvoei (symptomatic anthrax), endeavoring to find the effect exerted upon it by the living fluids and cells of rabbits. He used for the pur- pose the first and second vaccines of Arloing (prepared by the desicca- tion of the muscles of animals dead of symptomatic anthrax), and a dose of the virus was always very carefully weighed before being placed under the skin of the rabbit. His first experience led him to believe that this organism did not grow in the rabbit, for having in- jected a very small quantity, five milligrammes, of the second vaccine under the skin of a rabbit, and having examined the point of inocula- tion twenty-four hours afterward, he was unable to find any bacilli; but upon very carefully staining sections made from the inflammatory tissue, he always found a few leucocytes surrounding the remains of the vaccinal powder, and a few of the typical bacilli englobed in these cells; if a larger quantity of the vaccine (five centigrammes) were used, the bacilli were extremely numerous at the point of inoculation. Larger doses produced in the animal typical symptomatic anthrax, and inevitably killed it after from forty-eight hours to three days, and under these circumstances a very large number of the bacilli could be found at the point of inoculation, englobed in the leucocytes and in process of degeneration. The degenerative changes in the bacteria were absolutely the same as those seen in the leucocytes of guinea-pigs, and these facts led Buffer to try if the living fluids of animals comparatively refractory to the bacillus Chauvoei possessed a bactericidal power over this organism; a question which had already been studied partially by Boger, who made the remarkable observation that the serum of guinea-pigs, which are not refractory to symptomatic anthrax, had a very great bacteri- 1 Ann. de 1’Inst. Past., t. v. p. 673. 26 INFLAMMATION. cidal power over the bacillus Chauvoei, while that of rabbits, which are relatively refractory, was harmless toward this same bacillus, another confirmation of the fact that one cannot judge of the immunity of an animal to a disease by the bactericidal power of its dead fluids toward the bacterium of this disease. Moreover, it has already been empha- sized by Ruffer himself,1 that in the same way that the living blood differs by its optical, chemical, and physiological characteristics from the dead blood, in the same way does the action of living fluids upon bacteria differ entirely from that of dead fluids. Depending upon the principle that in order to study the action of the fluids of the economy upon a bacterium, they must be observed in the living body, a method employed by Metchnikoff and others was used. The powder to be studied was enclosed in a little bag of filter-paper, like what the pharmacists use to put up powders, the two folds of the bag being closed with paraffin. The bag, containing five decigrammes of the first vaccine, was introduced for twenty-four or forty-eight hours under the skin of a large rabbit, then taken out, the contents examined, and the whole placed in absolute alcohol to harden it well. The appear- ance varied a little if a cover-glass preparation was made from the powder. In the centre of the little packet, most of the bacilli developed were normal, although the growth of some of them was less than that of their neighbors. The contour of the latter was irregular, and staining by Gram’s method was less intense, and frequently replaced by the contrast color of vesuvine. Very frequently long filaments could be observed in which some bacilli appeared perfectly normal, and stained well with gentian violet, while others had an irregular contour, and stained by vesuvine. It would be extremely difficult to decide whether these differences were due to the partial degeneration of the bacteria, or whether one had to do simply with organisms whose development had been for one reason or another retarded. If the powder was ex- amined forty-eight hours after inoculation, these irregular forms in- stead of being more numerous were much less so, and even might not be found at all; and if, instead of examining the central portion of the powder, the dust made by it on the surface of the paper was studied, there were to be found there a quantity of absolutely normal bacilli. Here and there in the interior of the sac there were to be found a few leucocytes, and these experiments seemed to show conclusively that the bacillus Chauvoei grew perfectly in the tissues of refractory rabbits. Sections made of the paper of the bag (hardened in alcohol, then in chloroform, the chloroform saturated with paraffin, and finally in pure paraffin) showed many interesting things: first, a very great activity of the bacilli, for it could be seen that they had forced a passage for a certain distance between the fibres of the paper, while on the other hand the leucocytes, attracted by the poison secreted by the bacteria, had penetrated in immense quantities between the fibres of the paper, so that an encounter between the bacteria and the leucocytes had in- evitably taken place at a certain point. It could be seen that certain of the leucocytes in advance contained bacteria, either normal or in process of degeneration, while others had themselves perished in the struggle, as could be clearly seen by the signs of degeneration that they presented. Behind this advance guard could be found a mass of 1 British Medical Journal, May 24, 1890. DESTRUCTION OF BACTERIA BY AMOEBOID CELLS IN INFLAMMATION. 27 leucocytes, containing an enormous number of the bacilli more or less degenerated, and it was curious to see the small polynuclear leucocytes assembled in enormous numbers just at the points where their presence was useful. Finally, near the external surface of the section not a sin- gle bacillus could any longer be found. It was exceedingly important to know whether the second vaccine was still more enfeebled under the influence of the living fluids of the rabbit, and the following experiments were undertaken for this pur- pose. Fifteen centigrammes of the second vaccine were divided into three equal parts, and five were inoculated into a rabbit. An abso- lutely typical tumor developed in this animal, which disappeared grad- ually, and the animal completely recovered. A second portion (five centigrammes) of the vaccine was enclosed in filter-paper and placed under the skin of another rabbit. Twenty-four hours after, the wound was opened, and the paper cut in a way to permit the contents to es- cape in the tissues; the animal died forty-eight hours afterward of a typical symptomatic anthrax. The third portion of five centigrammes was introduced under the skin of a third rabbit in the same way. Forty-four hours afterward the paper was broken by pressure outside of the skin, and this animal died in twenty-four hours of symptomatic anthrax. Other experiments were undertaken to show that this result was not due to the fact that the virus had been introduced into a region enfeebled by the presence of the filter-paper. As the result of all, it was shown that in guinea-pigs, as in rabbits, the bacilli of sympto- matic anthrax develop as soon as they are introduced into the organ- ism, and that the leucocytes collect in the region where the virus is found; that the leucocytes are attracted by the chemical poison secreted by these bacteria, and that, once emigrated, they actively at- tack the organisms, englobe, and destroy them. It is to be remarked that the cellular emigration to the point of in- oculation varies inversely with the quantity and the strength of the virus introduced, but is proportional to the duration and benignity of the disease. The emigration of the leucocytes is feeble or negative when a large quantity of extremely virulent bacilli are injected, but becomes more marked when the inoculated bacilli are less numerous, or when they have been previously attenuated; further, if the leuco- cytes are prevented by any cause, mechanical or chemical, from reach- ing the virus, the disease makes progress, and the animal succumbs. The living fluids of an animal naturally refractory, or of an animal whose immunity has been reinforced by an anterior inoculation, have no bactericidal action upon the virus of symptomatic anthrax, since this virus, bathed in its fluids, if taken out and again injected into a refractory animal, produces its death; finally, the fluids of a diseased animal appear to have no attenuating or bactericidal action upon the bacterium of the same disease. What has been said upon cellular emigration cannot in any way be applied to exudation, another phenomenon accompanying inflammation. The two processes appear to be almost in inverse relation, as can be seen by comparing, for example, the sanguineous exudation of a. rabbit, dying in twelve hours after inoculation with the bacillus Chau- voei, and the thick, compact, almost solid substance that accumulates about the virus inoculated in a refractory animal. It appears to be 28 inflammation. evident that, in this disease at least, the serous exudation is always more abundant when the disease is most virulent, but in spite of the enormous quantity of this exudation, the bacteria appear to be in no way hurtfully affected by it, but, on the contrary, they flourish in it, and acquire an extraordinary virulence. Another very evident point brought out is that if the substances produced by the bacteria have already penetrated into the blood, the poison secreted by the same organism inoculated into other parts of the body of the animal does not attract the leucocytes, as is shown by the results obtained with the bacillus pvocyaneus. If a drop of a culture be injected into the eye of a rabbit, the leucocytes emigrate in great quantities to the point of injection, but if the poison produced by the bacillus pvocyaneus is pre- viously circulating in the blood, the leucocytes do not emigrate, and the eye remains intact. Finally, it seems necessary, before accepting the theory advanced by Massart and Bordet,1 to study the action upon inflammation of certain well-defined chemical substances injected at the same time under the skin and in the veins, which is a work that Ruffer promises to carry out very soon. Bacteria Causing Inflammation. Looking upon inflammation from the point of view here adopted— that it is a symptom of the effect of some irritant agent, and the ad- vance of the phagocytes against this agent—and considering, as we are obliged to do, that the most commonly occurring of these irritant agents are to he found among certain forms of the bacteria, it is im- possible to have a proper idea of the subject without a certain knowl- edge of what these bacteria are. Of course, a consideration of the whole subject of bacteriology would be out of place here, but the activ- ity of these micro-organisms has been shown to be so great and so widespread that a mention of a few of them is necessary. The number of those that have been shown to produce an inflammatory reaction, which inflammatory reaction not infrequently goes on to suppuration, is very large indeed, so that it is not possible to speak in detail of more than the most common; and the mention of those spoken of must also be limited to the organisms occurring in man, for the number of bac- teria which have been found to produce inflammatory changes in the lower animals is much greater than the number of those which have been found, either by inference or actual experiment, to produce the same changes in the human being; so that if the effort were made to consider all that may produce inflammation either in man or in the lower animals, an altogether too great prominence and space would of necessity be given to their description. Of those that produce inflammatory and suppurative changes in the human tissues, the most common is (1) the Staphylococcus Pyo- genes Aureus. This is an organism occurring very often in pus, in the air, and in earth, in the form of irregularly arranged micrococci of variable size, the medium diameter being 0.87/*. It is non-motile. On gelatin plates, at the end of forty-eight hours, it appears as small points with a yellowish tinge and sharp edges at the non-liquefied gelatin. 1 Vide supra. BACTERIA CAUSING INFLAMMATION. 29 In needle cultures it grows as a granular grayish line, which after about three days turns yellowish, afterward of an orange color, liquefies the gelatin, and sinks to the bottom of the liquefied portion. On agar- agar, after twenty-four hours, there is a dark opaque colony, which subse- quently turns from yellow to orange. On potato, it grows as a thin whit- ish layer, which afterward becomes slimy and orange-yellow, producing a strong putrefying odor. On blood serum, it grows as on agar-agar. It develops best at from 30° to 37° C., somewhat more slowly at sum- mer temperature. It develops rapidly; spores have not been observed, but it shows a marked resistance to destructive agencies of various kinds, is facultatively aerobic, liquefies gelatin, stains well after Gram’s method, and has pathogenic effects upon various lower animals. (2) Another very common organism of the same class is the Staphy- lococcus Pyogenes Albus, which develops precisely as does the preceding, excepting that it produces no pigment in its colonies. (3) A third is the Streptococcus Pyogenes, found in progressive ery- sipelatous processes, and occurring as small cocci arranged in chains often made up of as many as thirty elements. On gelatin plate cul- tures, it grows as fine round granular points. In streak culture, it is thickest in the middle, its color a dark brown, the contour growing thicker, swelling, and terrace-shaped. In needle culture in gelatin, the colony grows along the course of the needle track as a finely gran- ular line. On agar-agar, in a needle culture at from 35° to 37° C., it grows as a band-like grayish-white line with points. There is no sur- face growth, and only a very slight growth upon potato, the cocci changing so that under the microscope they appear of different sizes. On blood serum it develops as a thin band-like layer. Its best devel- opment is at 35° to 37° C., summer temperature being less favorable. Its growth is slow, it is facultatively anaerobic, non-liquefying, stains by Gram’s method, and produces a slow erysipelatous suppuration in the lower animals. (4) Very similar is the Streptococcus Erysipelatis, the only marked difference between the two being the greater apparent activity of the latter in the living animal tissues. (5) The Gonococcus occurs in secretions from mucous membranes affected with gonorrhoea, as kidney-shaped diplococci with the concav ities facing each other. It seems to have a rotary and oscillating move- ment, but no true motility. There is no growth on gelatin, agar-agar, or potato, but it develops well on acid gelatin. On human blood serum, it develops as a very thin, almost transparent layer, which by reflected light appears grayish-yellow, with a moist glistening surface, whose edges appear diffused in the surrounding medium. The best temperature for its development is from 33° to 37° C. Its growth is very slow. It stains best with fuchsin or methyl violet, but does not stain by Gram’s method. Successful inoculations have been obtained by Bumm. (6) The DijAococcus Intracellularis Meningitidis has been obtained in six cases in the fresh exudation of cerebro-spinal meningitis, occur- ring as micrococci, usually in pairs or in small masses, and in the in- terior of the pus cells in the exudation. There is no growth upon gela- tin, but upon agar-agar there is a free viscid growth, gray by reflected light, grayish-white by transmitted, the growth occurring only near the 30 IXFLAMMATIOX. surface of the needle track. On plates of one-per-cent, agar-agar and two-per-cent, gelatin, it develops as very small colonies in the interior of the mass, with larger ones upon the surface, of a grayish color. In the former, the small colonies under the microscope appear round or slightly irregular, finely granular, and of a yellowish-brown color. The superficial colonies have a yellowish-brown nucleus, surrounded by a more transparent zone. There is no growth upon potato, and a very slight colorless growth upon blood serum. There is no development at the room temperature; it only grows at the temperature of the body. It quickly loses its power of development in artificial cultures at the end of six days, and it is best to transfer it once in two days. It stains best with Loffler's alkaline methylene-blue, but does not stain by Gram’s method; it is pathogenic for mice, guinea-pigs, rabbits, and dogs. (7) An organism, the power of which in the human tissues has not yet been definitely settled, but which is found in the human secre- tions, is the Micrococcus Tetragonus; it is commonly found in the lung cavities affected with pulmonary tuberculosis, and is reasonably sup- posed to produce the purifonn discharge from such cavities. It occurs in pairs, or fours, and is non-motile. On gelatin plates it grows as small white colonies, which under a low power appear finely granular, with a glossy look. In needle punctures, its development is not along the whole of the needle track, but occurs in isolated colonies that are sharply defined, milky white, or yellowish in appearance. On agar- agar it grows in rounded separate white colonies; on potato, as a thick slimy layer, which can be lifted up in long shreds; and on blood serum as a white, moist, irregular layer. It grows best at room temperature, slowly, is not known to produce spores, is facultatively anaerobic, does not produce gas, and is non-liquefying. It may be stained by any of the usual aniline d}res, as well as by Gram’s double stain. There are a large number of other bacteria which have been found in man, and which have been shown to possess pathogenic powers in the lower animals in the way of producing inflammatory changes and suppuration, but their number is so great that those spoken of must serve as examples, and the reader is referred for a full list and descrip- tion to the Bakteriologisclie Diagnostik, of Eisenberg (1891), or to the Manual of Bacteriology, by Sternberg (1892). That the bacteria named are not all of those concerned in the pro- duction of inflammatory or suppurative changes, is well shown by the experiments of Condamin,1 in which he speaks of a case of multiple suppuration consecutive to a suppurative otitis, which presented char- acters different from those usually observed. The otitis developed sud- denly during the course of influenza, and rapidly culminated in perfo- ration of the tympanum, having been preceded by severe sore throat. Two days later the patient’s temperature was high, and he had several rigors. An abscess developed on the back of his right hand, which was opened two days afterward. From this time a series of abscesses occurred in different parts of the body, all subcutaneous and running a rapid course. From fifteen to eighteen of these, at least, were observed, and in each case cultivations from them developed Frankers Pneumobacillus in a state of purity. The common character of all 1 Lyon Medical, 7 Fev., 1892. BACTERIA CAUSING INFLAMMATION. 31 these abscesses was their quiet development; in fact, they behaved like “cold” abscesses. The pus was very thick, yellow, and odorless; there was little tendency toward diffusion, each collection tending rather to become encysted. The rapidity with which each disappeared after being opened by the thermo-cautery was remarkable. Of course such an instance is but one of hundreds that could be quoted, but it well illustrates the difficulties of the problem of definite etiology. Again, the fact that the exact separation of the different varieties of bacteria concerned in inflammation is not yet made, is shown by all the work done to differentiate or identify two organisms, the Streptococcus Erysipelatis, and the Streptococcus Pyogenes. The latest experiments in this direction are those in the Centralblatt fur Bakteriologie u. s. w. (No. 24, 1892), where it is said that the question of the identity of the micrococci occurring in chains in suppuration, and those of erysipelas, has been settled in different ways, according as the observer is governed by their resemblance in size and be- havior toward staining reagents and culture media, or by the difference in their pathogenic effects. Baumgarten relies upon the first hypo- thesis—their identity—which rests upon an observation of E. Frankel, who succeeded in producing an erysipelatous inflammation of the ear of a rabbit with the micrococcus in chains, cultivated from a peritoneal exudation. C. Frankel remarks upon this, that the only further point needed to show the identity of the two bacteria depends upon the pro- duction of erysipelas in man by the pyogenic streptococcus. Kirschner brings to support this theory an observation upon a patient who was attacked simultaneously with amygdalitis and erysipelas; an observation that had the value to his mind of an inoculation experi- ment. The person upon whom he made the observation was affected with phthisis, and after having received an injection of tuberculin, was on the following day attacked with tonsillitis, with a whitish exu- dation containing numerous streptococci, but no bacilli of diphtheria. Bacteriological examination showed these organisms to be the strepto- cocci pyogenes. Although the tonsils did not become worse, the tem- perature rose to 40° C., and this persistence of the general symptoms was attended by an erysipelatous blush, which appeared on the bridge of the nose, and extended from thence over the cheeks to the ears and to the neck, receding after four or five days. Bacteriological exami- nation of the erysipelatous vesicles showed the presence of many micro- cocci in chains, which were well-developed. Must it be admitted that the streptococcus of erysipelas produced the erysipelas, and the strepto- coccus pyogenes the tonsillitis—two different species of micro-organism producing two different affections in the same person;—or is it more probable that it was the same organism which by travelling produced the suppuration of the tonsils and of the vesicles? They were abso- lutely similar as far as their form and reaction went, and it is therefore probable that the streptococcus pyogenes can produce different affec- tions according to the degree of its virulence. From what has been said in the preceding pages, we are able to conclude that inflammation as occurring in man is, in most cases, a reactionary process against the invasion of bacteria; that these bacteria are of many varieties; that their activity in the production of the inflammatory processes is the result of the production of new toxic 32 INFLAMMATION. principles, which act upon the body cells in the way of exciting, first, their chemiotactic, and, second, their phagocytic powers. Necessarily, these chemiotactic and phagocytic powers do not explain all the phenomena seen in inflammation, but they surely form an im- portant part of such explanation, and further investigation may very probably make clear some of the points which are still obscure. At all events, no statement of inflammation is complete without a sum- mary of the knowledge thus far obtained in this direction. WOUNDS AND WOUND-TREATMENT. BY FRED. KAMMERER, M.D. SURGEON TO SAINT FRANCIS’S HOSPITAL AND TO THE GERMAN HOSPITAL, NEW YORK. I. Wounds. Although some modern authors still believe that an immediate union of wound-surfaces can take place without the interposition of granulation-tissue, and that the severed parts become reunited by an exact apposition of the corresponding microscopical elements of such surfaces, this view is no longer held by the majority of investigators. Even when wounds heal by primary intention, with no outward signs of inflammatory reaction, a certain amount of regenerative material is thrown out between the wound-surfaces, which, however minute in quantity, still tends to bind the latter together, and is Anally transformed into a scarcely perceptible mass of cicatricial tissue. When absolute asepsis has been secured by the efforts of the surgeon, this healing process is essentially of a regenerative nature, unaccom- panied by symptoms of inflammation. Before the antiseptic era such results were infrequently obtained, and even when sutured wounds did not afterward separate, inflammatory reaction showed itself in hyper- gemia and swelling along the line of suture. The causes which are instrumental in setting up such reaction in wounds are, mechanical ir- ritation of wound-surfaces, the presence of foreign material, mainly necrosed tissues, but more especially the introduction into the wound of micro-organisms which by their multiplication give rise to the symp- toms of wound-infection. We are to-day enabled to guard against the latter, but we are not always able to entirely avoid the effects of me- chanical irritation and of the interposition of necrosed tissues and blood- clots between the wound-surfaces. It is well to bear this in mind, when we study the histological changes during the healing of wounds. If we could observe the latter under the microscope, we would notice, as an indication of inflammatory reaction, an infiltration of leucocytes, how- ever small, in some parts of most aseptic wounds. But this manifes- tation is wholly secondary in importance. It has at times been regarded as the necessary precursor of all regeneration and repair in wounds. This theory has now given way to that which assumes that the fixed tissue and parenchyma cells are the active agents in the work of repair, and that the leucocytes which have emigrated from the blood-vessels are doomed to destruction either by absorption or expulsion, in the lat- ter instance as the main constituents of pus. 33 34 WOUNDS AND WOUND-TREATMENT. Karyokinesis or Indirect Cell-Division. — When new tissues are formed in the body, this is always accomplished by a division and mul- tiplication of cells, such division being ushered in by well-defined changes in the nucleus and protoplasm of the cell, mainly in the former. In the quiescent state the nucleus is composed of a fine network of threads, which readily stains and has therefore been called chromatine, and an intermediary substance, which does not stain, called achromci- tine. When karyokinesis, karyomitosis, or indirect cell-division, is about to begin, the nuclear threads and the nucleoli which are distrib- uted in this network become more distinct and increase in size (Fig. 1538). In some of the nuclei the chromatine assumes a more granular appearance (Fig. 1539), and in others again it arranges itself in con- torted filaments (Fig. 1540). In the further course of karyokinesis the threads and filaments become more and more distinct, the nucleolus dis- appears (Fig. 1542), as does also the contour of the nucleus (Figs. 1542, 1543, 1544). The chromatine has now become converted into separate loops, which lie in the equatorial zone of the cell with their angles con- verging toward the centre (Fig. 1545, 1546, 1547). Division in each loop now takes place in such a manner that a pair of similar loops results. About this time delicate threads, arranged in the shape of a spindle, have become visible in the nucleus. The ends of this spindle are called the poles, and the chromatine loops are now lying in the equator of this spindle as just stated (Figs. 1548, 1549; also Figs. 1553, 1554). The loops now begin to separate, moving toward each pole, at the same time individually changing their position, so that their angles are now directed toward the poles and not toward the centre of the cell. The result of this separation is the formation of two sets of loops, containing each about the same number of individual members as the original equatorial zone (Figs. 1549 and 1555). These gradu- ally move toward the poles, assuming more and more the appearance of the original chromatine network, and becoming enveloped by a new nuclear membrane. And thus after its division the network of the nucleus again returns to the quiescent state. During this last stage of karyokinesis a division of the cell-protoplasm commences as a constriction at the equator, and, becoming in time more pronounced, it finally ends in complete separation into two indi- vidual cells. It is very probable that the nucleus is the active agent in indirect seg- mentation, that the properties of the cell are transmitted by it to the new cells, and that the protoplasm is responsible only for the nutrition of the latter and assists in the development of new tissues. But this cannot be asserted otherwise than hypothetically, as our knowledge of the minute changes in the protoplasm itself during karyokinesis is very imperfect. We assume that as the result of a certain activity in the pro- toplasm the formation of a lucid area about the nucleus occurs (Figs. 1543 et seq.), and also that the radiation into the protoplasm itself at the poles is due to a like cause (Figs. 1549, 1553, 1554, 1555). But the explanation of these phenomena is not yet forthcoming. For and against the vital power in protoplasm it has been asserted that frag- ments of infusoria, containing no part of the nucleus, are not capable of reproductive action; and also that such fragments can develop into new individuals, possessed of all the attributes of a living infusorium. WOUXDS. 35 Fig. 1537, Fig. 1538. Fig. 1539. Fig. 1540. Fig. 1541 Fig. 1542. Fig. 1543. Fig. 1544. Fig. 1545. Fig. 1546. Fig. 1547. Fig. 1548. Fig. 1549. Fig. 1550. Fig. 1551. Fig. 1552. Fig. 1553. Fig. 1554. Fig. 1555. Karyokinetic Cell-Division. (Ziegler.) 36 WOUNDS AND WOUND-TREATMENT. In conclusion, therefore, we may say that the exact part taken by the nucleus or the protoplasm in the production of new cells has not yet been definitely determined, but that in all probability a very compli- cated reciprocal activity is manifested by them during this process. Direct Cell-Division.—Direct segmentation was formerly believed to be the only mode of cell-reproduction, before the researches of Flem- ming and others had brought to light karyokinetic changes in the nu- cleus. Now the term direct is restricted to that form of cell-division, during which no increase in the amount and no change in the arrange- ment of the nuclear chromatine is observed. It is division pure and simple, without any activity on the part of the chromatine. It agrees with this observation that direct segmentation is most frequently, per- haps only, observed in cells (leucocytes) which are destined to take no further part in regenerative and hypertrophic changes. Wherever the latter are going on, there indirect cell-division, accompanied by the cor- responding nuclear phenomena, is the rule. The immediate result of cell-division by karyokinesis is the formation of a mass of indifferent cells known as formative cells, or embryonic tis- Fig. 1556. Union of Incised Wound after Suture (6th day), a. Epidermis: b, corium: c, fibrinous exudate; d, regenerated epithelium partly undergoing karyokinesis; e. nuclear changes in cells at some distance from incision; /, embryonic tissue in adjacent connective-tissue spaces: some of the cells show kar37o- kinetic changes in nucleus; g and h, leucocytes; i, fibroblasts; k, sebaceous glands; I, sweat glands. (Ziegler.) sue. It is not apparent from the microscopical appearance of these cells, at an early stage, into what permanent tissues they will ultimately de- velop ; but it is safe to say that they will only produce cells to which they are embryologically related. Thus an epithelial cell, or more cor- WOUNDS. 37 rectly an embryonic cell the descendant of an epithelial cell, will never develop into connective-tissue, bone, or cartilage cells. Nor will a con- nective-tissue cell ever produce an epithelium. Healing of Wounds.—When primary union is taking place, we have seen that a certain amount of granulation tissue composed of leu- cocytes, but mainly of embryonic cells of the connective-tissue type, is found between the wound-surfaces. Some embryonic cells also lie in the adjacent connective-tissue spaces, and they, not the leucocytes, are finally transformed into connective tissue binding the wound-surfaces together (Fig. 1556). When healing by granulation occurs, it is not so easy to observe the process of repair, and the part taken therein by the Fig. 1557. Formation of Blood-Vessels from Granulation Tissue. (Ziegler.) fixed tissue cells, owing to the infiltration of the parts with leucocytes. The microscopical changes are, however, identical with those occurring during primary union. Embryonic cells, for the greater part derived from the connective tissue present in all the organs of the body, com- bine with the leucocytes that have emigrated from the blood-vessels to form a new tissue, which gradually fills up the wound cavity and is familiarly known as granulation tissue. The blood supply of this tis- sue comes from the most superficial capillaries in the wound surface. Here a thickening at certain parts of the vascular wall is the first inti- mation of the formation of a new vessel. It gradually grows in size, forming a projection, and finally a solid strand. The latter unites at its end with sprouts from other vessels, or, as is most frequently the case in granulation tissue, it returns in the shape of an arch to the vessel from which it originally sprang. It is finally converted into a hollow string 38 WOUNDS AND WOUND-TREATMENT. from an excavation beginning at its base, into which the blood, circulat- ing in the original vessel, immediately penetrates, assisting by its pres- sure in the canalization of the entire arch. The greater part of granulation tissue is finally transformed into con- nective tissue, known as cicatricial tissue, but when embryonic cells enter into the formation of granula- tions which are derived from other tissues than connective tissue, they will produce tissues similar to those of which they are the offspring. Thus osteoblasts will produce bone, myoblasts muscle fibres. The leuco- cytes in granulating surfaces are either discharged as pus, or disappear after having been absorbed by other cells in active proliferation. From all appearances this process of ab- sorption of one cell by another (phagocytosis) must be viewed in the light of an act of nutrition, as whole leucocytes as well as fragments of their nuclei and protoplasm are found in the embryonic cells before and after cell-division has taken place. (Fig. 1558.) When after karyokinetic division of the nucleus the protoplasm of the cell does not divide, giant-cell formation is the result. The giant cells are found in small numbers in healthy, more frequently in tuber- cular and syphilitic granulations. Fig. 1558. Phagocytosis. Embryonic cells containing leucocytes, etc. Healing of Wounds in Special Tissues.—Epithelium.—In granu- lating surfaces that have reached the level of the surrounding external tissues, the regeneration of the epithelial covering starts in from the border of the wound, or from isolated patches of epithelium lying on the granulating surfaces. All the karyokinetic changes previously described are observed in the cells undergoing division at the border line between epithelium and granulations, and a film of new epithelial cells finally spreads over the entire wound-surface. Not only surface epithe- lia, but also the epithelial covering of the intestinal tract and other glandular epitlielia show a marked tendency to regenerate under favor- able conditions. It has been demonstrated experimentally that defects in the mucous membrane of the stomach and intestines will heal very quickly, and will finally receive a new epithelial layer in which even the secreting glands have been reproduced to a greater or less extent. In this case, when healing has been rapid, it may be impossible to dis- tinguish the site of a previous ulcer; but where wound-surfaces in the intestinal tract have been granulating for some time, and more connec- tive tissue has in consequence been produced, the cicatrix readily be recognized and may have led to serious functional disturbance dur- ing life. In the kidneys and liver, the glandular epithelium when lost is rapidly reproduced, provided the lesion has affected the epithelium only. On the other hand, a large loss of substance in these organs is repaired by the development of cicatricial tissue, into which a more or less perfect budding of new glands may take place from the intact glandular epithelium of the neighborhood. Muscles.—The power of reproduction in striped and unstriped mus* 39 WOUXDS. cle cells is not very great, and, although we can no longer accept the theory that wounds of the muscles always heal by the interposition of connective tissue, in the majority of such cases this appears to be true. Karyokinetic figures and consecutive cell-division have been clearly dem- onstrated in both varieties of muscular tissue, showing the opinion for- merly held, that muscular tissue when regenerated was due to prolifer- ation of the interstitial connective-tissue cells, to have been wrong. After section of a striated muscle the fibres bordering on the cut sur- faces lose their vitality and are ultimately absorbed. The nuclei of other muscle fibres increase in number, some of them lying within the contractile tissue (Fig. 1559, a), others at the end of the torn fibre (6) within the sheath of the muscle cell. In both places karyokinetic figures are seen as early as the second day, resulting in the formation of polynuclear cells. Where the latter appear within the muscle fibre, their protoplasm is not sharply defined; there is, oh the contrary, a gradual transition from it to the substance of the muscle fibre (c, /, e). As they increase in size in all directions they form projections at the end and the sides of the original fibre, called muscle-buds, which un- dergo ultimate transformation into striated fibres. Quite frequently these buds split up into a number of new fibres, which grow into the tissue, binding together the divided ends of the muscle. The poly- nuclear cells that have appeared as independent protoplasma masses and do not lie within the fibres (6, d), do not, it seems, take part in the Fig. 1559. Regeneration in Striated Muscle Tissue. (Ziegler.) formation of new muscular tissue uuless they afterwards become con- nected with one of the muscle-buds. The regeneration of unstriped muscular tissue follows the same law, but in man is generally very imperfect, and a loss of substance in the muscular coat of the stomach or intestine is always repaired by a development of cicatricial tissue. In lower animals, however, karyokinetic cell-division of unstriped muscle fibres has been clearly demonstrated. Nervous System.—Regeneration of the central nervous system does not seem to occur to any great extent. Clinical as well as experimen- tal evidence is at hand to show that wounds of the brain are only partly 40 WOUNDS AND WOUND-TIiEATMENT. closed by tlie development of new tissues, and that larger defects are never entirely covered. The neuroglia is no doubt responsible for the regenerative activity displayed in brain substance, as the karyokinetic changes in the nuclei of its cellular elements show. Most observers, however, agree that karyokinetic figures are also seen in the nuclei of the ganglia cells. While it is held by some that such cells do not then further divide, it is asserted by others that the later stages of karyoki- nesis, resulting in complete final division, can be demonstrated in the embryo in the course of development, and in the adult after traumatism. The reparative processes after section of peripheral nerves have been most carefully investigated. After division of a nerve its distal part degenerates in all its ramifications, and is finally replaced by new fibres growing from the proximal portion into the degenerating distal end, or, at least, along the path marked out by it. This is the general mode of regeneration when the divided ends are separated from each other by some distance, however small. Primary union in peripheral nerves, if at all possible, is certainly of very rare occurrence in man, when we take primary union in the path- ological, not in the clinical sense, meaning by it an immediate union of the divided ends without degeneration. Experimental proof that the latter is not often met with is not wanting. When the sciatic nerve of the rabbit is divided only in its central portion, and the continuity of the entire nerve is, therefore, not disturbed, degeneration of the divided fibres on the distal side of the section nevertheless occurs, although it would appear that the conditions for primary union in this instance were the very best. Even clinical experience pointing to primary union of nerves must be accepted with some reserve. The return of sensibil- ity immediately, or very soon, after section of a nerve may take place through collateral nerve branches, and a really existing paralysis of small muscles, especially in the hand and arm, may be so disguised by the combined action of neighboring muscles, that a too hasty assumption of primary union may have been made in some of the cases reported. As regards the proximal end of the severed nerve, it is still an open question whether or not regeneration begins at the line of section, or at a little distance, one or two centimetres, above it. Even in the first in- stance the extreme ends of the fibres degenerate as far as the first or sec- ond constriction in the sheath of the nerve. The first microscopical changes indicating regeneration are observed in the axis cylinders, which swell and separate into several branches at their ends. The latter lie within the nerve sheaths, which occasionally also contain remnants of the old fibre. As they grow in length they perforate the sheaths and spread out in the connective tissue or endoneurium surrounding the latter. Finally they also perforate the perineurium and epineurium. The proximal end of the divided nerve is thus converted into a mass of new nerve-fibres, evenly distributed throughout the connective tissue. During this stage the new axis cylinders have also received new sheaths, most probably derived from the nerve cells lying within the old sheaths, which have begun to multipty and show karyokinetic nuclear changes. It has been suggested by some that the new axis cylinders are them- selves developed from these proliferating cells. But it is more likely that the mode of regeneration from the original axis cylinder, above described, is the general one. Meanwhile the space between the ends WOUNDS. 41 of the divided nerve has been filled by granulation tissue, and into this the young nerve fibres now grow. The result of their exertion to reach the distal end through the intervening tissue is dependent on the den- sity of the latter and upon the distance which has to be travelled. Five centimetres is mentioned as the limit, hut occasionally a distance of two centimetres is sufficient to prevent union, and then the ingrowing nerve fibres are lost in the surrounding tissues and do not reach the peripheral end of the nerve. But when they do meet it, the remaining nerve sheaths, containing the products of degeneration of the old nerve fibre, simply indicate the paths along which the further development of the new fibres proceeds. It is not likely that the new fibres enter the old nerve sheaths on the distal side. The majority again perforate the epineurium and perineurium, and then, continuing on their way toward the periphery, become so grouped that they more and more take on the appearance of normal peripheral nerves. The time occu- pied in the regeneration varies from one to twenty months. Bone and Cartilage.—The regenerative power of cartilage is very small, that of bone very large. Loss of substance in cartilage is gen- erally repaired by the interposition of connective tissue. The regener- ation of bone has been very carefully observed during the healing of subcutaneous fractures. The production of embryonic tissue is here due to an activity in the periosteum and in the marrow at the seat of fracture. The nuclei in the cells of these tissues show karyokinetic changes a few days after the lesion, and very soon a generous formation of embryonic tissue is observed, especially from the innermost or osteo- blastic layer of the periosteum. This embryonic tissue is ultimately transformed into osteoid tissue resembling in all respects normal bone tissue. The change takes place in the following manner: A homoge- neous or finely fibrillated ground substance between the formative cells at first appears, derived, in part at least, from the protoplasm of the os- teoblasts. Further on, this mass becomes impregnated with lime salts, and, after the disappearance of the greater number of osteoblasts, arranges itself around such as remain in lamellae, thus assuming the microscopical appearance of normal bone tissue. The impregnation with lime salts does not, however, occur uniformly throughout all the embryonic tissue, and those parts which are not transformed into osteoid are transformed into medullary tissue. Occasionally the em- bryonic cells furnish cartilaginous tissue, which is also finally trans- formed into bone. All these various transformative processes can be observed in one and the same fracture. At the end of the second or third week the ends of the bone are united by a mass of spongy tissue lying beneath the periosteum and within the medullary canal, which gradually becomes more firm by the apposition of more osteoid tissue. We speak, at this stage, of an external, an internal, and an intermedi- ary callus, the first two derived from the periosteum and medullary tissue respectively, the intermediate callus being considered a product of both, or, by some, of the periosteum only. This provisional callus is to a great extent absorbed during the following months, the absorption occurring simultaneously with apposition of new osseous material in other parts of the callus. Absorption and apposition follow certain laws and do not occur at random. The former takes place at those points at which, from the nature of the displacement always present to 42 WOUNDS AND WOUND-TREATMENT. a greater or less extent, new bone is not needed; the latter where greater firmness is required—at those points of the callus through which, for example, the weight of the body is transmitted. In most cases of fracture the continuity of the medullary canal is ultimately re- stored as a result of absorption in the callus, even when the displace- ment has been considerable. II. Wound-Treatment. 1 The technique of wound treatment has, during the last ten or fifteen years, become more complicated by the general adoption of the antisep- tic system. Much detail work has become necessary, the exact per- formance of which is alone a guarantee of good results. It matters not, however, how great the changes in the practical application of the method, first described by Sir Joseph Lister, have been during these years, the great principle involved in it remains unchanged. It is ow- ing to this fact that the older methods of wound-treatment have at last become obsolete, and that the advocates of the open method, of the treatment by occlusion, and of other similar methods, who were for a long time opposed to the antiseptic principle, have disappeared. The theory, if not the practice, of wound treatment has, therefore, cer- tainly been simplified. Whatever may be the nature of wounds, whether they be incised, contused, lacerated, or punctured, whether they be surgically clean or infected, the principle that primary or fur- ther infection must be avoided during our manipulations will always obtain. Great, indeed, have been the modifications in the original “ aseptic method” of Lister during the years since its publication. They have been brought about by a correct recognition and a further devel- opment of the great principle involved. On a sound theoretical basis, progress in the practical application of a method must be rapid and sys- tematic, and, accordingly, the advance made in the treatment of wounds during late years forms a marked contrast to the many attempts at rational treatment before the days of universal acceptance of the germ theory as the cause of all surgical ills. When Lister first published his new method he termed it the “ aseptic method,” to distinguish it from the other methods then in use, such as the open treatment of wounds, the treatment by occlusion, and the treat- ment with antiseptics,2 which were included among the “antiseptic methods.” Even at that time it had been abundantly proven that the older plans owed their successes to some antiseptic measure of which they were the unconscious exponents, and many of their failures to a lack of uniform application of the antiseptic principle. Thus, for in- stance, the open treatment, by permitting the free access of air, or more correctly of the oxygen therein contained, to wound surfaces, prevented fermentation, and by furthering evaporation and concentration of the secretions, retarded the growth of almost all forms of micro-organisms. But the opportunities for infection from other sources were so many that the good effects of these measures were simply a matter of chance, and did not become apparent with any degree of certainty. In those days the 1 For the classification of wounds and their special treatment, see Mr. Bryant’s article on Wounds, in Vol. II. 2 See Yol. II., p. 42. WOUXD-TREATMENT. 43 “ aseptic method” of Lister stood forth in hold relief against all these others, and it cannot be too frequently insisted upon that it was the first based in all its particulars upon the germ theory of infection, and con- sequently the only method which, in a systematic way, sought to pre- vent the entrance of micro-organisms into wounds. In the course of its further development it has come to pass that the words “antiseptic” and “aseptic” are used in a somewhat different sense from that which they at first imparted. Other methods than those based on the anti- septic principle are now no longer recognized. There are two ways of rationally applying this principle in wound-treatment. Following the one, we attempt to destroy all living germs deposited on instruments, upon the hands of the surgeon, the dressings, and other articles that are brought in contact with wounds, by subjecting them to sterilization by heat or chemical agents. When this has once been thoroughly accom- plished, the further use of antiseptics is discontinued, and care is espe- cially taken that these are not brought in contact with the wound itself. Such methods are termed aseptic. When, however, we con- tinue the use of chemical germicides during operations by irrigating the wound surfaces with antiseptic solutions and by immersing our hands in the latter, when we employ dressings impregnated with them, and when during the further treatment we take similar precautions, we are employing “antiseptic” methods. The first is certainly the ideal form of wound-treatment. If we can accomplish the same by both, that method which does away with the irritating effects of strong antiseptics upon wound surfaces deserves preference. It follows from what has been said that we would to-day include Lis- ter’s original aseptic method among our modern antiseptic methods. It will be of interest in this connection, to follow the changes which have taken place in the latter until the systems in use to-day have been de- veloped. Not many years after Lister’s publications, attention was called to the great inconvenience of the spray during operations and the application of dressings. So great had been the improvement in the results of wound-treatment since the Listerian method had been adopted, and so firm had the belief in all its details become, that it seemed a hazardous proceeding to discard one of the latter, deemed by its in- ventor of the greatest importance. Lister’s method was based on the assumption that infectious germs were everywhere suspended in the air, and that it was necessary, in order to render them harmless, to destroy them by some antiseptic in the shape of spray, before they should fall upon wound surfaces. When the great drawbacks of the spray, the drenching of both patient and surgeon, the interference with close ob- servation on the part of the latter, and particularly the cooling off of the patient during certain critical operations, became apparent, the question of its real worth was more critically approached, and experi- ments were made to test the efficacy of the spray in preventing the en- trance of active germs suspended in the air into sterilized culture tubes. While these demonstrated that some influence was undoubtedly exerted upon the growth of germs which had passed through a cloud of spray, they also showed that the vitality of these germs was not entirely destroyed. About at the same time Trendelenburg, and also Bruns, had found that the results of antiseptic treatment were equally good, whether the spray was used or not. Now it is a well-established fact 44 WOUNDS ANI) WOUND-TREATMENT. that after rain the atmosphere contains fewer micro-organisms than before it, due in part to precipitation of the floating matter to the earth. The spray acts in a similar manner. It carries along the im- purities in the air and deposits them upon the wounds, and it thereby apparently adds an element of danger to the method. In one way, however, it proves efficient. It keeps the wound surfaces covered by a thin layer of antiseptic fluid, which is in reality the equivalent of continuous irrigation. That the real value of the spray was due to this factor, was recognized by those who advocated its discontinuance, and it was by their efforts that it was gradually superseded by frequent irrigation of wounds, as a part of the antiseptic system. As we have said, the results following this change were in no wise altered for the worse. It stood to reason that thorough irrigation, occasionally re- sorted to during the progress of an operation, would be more effective in removing particles that had settled on wound surfaces and were but loosely attached to them, than the spray. During the last few years a great deal of time and labor has been spent in determining the nature and the number of germs suspended in the atmosphere. A given quantity of air has either been passed through a long tube coated with some culture medium upon which the germs are deposited during its passage, or such culture media have been liquefied, and the air has been forced through them in appropriate ves- sels, where, after solidification of the media, the germs develop as individual foci, and can easily be counted. More recently still, air has been filtered through sand, which is then mixed with the medium with a similar object in view. With the assistance of these methods it has been shown that the number of suspended germs varies greatly with the locality in which the experiments are made, with the disturbed or quiet condition of the atmosphere, and with the amount of moisture de- posited on the surrounding objects. I have already referred, in proof of this assertion, to the fact that after rain has fallen the atmosphere con- tains fewer particles in suspension than before. Petri, who examined the sewer-gas of Berlin at several points of the subterraneous canal, found scarcely any micro-organisms in the air. It can, furthermore, be easily demonstrated that samples of air taken from one and the same room contain more germs after the dust on the floor and the walls has been stirred up, and that these additional germs again settle down very rapidly in a few hours, if allowed to do so. Lastly, if really a practical demonstration of such a fact is necessary, it has been experimentally shown that moistening floors very materially interferes with the raising of dust-particles, and consequently of germs, into the atmosphere, and that even the strongest currents of air passing over liquids which teem with unknown numbers of micro-organisms, are unable to carry away in suspension any of the latter. All these data have been turned to advantage in the development of the aseptic system, and I shall refer to them again. They show the varying numbers of germs. But it is of even greater importance to ascertain their nature. In this respect it is very gratifying to the surgeon to know that very few pathogenic germs have been discovered in the air. Fungi and non-pathogenic bacteria are the varieties generally found in suspension. It is true that in the air of hospital wards the number of the former is somewhat increased, and it would not be wise, therefore, to disregard entirely WOUND-TREATMENT. 45 their presence. We can understand that in such operations as the opening of large joints or the cranial cavity, even the entrance of very few germs might be the source of much mischief, and it will not be amiss, on this account, to avoid increasing the number already in sus- pension by unnecessary manipulations in the operating room shortly before an operation. If we take this precaution, we may safely disre- gard the possibility of infection from this source in all surgical work. It has been estimated that about sixty or seventy germs are deposited upon a wound surface of sixteen square inches, in the course of half an hour, at von Bergmamvs Clinic, in Berlin, during the clinical hours. Bemembering how few of these are pathogenic, and remembering also the power of healthy tissues to inhibit the development of germs, espe- cially when present in small numbers only, the relative insignificance of their presence will become apparent. The dangers from this source are small when compared with those that threaten from infection when im- perfectly sterilized instruments and hands are brought in contact with wound surfaces. A minute quantity of pus in the furrows of a forceps, or under the nails of the operator, may contain many thousands of germs, and very likely of the pathogenic variety. It is further evident that the probability of an infection is greater when impure objects are introduced and brought into frequent and close contact with wound surfaces, than when a few germs settle very superficially on the latter. The most important factor in wound-treatment is, therefore, the avoidance of contamination by direct contact. All improvements in our methods must be based on this one consideration: how to render aseptic in the most convenient manner all objects which come in contact with wounds. Disinfection of Hands and Field of Operation.—In 1882, Wat- son Cheyne wrote: “It is unnecessary to wash the skin with soap and water, or with alcohol or ether, as is often done in Germany.” This applied to both the hands of the operator and the seat of operation. Cheyne assumed that the affinity of carbolic acid for the skin caused it to penetrate the latter, where it would then destroy the germ? lying in the folds and the grease of the epidermis. Although such an opinion was expressed by one most competent to judge, I think we shall not err in assuming that even at that time most surgeons began the disinfection of their hands and the seat of operation by a thorough washing with soap and water, before submitting them to the action of an antiseptic. It was, nevertheless, the opinion then held that a thor- ough rubbing with a 1-20 or 1-10 carbolic solution was more effective than washing with soap and water, whereas to-day we are ready to assume the reverse. In 1885, the experimental method was for the first time applied to determine the germicidal power of various anti- septics after thorough washing with soap and water. Carbolic acid, boric acid, corrosive sublimate, and other disinfectants were tested by Forster in these experiments with culture-media. He came to the con- clusion that corrosive-sublimate solutions alone prevented the develop- ment of germs. Shortly afterwards Kiimmel, and somewhat later Fuerbringer, repeated these experiments in a more satisfactory manner. They directed attention to the folds and fissures of the skin, and more especially to the subungual space, as places which harbor impurities, 46 WOUNDS AND WOUND-TREATMENT. and they also showed how difficult a task it was to dislodge the latter by mechanical means. It was a notable fact, which Kiimmel first observed, that the same method of cleansing and sterilizing his hands would not in one instance interfere with primary union of wounds, but would invariably in another lead to the development of at least a few germs in the culture-media. We may very correctly conclude from this that not all the germs upon our hands are pathogenic, and also that the living tissues under normal conditions can pre- vent their further development. The question, whether or not sterilization of the hands soon after their contamination with septic material is possible, is one of grave importance to the surgeon and obstetrician. Kiimmel came to the conclusion that under ordinary cir- cumstances a thorough cleansing with soap and water, followed by im- mersion and rubbing in a 6-1000 solution of thymol, a 1-1000 solu- tion of the bichloride, or a 3-100 solution of carbolic acid, was a sufficient guarantee for all practical purposes. In order to prevent with absolute certainty any development in culture-media, however, it was found nec- essary to use a 5-100 solution of carbolic acid, or a mixture of equal parts of chlorine water and water. But, when the hands had been infected at the post-mortem table, or by a septic wound, then the above method was not sufficient to accomplish complete sterilization, and this was only attained after washing the hands for five minutes with soap and water, and then for two minutes in the chlorine-water solution. To Fuerbringer undoubtedly belongs the credit of having first called the attention of surgeons to the necessity and the difficulty of thorough disinfection of the fingers in the vicinity of the nails. Even after most careful application of the then known methods of disinfection, Fuer- bringer was always able to obtain cultures from scrapings taken from beneath the nails. The result of his researches was that much more -effective sterilization was possible, when the hands after cleansing with soap and water were immersed in alcohol, before an antiseptic was ap- plied to them. He gives the following as the best mode of disinfection: After thorough mechanical cleaning of the nails, which ought always to be cut very short, the hands should be Avaslied for one minute with soap and water; then for one minute more in alcohol (not less than 80 per cent.); then the alcohol is allowed to evaporate and the hands are im- mersed in the antiseptics (3-100 carbolic acid or 2-1000 corrosive-subli- mate solution) and washed well for another minute, using sterilized nail- brushes for all these manipulations. Some doubt has been expressed as to the efficiency of alcohol, and it has been asserted that it makes the skin brittle and deadens sensation. These exceptions do not, however, appear to be well taken, and it must be regarded as an idiosyncrasy if alcohol so unfavorably affects some hands, something that is true of other disinfectants to a much greater extent. The different effect of carbolic acid and of sublimate on the skin of different individuals is too well known to need repetition. Geppert has shown that chlorine is one of the most powerful germicides, and consequently recommends it for the disinfection of hands. A paste containing chlorinated lime is rubbed into the hands, and these are then placed in a 2-per-cent, solu- tion of hydrochloric acid, where they remain for two minutes, until the separation of chlorine ceases. They are then washed in a solution of hyposulphite of sodium, and finally in sterilized water. This method, 47 WOUXD-TREATMEXT. although adopted by a few, has never found general favor. It is very efficient, but rather complicated. Others have recommended that the hands should be rubbed with gly- cerin or lanolin as a preliminary measure to sterilization, in order to soften the epidermis and make disinfection more effective. It does not seem that this plan has much to commend it. Kelly has lately de- scribed a method of hand-disinfection, based upon experiments, for which he claims superiority over the methods of Kiimmel and of Fuer- bringer. It is the following: The hands are scrubbed, with especial at- tention to the nails, in water of 104° F., which is frequently changed. They are then immersed in a solution of permanganate of potassium, made by adding an excess of the salt to boiling distilled water, until they are mahogany or black in color, when they are thrust into a saturated solution of oxalic acid until completely decolorized. The oxalic acid is finally removed by washing in distilled water. This method has been improved upon by immersion of the finger-tips, after the oxalic acid treatment, in peroxide of hydrogen, followed by a bath of the whole hands for three minutes in a solution of corrosive sublimate, 1-1000. Mikulicz thinks a combination of antiseptics more powerful than one alone. After cleansing the nails carefully, he washes the hands for three minutes with soap and water; then for half a minute in a 3-100 solution of carbolic acid, and finally in a sublimate solution, 1-2000. For laparotomies the strength of the carbolic lotion is raised to 1-20. The skin about the nails, more especially the subungual spaces, are rubbed with 10-per-cent, iodoform gauze, which has been moistened in 5-per-cent, carbolic acid. From all this experimental work, it will be somewhat difficult to select the safest and, at the same time, most convenient method. Several points have, however, been made clear by these investigations. It is insufficient to simply wash our hands in soap and water, even if this be repeated several times, giving them a final ablution in sterilized water. On the other hand, thorough washing with soap and water is the most important phase of disinfection. Not all hands permit of thorough disinfection with the same ease or difficulty. After each operation the surgeon should wash his hands with soap and water before again disinfecting them with an antiseptic, previous to further surgical manipulations. Infected hands are more difficult to sterilize than hands which have not been in contact with infectious material for some time. Of all the methods, Fuerbringer's seems to give suffi- oient guarantee of complete disinfection and to be the most simple in its application. Other parts of the body are less difficult to sterilize, if we except the cavities of the mouth, nose, rectum, and vagina, which cannot be ren- dered aseptic. To prepare a patient for operation, a bath, or a prolonged washing of the seat of operation with soap and water, if the former is out of the question, ought to be given some hours before, and the part should be shaved, not with a view of removing only the hairs, but also the su- perficial layers of epidermis, which enclose myriads of germs of every description. To assist in removing gross impurities the skin may now be rubbed with ether or alcohol, preferably, in my opinion, with the former. Next they should be covered with a moist antiseptic dressing (bichloride, 1-1000) which is only to be removed on the operating table. 48 WOUNDS AND WOUND-TliEATMENT. It is a vain attempt to sterilize mucous surfaces, even the vagina, which is most accessible. If this were possible, other considerations should here prevent the use of strong antiseptics, namely, their irritating qualities and the readiness with which they are absorbed. The use of warm water and soap, and of frequent irrigations with sterilized water or Thiersch’s solution, are the safest and most effective methods of cleansing mucous membranes prior to operations. Great care should be taken to have the brushes, used in disinfecting hands and skin, in an aseptic condition. New brushes should be cleaned with soap and water and then boiled for a few minutes. They are then placed in a 1-2000 sublimate solution, and are kept there until used. W7hen they have been once soiled—in cleaning the hands, for example, after operations in septic cases—they should again be care- fully disinfected, which can only be accomplished by boiling them. Wooden brushes will stand repeated boiling for a few minutes, for some time. It should not be omitted, as simple disinfection with antiseptics has been experimentally proven inadequate to the removal of septic matter from between the hairs of the brush. It has been asserted that sterilization with boiling water or steam is sufficient, and that it is un- necessary to keep brushes in antiseptic solutions. In hospital practice it is certainly wise to do so. We are sure of one thing: in the solution they will remain aseptic until used. Sterilization of Instruments.—Instruments can be sterilized by im- mersion in antiseptic solutions, or by heat. The former was univer- sally adopted until it became evident that the latter possessed many advantages. The first advance upon the plan of Lister, by which instru- ments were simply placed in a trough containing a carbolic solution, 1-20, was a recognition of the fact that in this instance, also, mechani- cal cleansing was a most important part of the entire process of steril- ization. To facilitate this as much as possible, care is now taken in the manufacture of instruments to avoid all uneven surfaces, indenta- tions, and furrows. Smooth metal handles, and instruments made of one piece of metal, are now used in preference to those with wooden handles. If these are carefully brushed and washed, they are well-nigh sterilized by this procedure alone, especially when subjected to an addi- tional rubbing with ether or alcohol. If they be next placed for one minute in either a 1-20 solution of carbolic acid, or a 1-1000 solution of sublimate, they will give no cultures when thrown into culture- media. But if they have not been subjected to the mechanical proced- ures above detailed, an immersion of from at least ten to fifteen minutes in antiseptics will be necessary to attain the same end. Here I must give a caution against implicit faith in these culture-tests. Some of the antiseptic, still clinging to the surface of the object brought in contact with the media, may prevent the development of germs that have not been removed by the process of sterilization. We have seen that their value in determining absolute sterilization of the hands is also doubtful. If we can sterilize by heat, this plan is, therefore, always to be pre- ferred. It is impossible in the case of our hands, but it is really sur- prising that it should have taken so long to establish this procedure as the only rational one for the sterilization of surgical instruments, when it had long been employed for a similar purpose in bacteriological WOUND-TREATMENT. 49 laboratories. Dry sterilization of instruments was at first tried, from a desire to prevent rusting. The disinfecting power of dry heat is far below that of moist heat, but this deficiency, it was believed, could be fully made up by a higher temperature. A number of apparatuses, in which instruments could be heated to 150-180° C., were now con- structed. But many drawbacks to this mode of sterilization became apparent, as it was more frequently employed. Just what it was sought to avoid occurred; when heated to a high degree, instruments became rusty during cooling. The temper of the metal also became seriously affected. Steel lost its hardness and, as a result of this, cutting instruments became dull. But the main objection to the method is the time Which it consumes. It is not an easy matter to raise a metal sterilizing oven to an even temperature of 150-180° C., and after rapid heating widely varying temperatures may be registered at different parts of the apparatus. All these disadvantages connected with dry sterilization were influ- ential in stimulating investigation in the direction of the application of moist heat for sterilization of instruments. Redard found that steam under pressure at 110° C. absolutely sterilized instruments in from ten to fifteen minutes, but that sterilization by boiling liquids could only be accomplished at a temperature of 120° C. He made many attempts at compounding a liquid “which should boil at 120° C., should be cheap, not poisonous, and not inflammable, should not emit any odor during ebullition, and, above all, should not harm the instruments.” He ex- perimented with glycerin, olive oil, and castor oil, but found these unsuitable for his purpose. He ultimately decided upon a mixture of forty parts of calcic chloride and sixty parts of water, which boils at 110° C. But Redard did not turn these results to any further practical use, believing in the superior efficacy of steam, on which principle he constructed a somewhat complicated apparatus. Many other appara- tuses for sterilization by steam have also been constructed, but, as the method has now been generally abandoned, I will not mention them. It appears that Davidsohn, a pupil of Robert Koch, first emphasized the advantages of sterilization by boiling, but to Schimmelbusch be- longs the credit of having definitely introduced the method into surgi- cal practice, after a series of experiments in von Bergmann’s Clinic, which demonstrated its simplicity and at the same time its efficiency. Instead of pure water Schimmelbusch recommends a 1-per-cent, solution of plain washing-soda. This has a double purpose. It intensifies the sterilizing power of boiling water by removing grease and dirt from the surface of instruments, and it absolutely prevents rusting. In- struments of proper construction, that is, with smooth surfaces, when thoroughly clean, can be sterilized by boiling for only five minutes in such a solution.1 It is quite immaterial whether instruments are boiled in special apparatuses or simple enamelled dishes or pots. In private practice the simpler a surgeon’s outfit the better, as long as the instruments are sterilized immediately before operation. It does not seem a wise procedure to sterilize instruments at home, to convey them to the patient’s house, and to assume that everything has been 1 Care should be taken to secure the necessary concentration of the soda-solution (one per cent.), as otherwise the instruments will suffer ; and it is well to remember that commer- cial soda is frequently adulterated to a large extent with ordinary salt and other ingredients. 50 WOUNDS AND WOUND-TREATMENT. done to guarantee perfect asepsis. This is the practice of some well- known surgeons. I do not contend that it is impossible to have absolutely clean instruments by this process, but the necessary manip- Fig. 1560. Rotter’s Portable Sterilizer for Instruments. ulations in drying and packing them away certainly add an unnecessary element of danger. And there is no analogy between instruments and dressings in this regard, as the latter can be transported in the very vessels in which they are sterilized, which need only be opened at the operation itself. It would be useless to enter upon an enumeration of Fig. 1561. Schimmelbusch’s Sterilizer for Instruments. ordinary commercial articles that may be used in the boiling of in- struments. A very good and simple way is to boil them in an enam- elled pudding-dish, using a similar dish, inverted, as a cover. Then, WOUND-TREATMENT. 51 after they are boiled, the surgeon needs two sterilized dishes for use dur- ing the operation. A compact apparatus for private practice has been described by Rotter. It is about three inches deep and a foot long, and contains three metal boxes with covers of various sizes, a folding stand, and an alcohol lamp. In using the apparatus care should be taken to make the soda solution with very hot water, so that it can he raised to the boiling-point in a very short time. It is safer to allow the alcohol to burn away, rather than attempt extinguishing it with the cover, and with a little experience it is easy to estimate the amount of alcohol necessary to keep the solution at the boiling-point for five or ten minutes. Other apparatuses have been devised of late for the simultaneous sterilization of instruments and dressings, but separate sterilization is preferable. For hospital-work, the large, non-portable sterilizers, which are heated by gas, answer a better purpose, as they can be kept heated and thus insure rapid sterilization of instruments between operations. With few modifications the idea of Schimmelbusch’s apparatus has been retained in their construction. This apparatus consists of a metal box (c) into which the soda solution is poured, one inch deep. Into this box, which is closed by a lid, perforated trays (e) can be placed, which hold the instruments to be sterilized. They are introduced into the apparatus as soon as the water begins to boil, and are allowed to remain for five minutes. They are then removed from the box by the wooden handles at each side, and are placed in a pan (/), which is filled with cool sterilized soda solution. The pan has also been previ- ously sterilized in the apparatus. The lid of the box fits into a groove (a) whch is filled with water, and thus closes hermetically. This prevents evaporation during ebullition, and raises the temperature of the solution to 104° C. Sponges and Mops.—Much difference of opinion seems to prevail in regard to the difficulty of rendering sponges aseptic. Some sur- geons, notably Kummel, have considered this a very easy task. Kum- mel says that when sponges have been thoroughly washed with warm water and soap for three or four minutes and are then placed in either a 5-per-cent, carbolic-acid solution, in chlorine water, or in a 1-1000 sublimate solution for one or two minutes, they will be disinfected with absolute certainty. But, in view of other testimony, this can no longer be accepted as true. The quality of a sponge has, doubtless, much to do with the ease with which it can be rendered aseptic. If in the process of preparation the sarcode, or gelatinous material, which covers the sponge and has fully penetrated its framework, is entirely removed, the antiseptics can more readily come in contact with all parts of the latter. In this respect it has been demonstrated that a dense-textured sponge is more difficult to sterilize than one witli a wide meshwork. The latter are cheaper, but have the disadvantage that loose pieces are frequently attached to their surface, a defect which becomes more noticeable with continued use. It is advisable, therefore, to use an open-textured, cheap sponge, but to use it only once. Neuber uses sponges in this way, but also includes them in the dressings of the case in which they have been employed. It is regrettable that sponges are so unfavorably influenced by heat. It is true that dry 52 WOUNDS AND WOUND-TREATMENT. lieat will sterilize a sponge in a few hours, but, if great care is not taken to have the sponge perfectly dry, it will shrink and become hard. The same objection can be urged against boiling them, which causes them to assume a dark-brown color, to shrink very much, and to lose most of their absorbing power, and when dry they will become per- fectly hard. Absolute sterilization is, therefore, owing to the structure of the sponge, impossible. But we can come very close to perfection by care- ful preparation. Sponges should be well beaten, to free them from sand and other gross impurities. They should then be placed and re- main for some time in cold water and be repeatedly manipulated, to free them from any further impurities. If it then seems desirable to bleach them, this is most readily accomplished by immersion for a few minutes, first in a solution of permanganate of potassium (one ounce to two quarts of water), and then in an oxalic-acid solution of the same strength. They are now washed in water and are ready for disinfec- tion. For this it is not sufficient to place them for a short time in either a 5-per-cent, carbolic or a 1-1000 sublimate solution. They should remain in one of these solutions, preferably the latter, for several days. Before being used they are put in sterilized water. Schimmelbusch recommends that before being thrown into the anti- septic solution, they should be immersed for half an hour in a 1-per- cent. soda solution, which has been raised to the boiling-point, but which has been removed from the fire before the sponges, wrapped in a cloth and wrung dry, are suspended in it. If sponges must be used a second time, they ought to be carefully cleaned, to free them from the fibrin which they have taken up, and which is only removed from the mesliwork with much labor. It still seems that Lister’s plan of placing the sponges for some days in a tank containing water, thus allowing the fibrin to decompose, when it can be easily removed, is one of the best. Then they may again be sterilized as new sponges. In most operations, we can, however, discard sponges altogether, and the substitution for them of small pieces of gauze, or of several layers of gauze sewed together in the shape of a flat sponge, or of cotton sewed into a small sack of gauze, has of late become very popu- lar among surgeons. All these are sterilized by steam, as I shall hereafter describe in speaking of dressings. The small sacks contain- ing cotton are thrown away after being used, but the pieces of gauze can be readily cleaned and re-sterilized. They become rather softer after frequent use, and absorb more readily, and can very conveniently be folded together in any way to suit the occasion. They can be held by dressing forceps, and thus may be used to mop up deep cavities with as much ease as sponges. The most convenient size seems to me from experience to be about eight inches square. The only drawback to their employment is the rather large supply of them which a major operation necessitates. They ought to be used dry, and not moistened with antiseptics, and in consequence thereof they must be laid aside when once saturated with blood or other fluids. Aseptic Ligatures and Sutures.—The materials generally used for this purpose are catgut, silk, silver wire, and silkworm gut. Wire and silkworm gut are readily sterilized by boiling, as they are both imper- W 0 UN D -TKE ATMEXT. 53 meable to moisture. It will, therefore, suffice to boil them before every operation during live or ten minutes in a 1-per-cent, soda solution, as has been recommended for the disinfection of instruments, and to pre- serve them, when once they are aseptic, in absolute alcohol until used. This will prevent them from becoming contaminated with germs that might resist the sterilizing effect of boiling when this has been limited to only five or ten minutes. The sterilization of catgut and silk is a much more difficult under- taking, more especially the preparation of aseptic catgut. Only a few years ago it seemed as if we should be compelled to entirely abandon the use of the latter, so utterly impossible was efficient sterilization by the then known methods believed to be. But we are now fortunately convinced of the contrary. It was undoubtedly an advance in the preparation of gut, when Kocher described his method with juniper oil, in which he placed the raw material for twenty-four hours before preserving it definitely in 95-per-cent, alcohol, and this mode of prepara- tion soon replaced those recommended by Lister for carbolized and chromicized catgut. The new gut was extensively used, until it was shown by scientific methods that the procedure by which it was pre- pared was quite incapable of producing an aseptic material. Catgut is absorbable, and for this reason it is almost indispensable in surgical practice. It is precisely this quality, however, which increases the diffi- culty of its sterilization. During the manufacture of the raw material from sheep’s gut, where no precautions whatever are taken, it is evi- dent that many impurities may find their way into the substance of the threads, if they are not already present in the substance of the gut from which the threads are twisted. It is not improbable that a case of anthrax infection from catgut, reported by Volkmann, was due to the presence of spores of anthrax within the substance of the thread. Other germs imbedded therein may also, as the catgut becomes ab- sorbed in the living tissues, be liberated, and, if still active, may de- velop, and cause all the symptoms of wound infection. It is custom- ary to grease catgut during its manufacture, to render it soft and less brittle. This answers an excellent purpose for the manufacture of musical strings, but it ought to be strictly avoided when making sur- gical catgut. This greasing has led to the necessity of placing the gut in ether before further subjecting it to disinfection by chemical aids. The fatty substances are thus extracted, which is important, as they form a very potent barrier to the penetration of watery solutions. When it was shown that juniper oil did not possess sufficient anti- septic power, the bichloride of mercury came into use some years ago, and it is still to-day acknowledged to be by far the best disinfectant for this purpose. Corrosive sublimate has been used in watery and alcoholic solutions for the preparation of catgut. Yon Bergmann uses alcoholic solutions at the Berlin Clinic. His method of preparation is the following: Surgical catgut is wound on glass reels or plates, and placed in ether for twenty-four hours, and then for at least forty-eight hours in a mixture of 10.0 parts of corrosive sublimate, 800.0 parts of alcohol, and 200.0 parts of distilled water, the same being changed every twenty-four hours until it no longer becomes turbid. Then sterilization is said to be complete, and the catgut may be indefinitely preserved in ordinary alcohol of 95 per cent. It is not quite certain 54 WOUNDS AND WOUND-TREATMENT. that this procedure is a guarantee of absolute sterilization. Experi- ments by Braatz have shown that spores of anthrax, adhering to the ex- ternal surface of catgut, can remain in this alcoholic sublimate solution for four days and not lose their vitality, hut that cultures can no longer be obtained when such threads have been suspended in a watery solu- tion of sublimate, 1-1000, for only twenty minutes. There is, there- fore, no reason for the preparation of catgut in alcoholic solutions, if there are no other disadvantages attaching to the use of watery solu- tions. It is true, the textile strength of the gut is considerably affected by aqueous solutions of sublimate, much more certainly than by strong solutions of sublimate in alcohol. This is, however, of minor impor- tance when compared with the question of thorough disinfection. Even if, by the method to be presently described, we produce catgut that occasionally tears, the additional labor during an operation on this account is hardly worth considering. On the other hand, when freshly prepared catgut has lost some of its strength, we may rely on its having been pretty effectively sterilized. The surest mode of chem- ical sterilization, therefore, is the immersion of the gut, after it is taken from the ether, in a 1-1000 aqueous solution of sublimate. It is important that the antiseptic should have uniform access to every part of the gut. If the coils of the latter are tied together with threads, these ought to be very loose, or otherwise the gut, swelling as it im- bibes the sublimate solution, will be constricted at these points and not properly disinfected there. The gut remains in the solution for twelve hours, the fluid being renewed once or twice during this time. Kiim- mel believes that six hours for the finer, and twelve hours for the coarser qualities, will effect certain sterilization. If the gut is not wound on reels, which is a better plan, it will curl in the sublimate and will finally form a mucli-entangled mass of threads, from which, how- ever, the individual threads may be drawn without much difficulty, and may then be wound on sterilized glass reels or plates. Then the gut is placed in absolute alcohol. Sterilization by heat, as everywhere else in the aseptic system, has also been applied to catgut, but in this instance with only moderately satisfactory result. Boiling water and steam in a few minutes convert gut into a shapeless, glutinous mass. After boiling in oil or gly- cerin the gut becomes very brittle, and too much of its strength is sacrificed. Xylol, the boiling point of which is 130-140° C., is recom- mended by Brunner, who states that catgut may remain in it, when heated to 100° C., for many hours without losing any of its essential qualities, and that this is more or less the case when the temperature is raised to the boiling point of xylol. This method would answer well if we could assume that the gut was sterilized by this procedure, but such does not seem to be the case. It is a well-known fact, which ap- plies also to xylol, that oily antiseptic mixtures possess little disinfect- ing power when compared to watery solutions, because they cannot penetrate as well. Another fluid has, however, been employed lately, and, as it appears, very successfully, for boiling catgut, namely alcohol. Boiling alcohol possesses very marked germicidal power. It will more readily destroy the most virulent germs without injuring the quality of the gut than any other antiseptic solution. It rather increases the textile strength of the gut, and it makes it less slippery. It furtlier- WOUNO-TREATMEXT. 55 more extracts the grease, which in the process of twisting has got into the interior of the strands. Fowler and Hodenpyl assert that boiling in 95-per-cent, alcohol will sterilize catgut in one hour. Supported as this method is by experimental proof of its efficacy, it would certainly have been more rapidly accepted by the profession, were it not that the boiling of alcohol is attended by some risk and inconvenience. Fowler lately recommends boiling under pressure. His method is the fol- lowing :— The catgut is cut into lengths, folded, and placed, half a dozen strands or more, in an ordinary four-inch test-tube. This is filled with 95-per-cent, alcohol to within half an inch of the top, and a wad of cotton is pushed into the mouth of the tube, and over this a cork is so placed as to be upon a level with the edge of the tube when its lower end rests against the cotton. Thus prepared, the tubes are placed inverted in a fruit-jar filled with alcohol of a percentage not lower than 95, and the jar is then hermetically sealed and placed in a water-bath. This is heated to slow boiling, and is kept at this point for one hour. The jar must be allowed to cool before being opened. Upon removing the tubes contain- ing the catgut, each one is carefully sealed over the cork by a layer of silicate of sodium. Fowler’s recommendation of boiling in alcohol lias been tested in many New York hospitals and has given entire satisfaction. The dis- advantages of his method are evaporation of the alcohol, which is difficult to prevent, even in tight- ly closed vessels, and oc- casional exposure of the gut to a temperature of 90-95° C., which, if sus- tained for an hour, is lia- ble to injure the material. Dowd for this reason sug- gests the use of a con- denser of copper (Fig. 1562, a) in which lies a coil (b) wherein the va- pors of alcohol are con- densed, returning to the glass jar (c) which con- tains the boiling alcohol. This jar is suspended in a water-bath by means of the end of the coil, which is shaped into a hook (d). The water is heated to such a degree only as will insure boil- ing of the alcohol. The open end of the hook is plugged with cotton. Within the jar (c) are placed three small cylin- drical screw-topped jars (e), which in turn hold the catgut, wound on three reels. These smaller jars are also filled with alcohol, and their Fig. 1562. Dowd’s Sterilizer. 56 WOUNDS AND WOUXD-TREATMENT. covers, fitted with rubber washers, are screwed on. They are then placed in the larger jar, entirely immersed in the alcohol, and are boiled for an hour. On cooling they are taken from the larger vessel, and their caps are tightened and only removed when the gut is to be used. Dry sterilization of catgut has been variously recommended. Rever- din, who was the first to adopt this method, heated the gut for five hours to 150° C. Although it had lost some of its firmness by this process, it was still of good quality. From culture experiments he con- cludes that sterilization for four hours at 140° C. is sufficient. Benckiser, on the other hand, asserts that absolute disinfection of the gut is obtained by a heat of 130-140° C. in from one and one-half to two hours. The material becomes somewhat brittle, but, if it is placed in fluid before being used, it again assumes its normal consistency. One of the latest advocates of dry sterilization of gut is Braatz. After a long series of experiments he recommends heating to 150° C. for forty-five minutes, for which purpose he has constructed a self-regu- lating apparatus, in which the gut is placed in a separate metal box. The box will close hermetically, excluding, as the inventor asserts, “dust and other impuri- ties.” After sterilization the box is opened, what is needed of the gut is taken from it, it is again closed, and can be thus kept for further opera- tions, but how long the author does not state. One of the most impor- tant points in steriliza- tion by heat is that it should, if possible, take place immediately before the articles thus prepared are used. When once exposed, however, they ought to be sterilized again, and it cannot be claimed, therefore that Braatz’s box is a distinct advance toward ideal asepsis. The gut it contains may remain sterile for a long time, and, as its interior has been once thoroughly heated and sterilized, we need not very much fear infection from atmospheric germs. If it does not occur, there is, nevertheless, a chance of infection by direct contact. It is rather against the principle that I contend, the introduction of an uncertain factor into the aseptic system. The method of sterilization by boiling in alcohol seems preferable, therefore, when sterilizing by heat. On the other hand, I am convinced that the method of steriliz- ation in watery sublimate solutions also furnishes a reliable material, and the simplicity of the method certainly is a strong factor in its favor. Silk is sterilized by boiling water or by steam. Neither method in- jures the material, even when frequently applied. It is safest to sterilize the silk before each operation, as preservation in 1-1000 subli- mate solution soon makes the finer qualities unfit for use, and even Fig. 1563. Braatz’s Box for Sterilizing Catgut. WOUND-TREATMENT. 57 affects the heavier threads. Halstead winds silk on glass spools, using about two metres for each. The latter are of such size that eight of them will fill an ordinary glass test-tube, and this plugged with cotton is placed in a steam sterilizer. When sterilization is finished, the spools are poured from the test-tube into a dish containing a solution of car- bolic acid, 1-30. Some surgeons prefer to use the silk in a dry state, after it has been sterilized by steam, claiming that antiseptics will irri- tate the tissues. Silk that lias been sterilized by boiling must be pre- served in some antiseptic fluid, or must otherwise be again boiled before being used. Therein lies an advantage of sterilization by steam, as silk once sterile can be preserved in that state for an indefinite period by the method of Halstead, just described. Dressings.—In no other particular has the aseptic principle exer- cised so beneficial an influence as in the matter of dressings. If materials impregnated with antiseptics have not yet been entirely dis- carded by all surgeons, it appears that this will soon occur. It is true that we strive to-day to accomplish just what Lister had in mind when he described his carbolized gauze dressing, to exclude by means of our aseptic appliances the causes of wound-infection, hut we take greater precautions now to obtain this result during other surgical manipula- tions before the dressings are applied, and not by saturating the latter with antiseptic fluids and by sealing wounds hermetically with imper- meable rubber tissues, as was the custom in the beginning of the anti- septic era. On the contrary, we have learned to regard evaporation of the discharges in the dressings as a very important factor in wound treat- ment. Many, indeed, have been the materials and the antiseptic sub- stances which have been recommended to the profession at various times since Lister’s first publications, for the preparation of antiseptic dressings. To-day we consider the following sufficient for all the needs of the surgeon: I. Dry sterilized gauze (cheese-cloth, tarlatan). II. Iodoform gauze. III. Moist antiseptic dressings. Lister was one of the first to call attention to the merits of gauze as a material for dressings, and, although various attempts have been made to supplant it by other cheaper materials, it seems to possess these merits to such a degree that surgeons in general have never looked on any of the others with favor. It is true that its absorbent qualities are not as great as those of the different varieties of cotton and of wood-wool, hut they are apparently greater than those of other materials, such as turf-moss, jute, and sawdust, which are also in demand as substitutes. The quality of being able to readily absorb wound-secretions has been recognized as a most important one in a good material for surgical dressings, and gauze possesses this quality in a marked degree. It, furthermore, allows evaporation of the discharges which it has ab- sorbed, more readily than most other materials. In one essential point, however, it surpasses all the others: it is especially well adapted to the tamponing of wounds, a form of dressing extensively used at the pres- ent day. It can scarcely be of more than passing interest to mention the methods in use during the past ten or fifteen years for the preparation 58 WOUNDS AND WOUND-TREATMENT. of antiseptic dressings, with the one exception of iodoform gauze, which is still very justly much esteemed. The sublimate dressings so largely employed but a few years ago have now been generally abandoned in favor of plain sterilized gauze, since it has been established that the small amount of the antiseptic in dry sublimate dressings quickly com- bines with the albuminous substances in wound discharges, forming compounds of very doubtful germicidal power. The value of the sub- limate in the gauze as an antiseptic is, therefore, very questionable, unless it is introduced in so large a quantity that it will also cause irrita- tion of the wound-surfaces and possibly intoxication by absorption. To obviate these disadvantages Lister has lately recommended an anti- septic gauze imjjregnated with the double cyanide of zinc and mercury. This salt is insoluble in wound-secretions, and is, therefore, not decom- posed by the latter. It is neither irritating nor poisonous, hut its preparation is unfortunately a very tedious process. We do not. how- ever, to-day look very much to the antiseptic properties of our dressings; we desire them in the first instance to be aseptic. This is not readily accomplished by impregnation with antiseptics. It has been shown that commercial antiseptic gauze frequently contains micro-organisms, even in the centre of the packages in which it appears in the market, and this is readily understood when we recall the various manipula- tions during impregnation, drying, and packing. The moist commer- cial article is, therefore, from this point of view preferable. The best manner of preparing sublimate gauze is the following: Boil the gauze in a solution of washing-soda, in order to remove fatty substances, then soak it in a watery solution of sublimate, 1-500 or 1-1000, to which two parts of chloride of sodium have been added for every part of the mercurial. Then dry and preserve in sterilized vessels. The simplest and at the same time the only certain way of obtaining absolutely sterile dressings, is through disinfection by heat. Dry heat is, we know, much inferior to boiling water or steam as a sterilizing agent, and, as boiling necessitates drying afterwards, steam sterilization has now been universally adopted. It is not much more than ten years since dry heat was exclusively used in the large sterilizing chambers of European hospitals for the disinfection of bedding, clothes, etc., but about that time the superiority of steam in this respect was made apparent by the researches of Koch, and it very soon supplanted dry heat. Bulky articles, exposed for hours to dry heat of more than 100° C., were not at all disinfected in their interior; in fact, it was amply" proven by experiments that the temperature in the middle of such bundles of clothing or other articles never, during their long exposure, reached a point anywhere near that of the air in the apparatus. This is quite otherwise with steam, which when saturated penetrates very quickly. The application of dry heat has another serious drawback, the fact that the high temperature necessary for sterilization fre- quently damages the articles in the chamber. Steam has none of these disadvantages. A great deal of experimental work has been undertaken in late years to determine the conditions under which the sterilizing power of steam is greatest. The following maybe taken as the conclusions arrived at: I. Simple, circulating steam at 100° C. possesses very great disin- fecting power. It kills the spores of anthrax in five minutes, whereas WOUND-TREATMENT. 59 it takes from three to four hours to destroy them by dry heat of 140° C. II. Circulating steam loses much of its disinfecting power when superheated without pressure. When its temperature is 140° C. it is not much more potent than dry air at the same temperature. III. The strongest disinfecting agent is superheated steam under pressure. When used in this way, all air should be expelled from the disinfecting chamber before the steam is put under pressure, as other- wise its sterilizing power will be much reduced. To insure the most rapid and powerful action of steam, the thermometer and steam pres- sure gauge should always correspond in their indications—for example, at 240° F., the pressure ought to be about ten pounds to the square inch; then the steam in the disinfecting chamber will be saturated, and consequently most powerful. In the construction of sterilizing apparatuses for surgical dressings, all these conclusions have been turned to advantage. In large hospi- tals, where a great amount of sterilized material for dressings is re- quired, the somewhat expensive permanent apparatuses employed in some of the hospitals in New York, notably the Roosevelt and Presby- terian, answer an excellent purpose. They work with superheated steam under pressure, and supply absolutely sterile materials. But where simplicity of procedure is imperative, sterilization by circulating steam will be found entirely sufficient. It certainly will put the dressings into fully as aseptic a condition as the means now employed in the sterilization of other things that come in contact with wounds (hands, catgut, etc.), and it will certainly destroy all those germs which are responsible for wound-infection in general. The apparatuses which have been devised for sterilization with cir- culating steam are numerous. It cannot lie within the scope of this article to mention the variations in size and shape to which the inven- tive genius of some surgeons has subjected the original steam-pot of Robert Koch. An apparatus which answers quite well is the familiar Arnold steam sterilizer. Schimmelbusch was, I believe, the first to embody in a practical way the principles of sterilization by circulating steam in the construction of his well-known sterilizer for dressings. It consists in the main of two copper cylinders of unequal size (Fig. 1564), the space B between the two being utilized as a reservoir for water. The latter is filled at M, and the glass tube S indicates the quantity of water in the reservoir. It is sufficient to fill it to about half its capacity. The gauze to be sterilized is placed in metal boxes, shown in Fig. 1564, a' certain number of which fit into the sterilizer. They are provided, at their upper and lower parts, with apertures in the shape of a band which can be opened and closed. These are opened before the box is placed in the sterilizer, to allow the steam to enter. Then the apparatus is firmly closed and heated. The water becoming warm, also warms the gauze before the latter is steamed, which almost entirely prevents condensation of aqueous vapor on its surface. When the water boils, steam passes through small openings at the top of the inner cylinder (not shown in the illustration) into the disinfecting chamber C, and then in the direction of the arrows through the previ- ously heated gauze, leaving the apparatus by the tube B. This in turn ends in a condenser N, filled with cold water, thus preventing the 60 WOUNDS AND WOUND-TKEATMENT. escape of steam from the apparatus, which would be an inconvenience. After the water has boiled for fifteen minutes it can be safely assumed that the steam has reached every part of the gauze, and then steaming should be continued for another half-hour. The boxes containing the dressings are removed while still warm, and, if kept open for a few moments, the aqueous vapor will escape, and the material will be quite Fig. 1564. Scliimmelbuscli's Sterilizing Apparatus for Dressings, Gowns, Towels, etc. dry. Then the covers and apertures are closed, and the sterilized material is ready for transportation or for immediate use as the case may be. In France more especially, sterilization by superheated steam under pressure has been much employed, and sterilizers, resembling in size and shape, and somewhat in construction, that just described, have been constructed. One of the latest is the sterilizer of Sorel, of WOUND-TREATMENT. 61 Paris. (Fig. 1565.) Here also the steam is generated between two cyl- inders, and passes through the tube G and the opening C into the inner chamber A, which contains the dressings. The apparatus is put under a pressure of thirty pounds. There is a safety-valve at L. The stop-cock K answers the double purpose of allow- ing the steam under pressure to escape from the inner chamber after sterili- zation is complete, and, afterwards, when the air in A has been exhausted by the current of water passing through F, of allowing the introduc- tion of sterilized air. This is effected by heating the platinum point of K by the gas-jet H. This brief descrip- tion will suffice to indicate the work- ing of the apparatus. It has the ad- vantage of rapid sterilization. Under pressure of thirty pounds to the square inch, five minutes is said to be suffi- cient. It is possible that sterilization by this apparatus is more certain than by those without pressure. But the latter will rarely fail to destroy all organic life, and are much less com- plicated. Similar apparatuses, more simple in construction and equally efficient, have lately been made in this country. Iodoform gauze may best be pre- pared in the following way : Boil the gauze with washing-soda and, after drying, determine by weight the amount of iodoform to be distributed in a certain quantity of gauze. Saturate the gauze with ether, and wring it out, and in the ether thus obtained dissolve the iodoform. Then place the gauze in the iodoform-ether, and, after it is uniformly saturated, raise it and spread it so that evaporation of the ether may rapidly occur, when the iodoform will be evenly distributed throughout the gauze. Weir’s method is to mix three drachms of powdered iodoform with six fluid ounces of suds, made with castile soap and a 1-5000 sublimate solu- tion. Pour this emulsion over and into two and one-half yards of gauze, which will make a 10-per-cent, iodoform gauze. A simple and good way is to rub finely powdered iodoform into sterilized gauze immedi- ately before using it. We do not get a definite percentage of iodoform in the gauze by this means, but this does not seem to be important. For moist antiseptic dressings, which are occasionally indicated, a 1-5000 sublimate solution or, preferably, Thiersch’s solution (salicylic acid, 2 parts; boric acid, 12 parts; water, 1000 parts) should be em- ployed. Acetate of aluminum in a one-per-cent, or two-per-cent, solution also answers very well in this case. Fig. 1565. Sorel’s Sterilizer for Dressings. Drainage.—The best material for drainage-tubes still is vulcanized 62 WOUNDS AND WOUND-TREATMENT. rubber. Glass and decalcified, absorbable bone tubes, which have been used as substitutes for India-rubber, are not as well adapted for the purposes of drainage as the latter. A drainage-tube should be elastic and flexible, so that it may not exert pressure upon the soft parts through which it passes. The absorbability of bone tubes is, moreover, a very uncertain factor, as pointed out by Neuber himself, the tube sometimes being absorbed too soon, but more frequently lying in wounds an unnecessary length of time Strips of gauze cannot always afford proper drainage for deep wounds. To render India-rubber tubes aseptic, they should be boiled in water for several minutes, and then be placed in a 5-per-cent, solution of carbolic acid, not in sublimate solu- tions. They can be sterilized a few times in boiling water without injury. Bandages, aprons, and towels used during operations should be sterilized by steam in the manner already described for dressings, in preference to moistening them with antiseptic lotions. Care should be especially taken not to apply wet towels immediately to the body of the patient, as in a serious and lengthy operation the loss of heat which this would entail might very perceptibly increase the shock. Dressing Wounds.—I have now described the materials which the surgeon who practises modern aseptic wound-treatment employs. It seems customary of late with writers on this subject to emphasize the simplicity which obtains in the technique of modern wound-treatment, when compared with the original Listerian system. What this asser- tion is in reality based upon, is not apparent. The disinfection of hands and field of operation has become a much* more complicated procedure; our instruments must be boiled, whereas formerly they were only placed in a carbolic solution; and the preparation of sterilized dress- ings, bandages, gowns, etc., and of iodoform gauze, as practised to-day, cannot well be termed a simplification in technique. The state- ment is better made of another part of wound-treatment, namely, the frequency with which wounds are dressed. That infrequent dressing of wounds was desirable under all conditions, was soon recognized in the new antiseptic era, and it has been the endeavor of surgeons to develop this idea in many ways. Even to-day some difference of opinion still prevails as to how this may best be accomplished, more especially in regard to the entire or only partial abolition of drainage in aseptic surgery. Neuber was the first to emphasize the importance of perma- nent dressings (Dauerverbande) and to elaborate, after many years of trial, a system of wound-treatment based upon this principle. That every dressing causes more or less irritation in wounds, and, at least theoretically, exposes the wound to the risk of infection, cannot be denied. That great differences, however, exist in the amount of irri- tation, according to the location and nature of the wound, must also be granted. Thus, for example, a change of dressings soon after opera- tion at the knee-joint, where it is difficult to avoid motion even with the greatest care, will more likely be followed by local or general dis- turbance than such a change after extirpation of a lipoma, say of the back. But, even allowing some individualization in this regard, the principle that strict indications for each change of dressing should exist, is now universally acknowledged. WOUXD-TIiEATMEXT. 63 If we can bring wouncl-surfaces into close approximation, if there has been no undue irritation of the same, and if no infection has occurred during the operation, the chances are that the amount of discharge will be very moderate, if any, and that primary union will follow without drainage. Are we able to guarantee this result, with the modern aseptic treatment of wounds, with such certainty, and are the risks we incur in closing all aseptic wounds so slight, that even careful dress- ing some days after operation, to remove drainage-tubes, must be considered a decided disadvantage? We have seen by what precautions in the preparation for an aseptic operation we may almost to a degree of absolute certainty avoid infec- tion. On the other hand, we know how difficult it is to secure thor- ough disinfection by any other means than by heat, and how true this is, especially of the hands and nails of the operator. Even the most painstaking surgeon will occasionally fall short of ideal asepsis in this regard, and, if infection does not always follow such failure, we must attribute this to the vitality of the body-cells and to other mechanical conditions in wounds, which make them an unfit medium for the development of the germs that have been introduced in small numbers. Still, we believe that even those who have most carefully carried out the treatment without drainage, have occasionally observed wound- infection in a distinct manner. Such accidents may be most surely prevented by thorough asepsis in the first place; in the second place, by avoiding irritation of the wound-surfaces. This is accomplished by clean surgical work, and by abstaining from irrigation with antiseptic fluids. The latter is entirely unnecessary when asepsis has been efficiently carried out during an operation, and it is safe to say that the surgeon who achieves better results by the use of antiseptic irrigation than without the latter, is not a master in this form of wound-treatment. When irrigation of -aseptic wounds becomes necessary to wash out blood-clots or bone chips, for example, this is best done with a physiological salt solution (7-1000), which ought to be boiled before use. It is more for their irri- tating than their poisonous qualities that antiseptics are unsuitable for irrigating purposes. Whenever strong carbolic or sublimate solutions are brought in contact with wound-surfaces, necrosis of the superficial cell-layers follows, and, although this may not become immediately apparent, it cannot but interfere with primary union. The dangers of intoxication with carbolic acid and corrosive sublimate are not as great as they have been said to be by some writers. It is astonishing, at least, that, if real, they should never have been observed by many who in former years used these antiseptics extensively for irrigating purposes. Some surgeons prefer not to irrigate at all, and their results are as good, apparently, as those obtained by others. When once properly disinfected, not a drop of fluid is brought in contact with the field of operation after the first incision has been made. While the surgeon is engaged at one part of the wound, the remainder is covered with gauze, and thus hemorrhage is controlled without ligatures at the time, but eventually, before suturing, the larger vessels are tied. The wound- cavity is then once more firmly packed with gauze for several moments. When this is finally removed the wound will be perfectly dry, and very large surfaces can then be united, using if necessary buried sutures, 64 WOUNDS AND WOUND-TREATMENT. without establishing drainage. It does not seem, however, that the question of moderate irrigation with aseptic fluids, or of no irrigation at all, is one of primary importance. Some individuality seems appro- priate here. In wounds of great depth, where the parts can only be exposed with much effort, and by the use of instruments, a piece of gauze may prove a positive annoyance to the surgeon during his work. In more superficial wounds the plan is a good one. It does not seem, however, that occasional irrigation with a sterilized salt solution should endanger the good results of the dry method of operating (Landerer). Care should only be taken to fulfil the other requisites of the method, to arrest hemorrhage, and to have the wound perfectly dry before suturing. In ordinary cases the arrest of hemorrhage is a most important factor in wound-treatment. Whether this is best accomplished by compres- sion, as already described, or by ligature or torsion of the vessels, is an open question. Both methods will probably always remain in favor. A ligature is a foreign body, which is either absorbed or remains en- capsulated in -the tissues. But if suppuration supervenes, as is now and then the case when the abdominal cavity has been tamponed, the silk ligature may become the cause of long persisting sinuses, which only close when the threads have come away—sometimes after years— a decided disadvantage. Ligatures should, therefore, be applied only to those vessels which cannot be controlled by torsion or compression. Catgut should be employed for this purpose with few exceptions, even though so distinguished an authority as Kocher has declined to further use it, believing that sterilization of the raw material is not always possible. Others have even asserted that the gut is an excellent medium for the development of germs that have accidentally entered wounds. But these arguments cannot weigh heavily when the prop- erty which pre-eminently qualifies catgut for the ligature of vessels, its absorbability, is considered. Moreover, we now know that catgut can be rendered absolutely sterile. In blood-clots which lie in wounds, germs find a very favorable soil for further development. When this occurs the clot is liquefied and disorganized, and escapes from the wound with the secretions. On the other hand, when perfect asepsis prevails, coagulated blood may lie in a wound for many days without apparently undergoing any change in size or shape. Gradually it begins to shrink, and to lose its dark color, and finally it disappears in the granulations which encroach upon it from all sides. This process of organization of blood-clot was first described by Lister, and also by Volkmann in the early days of antisep- tic surgery. The latter fully recognized its value, in cases in which large surfaces of bone, which would otherwise have lain exposed, were covered by a clot undergoing organization. Necrosis and exfoliation were thus often prevented. But it was Schede who first recommended healing under the moist blood-clot as a novel form of wound-treatment, claiming for it a large field of usefulness. His teachings were directly opposed to the opinions generally held by surgeons, who advocated, and still do advocate, the removal of all blood before closure of a wound. Schede’s attention was first called to his new method of wound-treat- ment by the good results obtained in the operation for club-foot as prac- tised by Phelps. There a large clot lies between the separated wound- WOUND-TREATMENT. 65 surfaces, and, if covered by a piece of protective silk, organizes in a few weeks, providing no infection has occurred. Schede applied the principle herein involved to resections of all the joints with the excep- tion of the hip, but more especially to the treatment of bone cavities, the result of operations for necrosis or tuberculosis, and of compound fractures, where a loss of substance has resulted from comminution. He also employed the method where large defects in the soft parts after extirpation of tumors and other operations did not permit an exact approximation of the wound-surfaces. To apply the method properly, the cavity in the bone or the soft parts should be rendered entirely aseptic. If the integuments can be brought together by sutures, shut- ting off the cavity, this is done, leaving for the discharge of super- fluous blood, generally at the uppermost part of the wound, one or two openings which are covered with bits of protective silk. If sutures have not been used, the opening to the cavity is also covered with protec- tive, overlapping the edges to prevent evaporation of the blood in the cavity, and also to guard against absorption of the blood by the aseptic dressing, which is next applied. It is important that there should be enough blood to fill the cavity, but this should not be under any ten- sion. If success attends this plan of treatment, the first dressing may remain for from two to six weeks, when on removal complete union will be found, or the clot will have been transformed into cicatricial tissue. The method is not, however, always successful. In rare cases, even if no infection has occurred, the blood does not coagulate, and does not, therefore, fulfil its purpose. In operations for necrosis of bone, also, where thorough asepsis cannot always mark the course of the surgeon’s work, owing to the infiltration of the surrounding bone with micro- organisms, failures are frequent. Then disorganization follows, and the bone-cavity must eventually be treated according to the old plan of tamponing and healing by granulation, and no further harm will result. In the treatment of tubercular bone affections, on the other hand, great care should be taken to remove all diseased tissue before healing beneath the moist blood-clot is attempted. Otherwise primary union may be followed by a recurrence of the old trouble, and a break- ing-down of the already organized clot. It is an especially difficult task to remove with certainty all tubercular material from a diseased hip, and resections of this joint have, therefore, never been considered suitable cases for healing beneath the moist clot. In operations where tendons have been exposed, and perhaps deprived of their sheaths, as is frequently the case on the dorsum of the hand, the method an- swers an excellent purpose; but it must not be assumed that divided nerves and tendons will re-unite without suturing more readily by this than by any other method of wound-treatment. I have frequently alluded to that form of wound-treatment, which, like the method of healing beneath the moist clot, aims at a reduction in the number of dressings and at total abolition of drainage, of which Neuber has been the main exponent. The means employed to attain these ends are exactly the reverse of those used in the method of Schede, just described. All hemorrhage is carefully arrested, and the formation of cavities within the sutured wound is scrupulously avoided, in the belief that close coaptation of wound-surfaces is the best guar- antee for rapid and undisturbed healing. According to the location of 66 WOUNDS AND WOUND-TREATMENT. wounds this is accomplished in various ways. In the soft parts, sim- ple compression will frequently suffice to bring the sutured surfaces into approximation with the underlying parts, or this may be done with the assistance of a few sutures (Fig. 1567, « p) placed subcutane- ously. (Figs. 1566, 1567.) If the wound-cavity is deep, buried sutures can be employed with advantage, as illustrated by Figs. 1568, 1569, 1570, 1571. In dealing with bone-cavities, the adjacent soft parts can be utilized Fig. 1566. Fig. 1567. Fig. 1568. Fig. 1569. Fig. 1570. Fig. 1571. Buried Sutures. (After Neuber.) in the formation of suitable flaps, which are implanted upon the de- nuded bone surfaces and held in place by nails and accessor}7 sutures WOUND-TREATMENT. 67 (Fig. 1572). This plan is also practicable in cases where the soft parts are too rigid to admit of approximation by buried sutures. After re- sections, the bone surfaces are brought into direct contact to pre- vent the formation of dead spaces, a precaution which is not at all neces- sary when such cases are treated with the moist blood-clot. During the first period of the development of this method, drainage was considered indispen- sable. Neuber at that time recommended the use of absorbable drainage-tubes, hoping thus to avoid a change of dress- ings for their removal. He soon abandoned them, however, for reasons already mentioned, and adopted a method of drainage which he termed “canalization of wounds.” This consisted in the punching of holes through the skin and subjacent tissues at certain intervals, through which holes ample drainage was afford- ed. But this plan was also soon given up in favor of loose sutures, which permitted the intervening wound-, edges to separate slightly, allowing the secretions, if there were any, to escape. Furthermore, the ori- ginal incisions were so placed that their ends, or one of them, corre- sponded to the lowest part of the wound, which was eventually left unsutured. (Fig. 1573.) Sometimes a small A'shaped flap was cut at the ends of the incision, and at the close of the operation its tip was sutured to the deepest part of the wound, thus establishing a groove Fig. 1572. After Neuber. Fig. 1573. Fig. 1574. Fig. 1575. along which the secretions could run into the dressings (Figs. 1574, 1575)—a plan especially well adapted to resections of the knee. In his latest publication Neuber discards drainage altogether, and, relying on 68 WOUNDS ANI) WOUND-TREATMENT. his method of wound-treatment, closes all aseptic wounds hermetically. To facilitate this a piece of sterilized gauze is packed into the wound at the end of the operation and allowed to protrude from the lower angle (Fig. 1576). The wound is then sutured, with the exception of that part from which the gauze escapes, and here a few untied sutures are placed (Fig. 1577). Firm compression is now exerted upon the line of suture, and continued until all the blood and secretions have been expelled from the wound by way of the tampon. The latter is then ex- tracted, the last sutures are tied, and the wound is entirely closed (Fig. 1578), compression being all the time exerted to prevent the entrance of air into the wound. An aseptic dressing is finally applied. Most surgeons to-day, we venture to assume, combine the methods of Neuber and Scliede in the treatment of aseptic cases. They still believe in removing all blood-clots from wound-surfaces where coaptation is possible, but they allow such spaces as cannot be oblitex’ated by suture or compression to fill with blood, and trust to organization. When dealing with wounds of any depth, even though perfectly aseptic, many surgeons still employ drainage-tubes, believing that the inconveniences which their use entails are fully offset by the assur- ance that no retention can occur, and that the risks of infection are in consequence minimal. When drainage-tubes are used, they should be entirely removed at the end of about a week, if everything has gone on satis- factorily. They should not be shortened, or removed and re- introduced. Their purpose has been to supply a safety-valve during the first days of reaction and secretion, and they can now be dispensed with, having ful- filled their object, since they fur- ther act only as foreign bodies in the wound. Their track will then close rapidly. To avoid a complete removal of the dressings, it has been suggested to so arrange the tubes at the outset that they can be removed without un- covering the wound. This plan is somewhat cumbersome, and has never met with general favor. It possesses no advantage over com- Fig. 1576. After Neuber. Fig. 1577. After Neuber. WO UN 1) -TREATMENT. 69 plete exposure of the wound under proper precautions. The dan- gers of infection and irritation by a renewal of the dressings have been much exaggerated. The inconvenience to the patient is almost of greater significance; and here there is another view to be taken of the matter. The patient will in all probability be more comfortable if the secretions are carried by drainage-tubes into the dressings, than if they remain shut up in the wound, even in an aseptic condition, awaiting absorption. From all that has been said, we conclude that a precise statement regarding the position of drainage in aseptic sur- gery is to-day impossible. It must remain with every surgeon to de- cide to what extent he can attain the ideal of no drainage and of healing under one dressing, with or without the moist blood-clot. His mastery of asepsis and the conditions under which he works will influ- ence him largely in his decision. There may exist, however, other indications for a change of dress- ings which are unequivocal. If the temperature of the patient, after the usual reaction of the first few days, when the thermome- ter is likely to register a few degrees above the normal, does not drop, and if his general con- dition indicates that absorption from the wound is going on, the dressings ought to be removed, and the necessary steps taken to insure free exit of the secretions, or of the blood clot, which the surgeon has not succeeded in keeping aseptic. It is a good plan, further, to apply in these cases a moist antiseptic dressing with Thiersch’s solution, or a solution of acetate of aluminum, as already described, whether the wound has been opened or not. In the latter event it may be possible to master the inflammatory symptoms without entirely sac- rificing primary union. It seems a better plan, in applying a moist dressing, to cover it with some impermeable material, such as rubber tissue or protective, than to rely on frequent irrigation for keeping it moist. If we are dealing with open wounds, a frequent change of dressings, once a day at least, is advisable, to guard against a too rapid development of micro-organisms, which shutting off the dressing with protective undoubtedly favors. It has been proposed to moisten only the deeper layers and to place over them a dry aseptic dressing. The full benefit of a warm and moist dressing is, however, better ob- tained in such cases by making it impermeable than otherwise. When the reaction has passed off, a dry dressing may be again employed. When soon after an operation a bloody or serous discharge appears on the external surface, it will suffice to protect the spot with a piece of sterilized or iodoform gauze, and to allow evaporation of the secretions to take place. If the discharge is more abundant, it will be proper to re- move the superficial layers, and to replace them by fresh pieces of gauze Fig. ir>78 After Neuber. 70 WOUNDS AND WOUND-TREATMENT. or other aseptic material. It has been suggested to cover that part of the dressing which corresponds to the wound, in cases in which we anticipate much oozing, with rubber tissue, which prevents the dis- charges from showing on the surface and from opening a path of in- fection from the outer world to the wound. But this should certainly not reach to any extent over the external surface of a dry dressing, otherwise evaporation of the secretions may be interfered with. The latter is justly considered one of the most important factors of modern aseptic wound-treatment. Nothing will more surely prevent the de- velopment of micro-organisms in dressings than rapid evaporation of the discharges that have escaped into them. It is not necessary for this that the discharge should have appeared on the external surface of the dressing; on the contrary, gauze and moss, for example, which ab- sorb rapidly, will also allow evaporation through much of their ma- terial which is still dry. On the whole, it seems a better plan to avoid entirely the use of impermeable materials in the application of a dry aseptic dressing, more especially as we are able to control ooz- ing by the proper manipulations in almost all cases, and because we can detect and remedy a weak spot in an aseptic dressing immediately. A method of wound-treatment which may be occasionally em- ployed with much advantage, is the tamponade of wounds. This may be either temporary or permanent. When used only temporarily, it is employed mainly to control capillary oozing from wound-surfaces, which cannot be checked by other means, and to lessen the risk of in- fection in cases in which the surgeon, apart from the nature of the ailment, does not for some reason or other feel sure of an aseptic course from the outset. Kocher some years ago extended this plan to the treatment of almost all wounds. His method was to tampon at the time of operation, and to introduce the necessary sutures for closing the wounds, leaving them, however, untied. At the expiration of two or three days, having assured himself of the aseptic condition of affairs, the tampons were removed, and the wounds, which had been treated with subnitrate of bismuth as an antiseptic, were closed by tying the sutures already in place. A second use of anaesthetics was thus avoided. Following Kocher, von Bergmann has used this method very extensively in the treatment of some aseptic wounds. A great advance in liis method was the substitution of iodoform for subnitrate of bismuth. He furthermore abandoned the introduction of sutures at the time of the operation, preferring, two or three days later, to again anaesthetize the patient for removal of the tampon and closure of the wound. The ad- vantages claimed for this plan are the easy control of hemorrhage, which may occur during extraction of the iodoform gauze, and the greater comfort to the patient and the surgeon during the neces- sarily somewhat extended secondary manipulations. Von Bergmann employed the method more especially in resections of joints, but also in compound fractures involving the joints and the skull. When, for example, after resection of the knee, the tampon is removed on the second day, the wound-surfaces will have a perfectly fresh appearance, and will be equally well adapted to suturing as at the time of the oper- ation. It is not improbable, however, that temporary tamponade in aseptic cases will soon be entirely abandoned, except in those in which excessive hemorrhage is going on. In operations on the brain, and WOUND-TREATMEXT. 71 even elsewhere, when severe venous hemorrhage occurs, it is some- times impossible to control this otherwise than by tamponing the wound for a period varying from several days to a week or more. But for general application to resection of joints, the method seems to possess no advantages over that which advocates arrest of hemor- rhage, close coaptation of the bone surfaces, and healing beneath the blood-clot, where open spaces are unavoidable. If we close such a wound at the end of the second day, we are no more able to guarantee against recurrence of tuberculous disease than by the plan just men- tioned. In both instances we avoid filling the cavity of the exsected joint with blood, which during and after organization is so excellent a medium for the rapid growth and dissemination of the tubercle bacil- lus, in case we have failed to remove all diseased tissue. The surest way of guarding against recurrence after operations for extended tuber- culosis, is to tampon permanently after resection, a method applicable to many joints. We can then detect a recurrence, and can deal with it before it assumes large proportions. But it is mainly after operations involving the mouth and nose, their adjacent cavities, and the rectum and vagina, that the perma- nent use of iodoform-gauze tampons is of inestimable value. There is perfect accord of opinion among surgeons as to the efficacy of this plan of treatment. The discharges, which otherwise become foul, caus- ing by their absorption intoxication and occasionally sepsis, remain sweet, even if the tampons are not removed for many days. The dan- gers of septic peritonitis after operations on the rectum and the uterus, and of septic pneumonia after resection of the jaw’s, have been much lessened since the iodoform-gauze tampon has been recognized as the proper dressing for these cases. Iodoform is, therefore, the one antiseptic which we occasionally apply to wounds with signal advantage. Its use is indicated in origi- nally aseptic wounds, which from their situation will be subsequently exposed to the risk of infection. Where this is not the case, iodoform ought not to be employed. It is not logical to prepare and perform an operation aseptically, and then, before applying an aseptic dressing, to dust the line of suture with iodoform, or to cover it with a piece of iodoform gauze, as is still frequently done. This could only be deemed consistent with an aseptic regime if sterilization of the powdered iodo- form and the preparation of iodoform gauze, with solutions of iodoform, always immediately preceded their use. Iodoform, it is said, can be sterilized by washing it in sublimate solutions. But that this is seldom done by those who apply the powder to wounds is quite certain. Others consider the powder sterile when it leaves the manufacturer’s hands, which is hardly a guarantee, however, that it is so when used. Iodoform gauze prepared from solutions in ether, or ether and alcohol, is, as has been shown, sterile, and there could be no objection to its use, if it were always thus prepared before operation. But this is, I feel assured, but rarely the case. It is a procedure which would, moreover, un- necessarily complicate asepsis. In aseptic surgery the aim must be to dispense with antiseptics about wounds and in the dressings. Does iodoform possess any antiseptic properties? When first intro- duced as a dressing for wounds by Mosetig-Moorhof, almost fifteen years ago, it soon gained favor with the profession, and was regarded, on 72 WOUNDS AND WOUND-TREATMENT. the basis of extended clinical experience, as a powerful antiseptic. It caused, therefore, quite a commotion among surgeons, when Hejn and Roosing in a well-known publication disclaimed for it all power in this direction. Surgeons were, however, unwilling to accept the results of culture-tube experimentation, even though verified by other investiga tors, as identical with the action of the drug when in contact with the human body. If iodoform has none or very little influence on germs in culture-media, it evidently does influence their growth in the living body. Various theories have been offered in explanation of this fact. Some believe that iodoform increases the vital action of the tis- sue cells in their conflict with germs; others that iodine, set free by decomposition of a certain quantity of iodoform, exerts an antiseptic influence. According to Koenig iodoform decreases to a great extent the secretion in wounds, and thus removes the medium in which germs develop. Of late, the chemical action of iodoform upon the ptomaines, the products of germ-life, seems to offer the best explanation of its action on wound-surfaces. We know from the work of several inves- tigators that ptomaines can cause suppuration without the presence of the germs which have produced them. On the other hand, the germs without the ptomaines do not always excite suppuration. But the most important outcome of the vast amount of experimental labor devoted to this subject is, that ptomaines, when mixed with iodoform, do not cause suppuration. The former seem to possess the power of decomposing the latter, but they are themselves rendered inert by this chemical change. We may assume, therefore, that the antiseptic qualities of iodoform are due to its affinity for the irritating pro- ducts of the growth of bacteria, but that it is not a parasiticide, exert- ing a directly destructive influence upon micro-organisms, as is carbolic acid or corrosive sublimate. The treatment of infected wounds should be conducted on the same principles as that of clean wounds. There is no reason why we should any longer to-day uphold the doctrine that clean wounds are to be treated aseptically, and infected wounds antiseptically, that is, with the liberal use of antiseptics for irrigating purposes and for the impregna- tion of dressings. The one great object in dealing with infected wounds should be the provision for free discharge of the secretions which are contained within the tissues or poured out upon the wound-surfaces. This end is attained by establishing convenient outlets for such secre- tions, and by keeping these outlets open until the symptoms of local in- fection have subsided. But it is not likely that we will benefit our pa- tients much in attempting to destroy the germs in wounds by the use of strong antiseptics. Recent investigations have shown that the germs contained in abscesses have to a great extent perished, and that the formation of pus is probably due to the irritation caused by their pro- ducts. It follows that, if we can establish ample drainage for all such collections, there will be no occasion to treat them further with antisep- tics. It will suffice to let them escape from the body. Nor does it seem rational to attempt the destruction of germs in the walls of cavi- ties or sinuses by antiseptic irrigations, in which we will probably be successful to a small extent only, and then very likely in a mechanical way. It is still an open question, whether or not the removal of tis- sues infiltrated with pus and micro-organisms, perhaps already ne- WOUND-TR E A T M E X T. 73 erotic, should always be undertaken in dealing with infected wounds. Some surgeons favor active interference, whereas others prefer to thor- oughly expose such cavities, to insure free and permanent drainage, and to trust to the vital action of the neighboring tissues in overcom- ing the sources of infection still present. We must support this vital action, and not lessen it. I have already alluded to the fact that strong antiseptic fluids impair the vitality of the superficial layers of cells, when poured upon wounds. If this is the case in aseptic wounds, it is even more likely to occur in infected wounds, where the cells possess less vitality. If we consider irrigation necessary for the me- chanical removal of secretions, we will, therefore, do better to employ in this instance also an aseptic fluid, preferably a sterilized salt solution. The dressing of an infected wound should also favor free drainage. It is a better plan to pack such wounds with gauze than to rely on the action of drainage-tubes. The latter will occasionally be indispensable, when free exposure of wounds is impossible for other reasons, such as their depth and their situation near vital parts. But, whenever possi- ble, such wounds should be laid and kept well open. This course has many advantages. It encourages evaporation of the secretions in the dressings, and about the wound-surfaces, inhibiting thereby the growth of micro-organisms. It further facilitates the entrance of air, and especially of oxygen, to wounds, which, we know from recent in- vestigations, has a marked influence in retarding or suspending the development of most infectious germs, that have become anaerobes within the tissue of the body. Very likely the favorable action of per- oxide of hydrogen on suppurating surfaces is due to the same cause. Moist dressings are often of value in the treatment of infected wounds. When the discharges are viscid and ropy, they will not be readily absorbed by dry dressings. They will, moreover, evaporate, and thus give rise to the formation of scabs and crusts, under which stagnation of the secretions and a lively development of micro-organ- isms may go on. If, in addition to this, much infiltration of the wound surfaces is present, moist dressings, frequently changed, answer an excellent purpose. They may act antiseptically to a certain extent, but their main purpose is to prevent exsiccation, and to keep the parts moist and warm. When infiltration and inflammation have subsided, and healthy granulation is beginning, the wound itself may be dressed with iodoform gauze over which a dry aseptic dressing is applied. The iodoform will stimulate granulation and lessen secretion. As the wound-cavity begins to fill up, special indications may arise for the treatment of the granulations. They may require stimulation, if slug- gish—or cauterization, if exuberant—until finally the edges of the wound can unite over them, or the intervening gap can be closed by skin-grafting. If irrigation with antiseptic fluids is at all indicated in modern wound-treatment, it is in the cleansing of fresh wounds proper, which have been contaminated with gross impurities. The conditions are different here from those which exist in wounds of which infection has taken a firm hold. No growth of germs, no infiltration of the walls of such wound-cavities with the latter, has yet occurred. There is a better chance of bringing the antiseptics into direct contact with the causes of infection and of preventing their further development in 74 WOUNDS AND WOUND-TREATMENT. these cases. But even here, antiseptic irrigation may be dispensed with. The cleansing of such wounds, including ample exposure with the knife, the removal of tissues which are much contused and lacer- ated, and of gross impurities, by irrigation, scraping, or exc'sion, is a mechanical procedure. What we cannot remove in this manner we will not be likely to destroy with antiseptic irrigation, especially when the impurities, as is often the case, are ground into the tissues. These wounds will also, in all probability, heal as well under thorough aseptic cleansing and irrigation, followed by packing with iodoform-gauze, a& when treated with strong germicidal solutions. DISEASES COMPLICATING WOUNDS. ERYSIP- ELAS; SEPTICAEMIA AND PY EMIA: HOSPITAL GANGRENE. BY OTTO (.. T. KILIANI, M.D., INSTRUCTOR IN CLINICAL SURGERY AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL ANI> HOSPITAL, SURGEON TO THE GERMAN DISPENSARY. I. Erysipelas. Erysipelas 1 is a peculiar infectious and contagious inflammation of the skin and its lymphatic ducts, produced by the micro-organism known as the streptococcus erysipelatis (Fehleisen), and always origi- nates in a lesion of the integument. It assumes the form of a sharply defined, spreading, and migrating redness, always accompanied by rise of temperature and the concurrent symptoms of fever. History.—The history of erysipelas presents for several reasons a very interesting study, because it shows what tremendous progress we have made in the knowledge of the etiology of wound-complications, since bacteriology became a science. It is not saying too much to assert that Hippocrates (460-377 b.c.) was nearly as well acquainted with this disease as we were up to the middle of this century. This is surely true, as far as the clinical symptoms, diagnosis, and treatment of erysipelas are concerned, though in earlier times, doubtless, some other diseases of similar character were confounded with it. As to its etiology, we had to wait for men like Trousseau, Billroth, von Yolk- mann, Lister, Hitter, Klebs, and Koch, till finally Fehleisen, whose name has been given to the specific microbe of the affection, proved beyond doubt the origin of this well-known and much-dreaded disease. The immediate apparent result of this great discovery has shown itself not so much in the treatment of erysipelas where it is already present, as in the prophylactic measures to be adopted, a common feature of all the results so far gained in theoretical and experimental bacteriology. Only for the student of medical history would it prove of interest to follow the different courses which the doctrines concerning erysipelas have taken in past centuries. It may be sufficient to say that Hippo- crates, as stated above, in his third book of the Epidemics, gave an exact 1 For synonyms and derivation of the word erysipelas, see Prof. Alfred Stille’s article ins Yol. I. 75 76 DISEASES COMPLICATING WOUNDS. description of erysipelatous affections originating from slight lesions, and destroying the skin in a great measure by gangrene. Diodorus and Thucydides, who was himself attacked by the disease, described excel- lently the “Attic plague,” 430-425 b.c. Galen related the plague of Antoninus, 165-180 a.d., which raged from Persia to the Rhine, a great deal of which surely was malignant erysipelas. Afterward, in the fifteenth and sixteenth centuries, it seems that the definition and the limits of the disease were not as clearly understood, and it is well-nigh impossible to distinguish erysipelas from the many other diseases with which it was confounded. The prominent leeches of the sixteenth and seventeenth centuries believed with Galen and his pupils, that the gene- sis of erysipelas was accomplished through the agency of the bile (bilious erysipelas). Choleric and full-blooded individuals were specially susceptible; some physicians differentiated two forms of the disease, one in connection with the bile, “biliary blood,” which offered a better prognosis than the other, which was observed at times “when an en- venomed air prevailed.” This “mixtum compositum” grew worse and worse till the beginning of the present century, when the reports of epidemic erysipelas were of more value. Those outbreaks which occurred in all forms, from the mildest to the most malignant types, from 1830 to 1860, at different places in Europe—Scotland, Denmark, Germany—and in North Amer- ica,1 are specially interesting. European, and especially German, litera- ture, which treats of other epidemics very fully, seems to have taken very little notice of those in the United States. Among the reports of American physicians, those of Drake, Peebles, Shipman, G. Sutton, Charles Hall, G. Dexter, and others, deserve our special attention. We find the first traces of this pandemic, especially of the so-called typhoid erysipelas, in Canada, in 1841, whence the affection spread over the whole territory of the United States, especially toward the southwest. The intensity and extent of this so-called typhoid erysipelas varied very much. Sometimes the disease occurred more or less generally at a place, while at other times the cases were only sporadic, or were restricted to hospitals. Drake, in his excellent treatise,2 describes the course of the epidemic thus: After having started in the winter of 1826 in Burlington, Vt., in 1832 in Ogdensburg, N. Y., in the spring of 1833 and winter of 1836 in St. Clairsville, the general outbreak of the great scourge occurred in 1841, when the affection first manifested itself in Canada. Thence it came in the following year to New York and Vermont, and at the same time to Indiana. The winter of 1842-1843 brought it to Missouri and Ohio, and in the winter of 1843-1844 the epidemic reached its height and largest distribution in Canada, Wis- consin, New York, Indiana, Illinois, Kentucky, Tennessee, and Missis- sippi, while the following spring showed only Missouri, Alabama, Tennes- see, and New York infected. In the latter states the epidemic slowly died out until 1849, so that in the winter of 1849-50 we find reports only from Vicksburg, New Orleans, and a few other places. The spread of the disease was from northeast to southwest, through fifteen degrees 1 It may be said here that the first epidemic of erysipelas in the United States did not oc- cur in 1843, as is generally believed, but that the epidemic of smallpox of 1699 was accom- panied by erysipelas, as Haser, in his history of epidemic diseases, abundantly proves. ‘2 Principal Diseases of the Interior Valley of North America. ERYSIPELAS. 77 of latitude; many places in the infected region remained entirely free from the contagion. We must not forget, however, that a number of the highest author- ities do not believe in the erysipelatous character of the epidemic just mentioned. Men like Hirscli and von Volkmann have grave doubts whether a good many of these cases were not more of a diphtheritic nature than truly erysipelatous. We must bear in mind that those who observed this epidemic had to base their diagnosis entirely on the clinical symptoms, and did not have the absolute bacteriological proof of its nature, so easily accessible to any student of medicine now- adays. Therefore, with all respect to the high abilities of the above- mentioned authorities, we have to leave in doubt whether some other diseases, especially diphtheria and dysentery, were not confounded with it, though it is beyond question that, if this be true, a great many cases were complicated by erysipelas; and it is only fair to mention that Tillmanns, in his admirable treatise on Erysipelas,1 is all but convinced of the truly erysipelatous character of this most interesting epidemic, which is unparalleled in medical history. Etiology.—While in those times the clinical features and epidemic character of the disease excited the special interest of physicians, the question of the causative agent has come into prominence since the be- ginning of the bacteriological tendency in medicine. As has been the case with most of the infectious diseases, the bacteriological investiga- tion of erysipelas has also been crowned with success. Its bacteriological nature was made probable by the discovery of cocci, found in the skin, lymph, and blood of patients with this disease, by von Volkmann, Wilde, Orth, von Recklinghausen, Lukowsky, and Tillmanns. This was in the decade from 1870 to 1880, when our modern ideas about the etiology of diseases had gained ground, though an absolute result was unattainable with the methods of examination then possessed. The reason why we could not get beyond the probability that the microbes which we saw were really the specific agents of erysipelas, was that the direct proof was still wanting. The latter was not possible till Koch’s great dis- covery of a solid, transparent, culture medium (Nahrboden), and the modern development of bacteriological technique by his agency, which permitted the differentiating of various bacteria occurring at one and the same time, and their cultivation in pure cultures which could he used for experiments on animals. After this was established, it was Fehleisen who brought forth, in 1882 and 1883, his streptococcus ery- sipelatis as the specific cause of the disease in question. This was proved beyond any reasonable doubt, as he could fulfil the three princi- pal demands of Koch’s doctrine. For he found the microbe constantly in the lymphatic system of erysipelatous skin; secondly, he could culti- vate it in pure cultures outside of the human body; and lastly, he could generate erysipelas by inoculations with cultures not only in animals, but also, what is vastly more important, in man. The exposition of the etiology of erysipelas is very simple and short, if we admit the modern point of view, and accept what the whole sci- entific world has accepted. The definition can be condensed into one short sentence: erysipelas is a wound-complication of the skin and 1 Deutsche Chirurgie, Lieferung v., 1880. 78 DISEASES COMPLICATING WOUNDS. mucous membranes, caused by the inoculation of the only specific agent, the streptococcus erysipelatis (Figs. 1579, 1580, 1581), into a lesion of these parts. Of course, it may be said that it is easy enough to set up a definition, and then to declare only those cases to be really ery- sipelas which answer the postulate, and exclude all others. But this objection is weak enough, because, after all, we have to confine our- selves to one definition of the disease, or we shall never be able to make the diagnosis. It is self-evi- dent that a great many ob- servers, otherwise perfectly reliable, deceived themselves and others by their reports, as long as they had to guess at the nature of the virus, and that they worked out hypotheses sometimes as in- genious as they were incor- rect. First of all, I must deny em- phatically that there is any- thing like spontaneous In most of those cases which were claimed to be such, it is not very difficult to trace the source of infection, and in others it might have been easy enough to do so, if attention had been called to the way of infection. The locality where most cases of the so-called spontaneous erysipelas occur, is the face, that is, a part of the body which is exposed, uncovered, to wind and weather and to other mechanical and chemical influences of all kinds. If the face were examined daily with a magnifying-glass, there would always be found lesions of the skin big enough for the invasion of the poison. Besides, a great many cases of erysipelas of the face represent a continuation of an erysipelas existing in the mucous membranes of the cavities of the head, especially of the nose. This fact has not been taken into consideration enough by the advocates of the spontaneous genesis of erysipelas. That this erysipelas of the mucous membranes of the nose is not spontaneous either, is a matter of course, easy enough to understand if it be remembered how many persons have the habit of boring the fingers into the nose, which is the most frequent source of erysipelas of the face. Furthermore, it must be considered that ery- sipelas does not necessarily start and make its appearance at the point where the lesion of the integument takes place. It quite frequently shows itself at a certain dis- tance, the virus having wandered through the lymphatic ducts till it becomes established. How easily these first lesions, the place of entrance, may be overlooked, every- body knows who has the opportunity to observe other septic infections of a phlegmonous character. We see every day most severe phlegmons start from a little scratch, such, for instance, as butchers get from handling meat and bones. The cause of infection is clear enough here, though very often we are hardly able to find the Fig. 1579. a, Streptococcus erysipelatis. X 950. b, Pus with strep- tococcus. X 800. Fig. 1580. Culture of strepto- coccus erysipelatis. ERYSIPELAS. 79 primary lesion. It frequently is healed up in from twenty-four to thirty-six hours, in spite of the infectious character of the disease, which is severe enough to infect other, more remote parts, or even the whole system. Or, to pick out another instance, we very often observe the so- called idiopathic bubo in the groin, an adenitis which has its cause in a badly cut corn of the toe, or in a slight sore- ness of the toes produced by hyperidrosis (sweating feet). It has been said that the possibility could not be denied a priori, that in rare cases erysipelas might originate in le- sions of the digestive apparatus, the ute- rus, or the lungs, or, generally speaking, of the internal integuments of the body which communicate with the outer air. This, then, might produce a metastatic erysipelas of the skin. After careful study of the whole literature on this point, I am inclined to say that we have not a single reported case which proves with absolute certainty an infection in this way. Besides, the modern conception of erysipelas inclines strongly to the belief that there is no metastatic erysipelas, and that those metastatic cases which show most of the symptoms of true erysipelas have nothing to do with that disease. The extremely interesting question whether the cocci of erysipelas can enter the body through its natural openings, the uninjured suda- tory and mucous glands and hair follicles, is not as easy to decide. Since it has been shown experimentally that micro-organisms can leave the body through these natural openings, it cannot be denied, without further investigation, that they are able to enter by those channels. The experiments above alluded to proved the existence in the sweat of pigs of the same microbes with which they had previously been infected. Of course, the snout, through which alone the pig sweats, had been thoroughly disinfected, the animal being treated with pilocarpine, to produce profuse sweating. Besides, Garre, professor of surgery in the University of Tubingen, has proved with absolute certainty that infec- tion by the staphylococcus pyogenes aureus through the uninjured skin, is possible. He took a small particle of pure culture of the coccus and rubbed it on his forearm, whereupon he got no less than twenty-nine furuncles of the severest kind, the experiment nearly costing him his life. Erysipelas in coincidence with internal diseases, acute as well as chronic—as, for instance, typhoid, variola, varicella, intermittent fever, pneumonia, Bright's disease, cirrhosis, heart disease, intestinal disor- ders, etc.—used to prove of especial etiological interest. With our idea of erysipelas, we can hardly understand that such excellent observers as those who described these cases were not able to keep the two diseases apart, since they had nothing whatsoever to do with each other. This is one of the great results of our modern study of the etiology of diseases, that we know exactly the symptoms which can be produced by a specific Fig. 1581. Streptococci Eryslpelatis. X TOO. Sec- tion through a lymphatic duct of the skin. (Fluegge.) 80 DISEASES COMPLICATING WOUNDS. disease, and can differentiate other coincident symptoms which have noth- ing to do with the original malady, and can ascribe them to their proper causes. It cannot surprise us, to-day, that out of one hundred or one hundred and fifty patients with typhoid fever, some of whom will have bed-sores, one should develop the symptoms of erysipelas, starting, of course, from the ulcer; and we should never think of constructing a com- plicated explanation of this phenomenon. There is quite an extensive literature, with most exact statistics, about the concurrence of erysipe- las with typhus abdominalis and typhus recurrens, which is entirely without value for us. We cannot be surprised, either, to find reports of erysipelas starting from the point of administration of a hypodermic injection, which is really a true bacteriological experiment of inocula- tion on man. It is hardly necessary to go through the other diseases mentioned above, which may concur with erysipelas; but it seems to me that one point should not be omitted, and that is, the connection of erysipelas with puerperal fever. It is sufficient to mention the names of Ingleby, Hutchinson, Levergood, Clarke, Storrs, Simpson, Graves, Minor, Hincks Bird, Kneeland, Elkington, Hodge, Wilson, Spencer Wells, Squire, Tilbury Fox, Nunneley, Trousseau, Masson, Hadry, Vir- chow, Hirsch, Rust, and a great many others, to show what able authorities have directed their attention to this combination. It is somewhat remarkable that not before our century was the iden- tity of erysipelas with some forms of puerperal fever accepted, since it is eminently obvious that the puerperium is especially favorable to erysipelatous infection, if we only think of all the lesions, lacerations, and abrasions on the labia, in the vagina and cervix uteri, and specially of the large wound in the uterus itself at the insertion of the placenta. The close relations which are said to exist between erysipelas and puer- peral fever may be formulated thus: Wherever the conditions in hos- pitals, lying-in hospitals, etc., are such that we find epidemics of puerperal fever, there is just as much chance for erysipelas as for any other wound-complications, so-called puerperal fever, septicaemia, etc., as all these infections are brought about, not by any impalpable virus, as poisonous air, but by bodily inoculation with hands, instruments, cloths, bandage-material, etc. The practical result of our study of this question is indeed a very beneficial one; every midwife and phy- sician, who has a case of erysipelas in confinement, must know that she or he is alone responsible for it, if in charge of the case from the beginning. If nurses or physicians, who have treated cases of ery- sipelas, cannot avoid attending to confinements, they must be aware of the danger to their patients, and therefore disinfect their hands, clothes, etc., as rigidly as possible. All the reports about the occur- rence of epidemics in hospitals of erysipelas and puerperal fever, explain themselves very easily to us by contact-infection; and that we are right in this explanation, is shown by the fact that we know how to avoid such epidemics to-day. It can be of but little interest to us to follow studies about the oc- currence and distribution of erysipelas, the influence of climate, season, weather, etc. It is enough to say, that erysipelas can and does occur anywhere on the face of the earth, and at any time. Surely, of just as little importance is the question of race, sex, and constitution. 81 ERYSIPELAS. In regard to the different parts of the body where erysipelas most frequently occurs, Bardeleben says that there are twenty cases of erysipelas of the head to one on other portions of the body. This is easily explained by the fact that, in the first place, the tender skin of the face is most exposed to injuries, and, on the other hand, that the scalp is the most difficult part of the body to clean. This is surely also the reason why erysipelas used to be especially dreaded, and of such frequent occurrence, after injuries of the scalp. Hardly anything remains to be said about the epidemics and en- demics of erysipelas. There is nothing mysterious about them, if we look at them from our point of view. Infection through the air surely occurred only in the rarest cases, if ever, while the mode of transpor- tation of the virus was clearly by means of contact; first, by imme- diate contagion through the hands of a patient suffering with erysip- elas, or of those attending upon him; next, the surroundings of a patient, as clothes, bedding, furniture, carpets, curtains, etc., through contact-infection became bearers of the virus, which was through this intermediate link communicated either directly or indirectly to other persons. To avoid endemics in hospitals, it is not only desirable but im- perative to have everything prepared to isolate erysipelatous patients entirely, which means to have ready for them not only an entirely se- cluded pavilion or ward, but also separate physicians, nurses, etc. Several large modern hospitals, for instance the new State Hospital of Hamburg Eppendorf, have created the position of a so-called septic as- sistant, who, with his own staff of head-nurse and nurses, has entire charge of all septic cases, as of phlegmons, gangrene, erysipelas, etc. All the necessary operations are performed in a special operating-room in the septic ward, and the assistant is excluded from helping in or look- ing on at laparotomies. Under these circumstances, with the necessary care, an endemic in such a hospital is next to impossible. Not only this, but the general results of operations are much better, because the assistants are not exposed to infection from poisonous material. We cannot omit the question of recurrence of erysipelas. It is a disease which surely has such a tendency, but it is hard to give exact figures of frequency of recurrence, as statistics, especially in this line, are bound to be unreliable. But 5 per cent, seems to be about the right number. As to the etiology of recurrences, it is without question that the greater part of the so-called recurrences which come to our observation shortly after the primary infection, are nothing but its late manifestations, while some of the later recurrences may be traced to new infections. In spite of all this, some persons show for a number of years a striking disposition to infection by erysipelas, and they are attacked for five, ten, fifteen years, and longer, once or several times every year. This is the so-called habitual erysipelas. Nearly always these patients show local alterations whence the erysipelas starts; as such we find chronic pustulous or ulcerous affections some- where in the skin, chronic suppuration of glands in scrofulous individ- uals, chronic eczemas of the face, at the introitus of the nose, at the lips, ulcerous or catarrhal processes in the nose, pharynx, or mouth, affections of the ear, suppurating processes of the tympanic cavity, with perforation of the tympanum, affections of the neighborhood of the eyelids or lachrymal sac, varicose veins or varicose ulcers, 82 DISEASES COMPLICATING WOUNDS. eczemas of the lower extremities, etc. Moreover, we must not forget that other diseases are frequently mistaken for erysipelas, as for in- stance, those erythemas which occur after eating crayfish, crabs, lob- sters, fish-liver, mushrooms, strawberries, etc., as well as herpes zoster and gouty eczemas of the skin. Symptoms, Diagnosis, and Prognosis.—The clinical picture of the so-called legitimate erysipelas of the skin, without complications, is in typical cases characterized by an acute, rapid rise of temperature, mostly up to high degrees, developing simultaneously with erysipela- tous inflammation of the skin, and a correspondingly rapid disappear- ance of the feverish symptoms, with an acute declination to normal temperature, or below it, as soon as the local inflammation ceases. The local inflammation is so typical, that it is impossible, after hav- ing seen it once, to overlook it or to mistake it for something else, in well-developed cases. As mentioned before, it starts from a small lesion in the skin, which may even, at the time the erysipelas is ob- served, be healed up. In its nearest neighborhood, we either find red dots, which merge into each other after a short time, or we find one continuous reddened surface. The color varies from brick-red to dark- red or livid. The surface of the inflamed part is slightly swollen, and therefore higher than the surrounding skin. The outlines of the affected spot are usually irregular, sometimes tongue-shaped peninsulas projecting quite far. One of the typical features is that the boundaries where the reddening stops and the apparently sound skin begins, are in most cases very sharply defined. During its progress the inflamma- tion wanders, that is, the disease not only affects new parts by pushing forward its outer boundaries, but the affected spot in toto changes its location, the inner frontiers apparently being absorbed, a condition which cannot be better described than by comparing it with the way in which spilt burning alcohol moves along, or in which, according to Yolkmann, a sheet of paper is devoured by a fire starting at its edge. The erysipelatous reddening is accompanied by a more or less developed doughy swelling, that is, a serous transudation in skin and subcutaneous tissue. The redness disappears on pressure, but reappears again im- mediately, while the transudation pressed away by the finger cannot come back as quickly as the redness; therefore a small dent remains. Owing to the increased flow of blood to the infected spot, the latter feels hot to the touch. According to the degree of the swelling, which gives the skin a shiny, more or less tense appearance, the pain is usually tolerable, but increases much on pressure. The greatest tran- sudation is found in the lids, lips, scrotum, penis, labia, and vulva, and then on the ears, toes, fingers, point of the nose, etc. The serous imbi- bition of superficial strata of the skin and the rete Malpighii produces not rarely blisters in the epidermis, with serous contents, which in the beginning are absolutely clear, or yellow, but after a short time may grow turbid and purulent. The blisters usually dry up rather quickly, forming crusts. We then find sometimes, under the latter, superficial suppuration, which only in rare cases of more malignant character progresses toward the deeper tissues, especially if the erysipelas is com- plicated with phlegmonous symptoms. It is hard to draw the line between erysipelas and other wound complications, if we have to deal 83 ERYSIPELAS. with phlegmons and gangrene. It is the more difficult, as we have no means by which to discriminate distinctly between Fehleisen’s coccus of erysipelas and the usual streptococcus pyogenes, a differentiation which has been given up entirely by most bacteriologists. Therefore, phlegmonous and gangrenous erysipe- las very often has nothing at all to do with erysipelas proper, but comes un- der the head of septicaemia and pyae- mia. If we read the histories of the cases reported by von Pitha, which are generally declared to give most exact and definite descriptions of this form of erysipelas, we cannot be in doubt that we should class all these cases nowadays as examples of septicaemia. Nevertheless, there are a number of cases which must be classed, not as instances of mixed infection, but as cases of true, genuine erysipelas. The explanation of the formation of abscesses has to be given in the fol- lowing manner: the usual way for propagation of erysipelas being by the lymphatic ducts, we usually see erysipelas spread on the surface, but if the cocci get into the blood, as it has been proven that they do in some cases, the formation of abscesses in the tissues surrounding the primary spot of infection, or even at more or less remote places, cannot be surprising. We must, however, always bear in mind that this is not the usual course, but an exception to the rule. The rapidity with which erysipelatous inflammation spreads is very variable; sometimes it moves within twenty-four hours from half an inch to an inch, sometimes as much as ten inches. In typical, uncom- plicated cases, which are by far the most frequent, inflammatory red- Fig. 1582. Chains of Cocci, a, Cocci of erysipelas: 6, cocci of phlegmonous inflammation. (After Rosenbach.) X 962. Fig. 1583. No. 1.—Fever-curve of erysipelas of two days’ duration, with typical quick defervescence. No. 2.—Fever- curve of erysipelas with recurrence after transient defervescence. Cure. dening and swelling pass into a complete restitutio ad integrum, with- out leaving any trace whatsoever of the process which has taken place. Sometimes, however, abscesses are formed even in the deeper layers of tissue, but only in cases of mixed infection by streptococci and other bacteria. 84 DISEASES COMPLICATING WOUNDS. The general condition of the patient corresponds to the intensity and extent of the local erysipelatous affection. The temperature (Fig. 15s3) suddenly, with acute violence, goes up to 104° F., or more, accom- panied by one or several chills, and just as quickly sinks again to the normal, when the affection is over. As long as the erysipelas subsists, the temperature at the height of the attack varies mostly between 104° and 100°. Sometimes, immediately after coming down to the normal, it rises again at once to its former height, which is usually thought to indicate a recurrence, a term which does not quite cover the facts. The other symptoms are those which usually accompany any high fever; thus, the region of the stomach and liver are sensitive to the touch, and there are lack of appetite, nausea and vomiting, great thirst, a furred, dry tongue, etc. The spleen is often enlarged, the region of the kidneys is not rarely tender to the touch, the urine is mostly dark colored, and contains albumin, blood or gall-pigment, and micrococci. The quantity of urine is lessened. A fatal result in erysipelas either is due to the general poisoning of the system by ptomaines, or ensues because a vital organ, as for instance the cavity of the skull, has been attacked. It is easy to understand that the duration of erysipelas cannot be to any extent uniform. There are cases of erysipelas, with no doubt in the diagnosis, which last twenty-four hours or even less, while others persist for several weeks, with changing intensity and so-called recur- rences, sometimes even the same places being invaded and covered again and again by the inflammation. The average duration is from six to eight days, and every case of erysipelas lasting longer than two wxeeks is, as Billroth says, an exception. Besides the more frequent complications, as formation of abscess, etc., we have to mention others of more or less rarity. Of special interest are those of the eye, which may occur in manifold forms, as, for instance, impairment of acuteness of vision, transient blindness (very rare), panophthalmia with atrophy or suppuration of the bulb— which occurs particularly when an erysipelas of the face attacks the orbital cellular tissues—turbidity of the optic media, iritis, ulcerative processes of the cornea, retinitis, and optic neuritis with atrophy of the optic nerve. Erysipelas of the head is sometimes complicated by catarrhs and suppurative processes of the auditory tract, inflamma- tions and suppurations of the parotid, difficulty in swallowing, and occasionally diphtheritic lesions of the pharynx. The so-called erysipe- latous pneumonia must be strictly" discriminated from ordinary pneu- monia and bronchitis in erysipelas; while the latter, especially bronchitis, are of very common occurrence in anyT severe erysipelas, the so-called erysipelatous or wandering pneumonia has, likely, no connec- tion whatever with that disease. It seems as if the clinical similarity in the course of the skin-affection and that of this special malady of the lungs had led to the name, without anyr real reference to its etiology. Of course, it cannot be entirely denied that in some cases erysipelas of the pharynx may progress downward in its course, and attack the bronchi and, in time, the capillaries of the lungs. If we mention the occurrence of icterus (jaundice), caused by gastric disorders or occurring in its haematogenous form in severe cases of ery- sipelas, and nephritis, which in the very worst cases may lead to urae- ERYSIPELAS. 85 mia, there is nothing left except the very interesting appearance of ulcers in the small intestine, and of transitory liyperaemia of the mu- cous membrane of the gut, with hemorrhagic diarrhoea. We have also to speak shortly of erysipelas of the mucous membranes, which doubtless occurs, and the course of which is very analogous to the course of erysipelas of the skin. The only difference is the great difficulty in the diagnosis of erysipelas of the mucous membranes, which really cannot be made with any certainty until the disease has passed over to the cutis, and there shown its typical symptoms. This difficulty makes it more than probable that a great many of these cases have really very little or nothing to do with erysipelas, which has been mixed up with diphtheria, pyaemia, and other acute infectious diseases. The favorite places of erysipelas of the mucous membranes are the cavity of the mouth, with its adnexa—nose, pharynx, larynx, etc.—the female genital tract, and the rectum. There are also cases reported where ulcers in the antrum of Highmore, and in the sphenoid and ethmoid cavities, gave rise to erysipelas, which was recognized as such when it made its appearance upon the skin. Of the first group, erysipelas of the pharynx with its complications, especially oedema of the glottis, is most dreaded. Glottic oedema in erysipelas seems to be mostly fatal, in spite of intubation and tracheo- tomy. An explanation of this can only be found in the fact that the serous infiltration of the mucous and submucous cellular tissue in the region of the epiglottis, ary-epiglottic ligament, etc., is transformed into pus, leading to fatal septic and pyaemic symptoms. Or fatal ca- chexia may he caused by extensive suppuration of the larynx itself. Be- sides this, the usual dangers, as in diphtheria, such as poisoning by carbonic acid, and its consequences, come into consideration. The second group occurs especially in the puerperium; I have men- tioned above the many lesions which delivery brings about, from any of which erysipelas may start. It is, of course, a contact-infection, like all the others, a fact which has led modern physicians to avoid internal manual examination, during delivery, as much as possible. All that has been said of erysipelas in other organs might he repeated here, with only slight modifications. The danger of mistaking other infections, especially pyaemia, for erysipelas, is very great. There is one point which is characteristic of erysipelas in the puerperium, which is the possibility of an infection by way of the milk from the mother to the child, streptococci having been found in the milk. Another fact to be mentioned is, that an erysipelatous infection, starting from the genital tract of the mother, during the last days of pregnancy or even in the beginning of delivery, may be transferred infra uterum from mother to foetus, by way of the lymphatic ducts. The diagnosis of well-developed ordinary erysipelas of the cutis is, in typical cases, very easy and hardly to be mistaken. All the character- istic local symptoms mentioned above, especially the local reddening and swelling of the skin, with the acute rise of temperature, and the course of the disease, already described, are so well-marked that any one who has seen them once will not fail to recognize them again. The prognosis of erysipelas is generally not unfavorable, but, since we have no absolutely reliable means by which to stop its propagation, as will appear hereafter, we cannot guarantee a favorable result, even 86 DISEASES COMPLICATING WOUNDS. in apparently slight cases. The prognosis depends upon a great many circumstances, such as, especially, the location of the affection, its dura- tion and extent, the constitution and age of the patient, the intensity of the fever, etc. The rate of mortality has been very differently re- ported by different authors, but 11 per cent, seems to be about the right figure, taking into consideration Ziilzer’s statistics and those of Ameri- can physicians, based upon a large number of cases. For the sake of completeness, I must mention here the so-called zoonotic erysipeloid, or wandering erythema (erythema migrans) of the fingers and hands. Etiologically, it really has nothing to do with true erysipelas, as it is caused, according to Rosenbach’s investigations, by a particular micrococcus, larger than a staphylococcus, of special quali- ties, which seems to have much analogy with Cohn's cladothrix dicho- toma. It especially attacks individuals whose occupation brings them in contact with dead animal substances, such as, dealers in fish and game, cooks, oyster-openers, barkeepers, butchers, tanners, and dealers in cheese and herrings. Its clinical course is entirely different, as it always occurs without fever, and almost without exception stops at the wrist. It is often quite persistent, lasting sometimes from three to four or six weeks, while other cases disappear spontaneously in one or two weeks. Its rational treatment consists in an injection of a two-per- cent. solution of carbolic acid into the inflamed skin, especially at its boundaries. Treatment.—We have no remedy which is even reasonably reliable against erysipelas. This somewhat striking assertion is proved by the enormous number of medicaments or methods of treatment which are recommended. Whenever this is the case with a disease, it is self-evi- dent that none of the would-be remedies is reliable, or there would be no reason to try new ones. Quite often an infallible remedy has been supposed to have been dis- covered, but has soon proved to be a deception. This is very possible, especially with erysipelas, as we have in this case to deal with a disease of entirely inconstant and untypical duration and intensity. We know that there are cases which last only for a few hours, and some which last for weeks. So we understand how little we may trust in the so-called abortive methods. It is quite out of the question even to mention all the “ remedies” employed in earlier years. They vary from the use of a hot flat-iron and leeches, to the employment of oils, lard, glycerin, chalk, flour, milk, brandy, water, decoctions of lilacs, poppy- seed, all sorts of salves, the thermo-cautery, and vesicatories. But these were only external remedies; to recount those for internal use would be impossible. The internal treatment of erysipelas has to be mostly symptomatic, since all efforts to find a specific remedy for erysipelas have been in vain. In light, uncomplicated cases, treatment is unnecessary; ade- quate diet, care for the proper function of the bowels, plenty of fresh air, and perhaps a mild laxative, are sufficient. It is not to be recom- mended to treat patients with erysipelas antiphlogisticallv, as the bodily strength may be needed very badly, and sudden lowering of the tem- perature may cause a fatal collapse. The most important factor in the treatment of erysipelas is the use of alcohol, strong wine, beer, ERYSIPELAS. 87 whiskey, brandy, or champagne, with strong, nourishing, but easily digestible food. I want to call attention to the necessity of giving these stimulants early, and not only when collapse has set in. AtVolk- mann’s Clinic, it was usual to give quite large doses of alcohol, from forty to one hundred grammes daily (with equal parts of syrup and an aroma- tic water), which dose was sometimes increased considerably for heavy drinkers. It remains to be said, that Volkmann avoided alcohol in cases with very high temperature and absolutely dry skin, while nervous complications, like delirium, do not contraindicate its employment. Beside alcohol, quinine, or iron, perhaps also camphor, may be used. English authors especially emphasize the use of iron very strongly, and many of them call it a specific against erysipelas. It is hard to under- stand its effect, if we do not accept the explanation that the ptomaines of the cocci of erysipelas have a deleterious influence on the red blood- corpuscles and deprive them of their haemoglobin. The different forms in which iron is given are the tincture and solution of ferric chloride, which were recommended in large doses by Hamilton Bell, the solution of ferrous chloride, and the bromide of iron. Bell’s tincture was usually given in doses of fifteen or twenty drops in water, every two hours, and in very severe cases twenty-five drops every two hours, day and night; for babies, two drops in sweetened water every two hours. About the same dose of the other compounds of iron was employed, only given in gruel, instead of in water. Beside iron, oil of turpentine, tincture of aconite, ergot, iodide of po- tassium, chlorine water, and belladonna have been given. For the complications, especially the gastric symptoms, emetics were adminis- tered as early as possible; for high fever, camphor, large doses of qui- nine, digitalis, veratrine, salicylate of sodium, cold baths, etc., were especially recommended. Pirogoff was especially emphatic in the rec- ommendation of camphor, while others, like Thiersch, Burckliardt, Volkmann, Busch, Oettingen, and Sporer have not observed its much- vaunted results. In regard to the remedies just mentioned for the fever, I may say that Volkmann was generally not in favor of trying to check or reduce it, as he thought that the fever was a natural reaction and “self-help” of the organism against the invasion. This idea does not seem to be very wrong, since we know from experiments that most of the micro-organisms find their most favorable conditions in the nor- mal temperature of the body, and that many of them can endure quite low temperatures—living bacteria can exist in ice—but can stand an elevation of the temperature above the normal even by a few degrees, for only a very short time. Only in exceptional cases is the height of the fever itself of immediate danger to th§ patient, and many surgeons, at least, do not acknowledge that they have ever lost patients by high fever; they claim that not the temperature has been fatal to the living cell, but the toxic effects, which we cannot counteract. The narcotics, opium, morphine, chloral, sulfonal, etc., are of great value if the patient becomes very restless and excited, but they must be given in large doses, since small ones only intensify the febrile excite- ment, instead of inducing rest and sleep. Wherever it becomes neces- sary to lower the excessive temperature, cold baths are surely the best and most reliable remedy, being also one which acts promptly. As manifold as the internal remedies for erysipelas are those for local 88 DISEASES COMPLICATING WOUNDS. treatment. Of late, greater stress has been laid by most surgeons on external applications. To begin with the simplest of these, elevation of the affected part is certainly of some value; in cases of erysipelas of the fingers or scrotum, we can thus avoid gangrene. Then oil, grease, vaseline, and powders in all forms have been applied. Hebra recom- mended the extensive use of ice, while his followers went so far as to freeze, so to speak, the infected spot. In spite of Hebra’s favorable results with this treatment, it is beyond question that gangrene sets in more easily when the vitality of the tissues is thus lowered. Theoreti- cally, it was a decided step forward, when the attempt was made to destroy the poison produced by the cocci of erysipelas in loco by the hypodermic injection of remedies. Everything has been tried for this purpose, beginning with carbolic acid aud like antiseptic solutions, ergotine, quinine, morphine, etc. The results of this treatment have been varied, and at present the method seems to be used only to a very small extent. Starting from the same theoretical idea which led to the hypodermic injection of carbolic acid, inunction with turpentine was recommended by Liicke and others. Besides this, the use of tar and mercurial ointment was advocated. Of other remedies which are still in use, we have to name Churchill’s tincture of iodine, nitrate of silver, and collodion. Some absolutely reliable authors recommend the tincture of iodine very strongly, but dwell specially upon the fact that this remedy must be used very energetically. We must not forget, however, that its application is extremely painful, and is surely con- traindicated in the severer cases of erysipelas, with tendency to gan- grene and phlegmon. Nitrate of silver has been employed in different forms, but is applicable only in certain portions of the body. The im- portant point is, that that part of the skin to which the remedy is to be applied shall be thoroughly freed from fat, and that not only the red- dened portion shall be thoroughly treated, but also the adjacent parts. Some years ago, Volkmann had entirely given up the use of solutions of less than ten per cent, in strength, and applied exclusively and ener- getically the caustic pencil. The theoretical explanation given for its use is, that the nitrate of silver produces an infiltration of small cells in the part surrounding the seat of infection, forming as it were a wall of living cells of the greatest vitality, which the erysipelas coccus cannot overcome. Collodion, which was used for quite a long time, seems to have been given up entirely till very recently, when Niehans, Saclio, Schneider, and Ratcliffe have recommended it emphatically. Its effect is explained simply by mechanical constriction. It should be avoided on the scalp, whence it is very hard to get it off again, and of course on the eyelids, where its application has been reported to have once caused panophthalmia. It is needless to mention more fully the use of the thermocautery, as it has been abandoned entirely: but scarifications seem to be of the highest value, especially if they are applied in the way which is known as Kraske-Riedel’s method. This consists in making cuts somewhat like a worm-fence, from one and one-half to two inches in length, which form an enclosure entirely around the affected spot, at a distance of at least one inch, if possible, from the latter. Special attention must be paid that each cut crosses the two adjacent ones, so that the skin on the one side is really fenced off from the other. After this has been done, and the wound has bled ERYSIPELAS. 89 freely, which is only advantageous, a 1-500, or 1-1000 corrosive-subli- mate solution is rubbed in with some force. Then a bandage wet with the same solution is applied, and must be changed every six hours. Of course, this method is limited to the extremities and the trunk. The cuts should not be deeper than just to penetrate the integument, and should not go down as far as the subcutaneous fat. Of all the modes of treatment which I have used and seen used, Kraske-Riedel’s seems to be the most valuable. Special stress must be laid, however, upon operat- ing only in healthy tissue, which is the more important as it is well known that the infection has commonly progressed farther under the cuticle than the surface-inflammation shows. Wherever the fence is too near, we find that the erysipelas has broken through; that is, it ex- isted already, before the operation, in the lower strata of the epidermis, and simply became apparent on the surface on the following day. Where- ever such a break occurs, it is sufficient to draw a semicircular series of similarly crossed cuts around the new tongue-shaped place, starting and ending in the original enclosure. As to the way in which this operation influences erysipelas, I have more confidence in its quality of dividing the continuity of the skin, than in the action of the antiseptic which is applied afterwards. Although the latter may contribute to the wholesome effect, the cutting of the lymphatic ducts, through which the infection principally spreads, mechanically stops its progress. Where this method cannot be applied, as for instance in the frequent cases of erysipelas of the head, properly applied compression by means of adhesive plaster or a rubber bandage shows good results. If the in- fection starts, for instance, from the nose, the whole head, with men, is shaved, while with women only a circular band of hair, about an inch wide, is shaved out. With the hard skull as a basis, we have an excellent chance to use compression on the skin threatened by the ad- jacent erysipelas, whose spread seems to be actually stopped by this method. The theoretical explanation of its action is the same as that of Kraske-Riedel's method, the continuity of a vessel being severed by thorough compression as well as by cutting. Effect of Erysipelas on Neoplasms.—It has long since been ob- served that intercurrent erysipelas of the skin has sometimes a striking influence on neoplasms, particularly of lupous and syphilitic nature, with or without ulceration, and then, especially, on genuine tumors, for in- stance sarcoma and carcinoma (so-called curative erysipelas). It has been noticed that the above-mentioned affections disappear lastingly, that long-existing ulcers and chronic diseases of the skin grow better, and sometimes even heal after accidental erysipelas has travelled over the affected surface. French authors call this very aptly “ erysipele salutaire,” and we find many reports of such cases (W. Buscli, Biedert, Schwimmer, Janicke, Neisser, P. Bruns, Langenbuch, Tillmanns, and others). While the results in lupus, syphilis, and other ulcerous affec- tions, have proved to be inconstant and only of temporary value, the closer study of the influence of erysipelas upon carcinoma, and especially on sarcoma in its different forms, has proved to be of the highest inter- est. W. Busch has shown that even large tumors, especially sarcomas and lympho-sarcomas, may undergo, under the influence of erysipelas, a rapid fatty metamorphosis, and thus be absorbed and entirely disappear. 90 DISEASES COMPLICATING WOUNDS. It is easy to understand why this most remarkable relation between erysipelas and malignant tumors, against which only too often even the most heroic operations are of no avail, has not led to the systematic treatment of these tumors with erysipelas; because until recently we had to produce genuine erysipelas, which was entirely beyond our con- trol as soon as it made its appearance, and which sometimes killed the patient instead of curing him. Lately, however, C. H. H. Spronck (Utrecht) has published in the Annales de l’lnstitut Pasteur, for October, 1892, a series of 26 cases of malignant tumor, which he and his co-operators have treated with a preparation of the toxic products of erysipelas, obtained in the same way as that by which Koch prepared his tuberculin. Before this, Rogers published in the Revue de Medecine, for December, 1891, his experiments on animals with heated or filtered cultures. William B. Coley (New York) has also made experiments with filtered toxines (ob- tained in the usual way through clay filters by suction), and has pub- lished his results in papers in the American Journal of the Medical Sci- ences, for May, 1893, and the Post-Graduate (New York) for August of the same year. His latest report of 35 cases of malignant, inoperable tumors treated with the toxic products of erysipelas and the bacillus prodigiosus, are to be found in the Transactions of the American Surgical Association for 1894. While the author seemed to be very enthusiastic about his results, W. W. Keen, Roswell Park, and others, in discussing the paper, said that in the cases in which they had made injections with the extract furnished by Dr. Coley himself, they had been unable to obtain any cures. This has also been my own experience, in the few cases which I have had occasion to observe. Nevertheless, these in- vestigations are of the greatest importance, and invite further research, as they show at least the possibility of curing even the most malignant tumors. II. Septicaemia and Pyaemia. There is such confusion in the nomenclature of these affections, and so much discussion about the etymological correctness of the different ex- pressions used for the same disease, that I cannot do more than men- tion all the different names, and leave it to the reader to select that which he likes best, or to which he is most accustomed. Piorry first used the expression septico-emie, from which all other writers, especially German authors, have derived the following differ- ent expressions: Septicsemie, septichaemie, and septikaemie. The roots of all these words are * Efficacious 5 f 5 Cauterization j 2 1 No cauterization 3 2 21 1 on 9 \ 1 13 ) 09 19 f 1 4}ft 4f8 Ajitfljs innieteu on liands ( Efficacious Cauterization *\ -^t / JNon-emcacious 11 16 3 No cauterization 18 15 5 5U ar 4u 4f8 1 6|6 2 Bites inflicted on limbs and body -j -Multiple j Efficacious cauterization ■< -vr 1 JNon-efficacious 4 2 1 No cauterization.... 3 5 3 Clothes torn 2 3 Bites inflicted on bare parts 5 1 i Bites on different parts of body .. .5 n.n,t„n',nt:An i Efficacious 1 Cauterization < -vr ,,, { JN on-efficacious 1 No cauterization 3 General total, 104. 47 42 15 The column A refers to persons bitten by animals in which hydro- phobia had been evidenced by experimentation, or by death of some other persons or animals bitten by them; column B to persons who had been wounded by animals recognized as rabid by the clinical or veterinary examination; and column C to cases in which hydrophobia could only be suspected, as the animals had disappeared or were killed instantly and their bodies thrown away. HYDROPIIOBIA. 131 No death has been reported among these 104 persons, treated in 1892. It will be of interest to those who may desire to follow up the his- tory of these cases, to know from what localities the persons came, as follows:— 2 Alabama. 13 Connecticut. 2 Iowa. 1 Louisiana. 4 Maryland. 5 Massachusetts. 1 Michigan. 1 Mississippi. 2 Missouri. 40 New Jersey. 7 New York. 2 North Carolina. 2 Ohio. 2 Pennsylvania. 1 South Carolina. 3 Tennessee. 2 Texas. 14 Virginia. The following statistics of various Institutes on the principle of the Pasteur Institute in Paris, which have a historic value in the records of inoculation, are given by Dr. Paul Gibier1:— In St. Petersburg 484 people were vaccinated from July, 1886, to September, 1888, with a mortality of 2.68 per cent. In Odessa 324 persons were vaccinated in 1886 by the primitive method, with a mortality of 3.39 per cent. But in 1887 and 1888, 709 persons submitted to the intensive treatment, and the mortality was reduced to 0.60 per cent. In Moscow the Institute received 107 persons in 1886, who were subjected to primitive vaccination with a mortality of 8.40 per cent. But having adopted the intensive treatment in 1887 and 1888, 526 persons were subjected to it, with a mortality of only 1.45 per cent. In Warsaw, out of 370 people treated by the new method, not a single death occurred. In Milan 335 were inoculated; deaths, 0.60 per cent. In Palermo 109 inoculated; no deaths. In Naples 246 inoculated; mortality, 1.5 per cent. In Havana 170 were bitten and inoculated, and the mortality was only 0.60 per cent. In Rio de Janeiro, where Dom Pedro II. founded a splendid Institute, 53 were inoculated within a short time without a single death. It is stated by Gibier that England has been one of the chief sub- scribers to the Pasteur Institute of Paris, where a number of British subjects are daily cared for. He refers also to the report of Mr. Y. Horsley, the eminent physiologist, who in the name of an official commission composed of the principal scientists of England (among them Sir James Paget), recently declared that “M, Pasteur had dis- covered a method preventive of rabies, that was comparable to vaccina- tion against variola.” The technique of the successive operations required for the prepara- tion of the anti-rabic virus is as follows: The vaccinal matter consists of fragments of the spinal cord of a rabbit killed by hydrophobia, wliiph are progressively desiccated at a fixed temperature, and in the dark. Every day a fragment of this substance is injected, but every time a less dried specimen is employed, being nearer to the virulent state. The introduction of the active principles of the cords of rabid animals into the peritoneal sacs of rabbits, was found by Colli to produce rabies in from ten to twenty days. The period of incubation in dogs varies, and a report of the cases of six dogs bitten by a rabid animal gave the period of development as twenty-three, fifty-six, sixty-seven, eighty- eight, one hundred and fifty-five, and one hundred and eighty-three days respectively. 1 The North American Review, August, 1890. The Pasteur Treatment, p. 163. 132 HYDROPHOBIA. In human beings, statistics show that in sixty per cent, the period of incubation varied from eighteen to sixty days, while in thirty-four per cent, the period exceeded two months. In some cases the outbreak occurred from three to six months, and in others from one to two years, after the bite. Incubation in six per cent, extended from three to eighteen days only. It is estimated that forty-seven per cent, of per- sons bitten by mad dogs develop hydrophobia. According to Youatt, two-thirds of the dogs bitten by rabid animals become affected; while Hertwig found that only six, out of one hun- dred and thirty-seven dogs bitten, died from the disease. Renault declares that he could only impart the disease by inoculation in sixty- seven per cent, of dogs so treated. Of 796 human beings affected with hydrophobia in France, Wur- temberg, and Milan, 715 were bitten by dogs, 30 by cats, 31 by wolves, 19 by foxes, and 1 by a cow. Watson quotes 75 cases of human beings, in 40 of which the hand was bitten by rabid animals, in 15 the face, in 11 the leg, and in 9 the arm. Bollinger reports 495 cases, in which the wound in 53 per cent, occurred on the upper extremities, in 22 per cent, on the hands and face, in 22 per cent, on the feet, and in 3 per cent, on the body and scrotum. In wounds of the face, 90 per cent, are followed by hydro- phobia, in those of the hands 63 per cent., in those of the lower ex- tremities 28 per cent., and in those of the upper extremities 20 per cent. The variability of the period of incubation is owing in part to the site of the wound, and an explanation is offered by Gibier for the shortness of incubation observed in wounds of the head and face, as well as its longer duration when the limbs, and especially the lower ones, have been bitten. He says, that after the rabic virus has been deposited upon the tissues which have been lacerated by a bite, one of two things may take place: either the virus remains on the wound, or it is carried into the general circulation by some torn blood-vessel (com- monly a vein). In the first case it may happen that the phagocytes destroy the microbes, and no rabies occurs; but more frequently, the germs coming into contact with torn nerves are developed within the central portion of these organs, and thence are propagated as far as the nervous centres. This, in his view, explains the long duration of some incubations; for the march of the virus, that is to say, the devel- opment of microbes, may take place at first, and then only in a minute nervous fibre, whose cells offer a more or less important resistance to the invading germs; and before being able to reach the medulla and cerebral centres, the journey’s length must vary according to the dis- tance from* the inoculated spot to the medulla or the brain. Gibier remarks that if the absorption takes place through a blood- vessel or a lymphatic, it is easily understood that the incubation will not be of much greater duration than in those cases in which, for experimental purposes, the rabic virus is injected into the veins of an animal. In this event the duration is independent of the situation of the wound. The incubation seldom lasts less than three weeks, and generally lasts much longer. It was the knowledge of this fact that suggested to Pasteur the idea, which has since proved so useful, that if one could render an animal refractory to rabies by means of injec- tions of attenuated virus, it might doubtless be possible to produce this HYDROPHOBIA. 133 very state during the interval which separates the time of biting from that of invasion. There has appeared upon the scene another claimant, not only as a prophylactic but as a curative process, in the action of gastric juice upon the cords of infected rabbits, as proposed originally by Eusebio Yalli, and since adopted by Centanni. The emulsion, thus prepared, is said to arrest the progress of rabies in rabbits which have been under its influence for six days, while animals subjected to the opera- tion of the same virus without its antidotal effect die within seventeen to eighteen days. Tizzoni and Centanni concluded from their experi- ments that the disease already developed in rabbits was cured by inoc- ulation with this matter; and the inference drawn from these results encourages a resort to this injection in human beings who have been bitten by mad dogs or other rabid animals, and who have already the premonitory symptoms of hydrophobia. It is held to be not simply protective, but to be curative in its action. My personal observation extends to three cases cf hydrophobia treated in Brazil, during my residence in that country, and I am able to add to these the report made of a case in. this country, since return- ing, which I was called upon to investigate by Mr. Henry W. Grady for the Atlanta Constitution. The first case occurred in the person of a white boy, eight years old, at the City of Campinas, in the province of San Paulo, Brazil. He was bitten by a dog, which presented all the characteristics of rabies, on the 28th of June, 1882, and was brought to my office shortly afterward, with the blood still oozing from the tooth-wounds upon his leg. After washing thQroughly the parts, I gave directions to have each of the openings and the abrasions of the skin well cau- terized with strong nitric acid. The father of the boy was then instructed to await developments, and in the event of further trouble to let me know promptly of any disturbances. On the last day of August, sixty-four days after the bite was inflicted, I was called at 4 a.m., with the statement that the boy had been nauseated, with retching, on the previous day, but had been unable to bring up anything. My son, Dr. T. D. Gaston, was dispatched at once to see the patient, and finding him in a state of great agitation and restlessness, he administered by inhalation, at short intervals, four ounces of chloroform, before any material relief was afforded. I saw him with my son at 10 a.m., and found the boy writhing with spasmodic contractions of almost every muscle of his body, and constant convulsive movements of the arms and legs, with hideous contortions of his face. He would cry out as if in great pain, when the spasm was intensified, and spring up in the bed, spitting from the mouth foam mixed with blood. While his mental faculties were greatly excited, he was not delirious, but seemed conscious of passing events, and answered questions understandingly as to his sensations. Upon giving him a cup with water, there Avas an aggravation of the convulsive movements, and yet he attempted to drink Avithout the ability to sAvalloAV. The cup, being seized with his hands, Avas turned up, so as to spill out the Avater from his lips; and yet none of it went down his throat. Morphine having been given Avithout effect, the use of garlic Avas resorted to in- ternally and externally, as I had read an account of a man with hydrophobia having been shut up in a room Avhere, suspended on the walls, Avas a quantity of garlic, which Avas ravenously eaten Avith salutary result. This boy ate the garlic freely, and even asked for more when the first portion Avas consumed. It was beaten up also and applied over his chest and boAvels in the form of poultices, Avliile a decoction of the garlic Avas used as an enema. 134 HYDROPHOBIA. At 1 p.m. I took Dr. Melchert to see the patient, and found the spasm in- creased, with aggravation of all his sufferings. We resorted to inhalations of nitrite of amyl in doses of 15 drops every five or ten minutes for more than an hour, the boy being held by his father, but it had no perceptible influence upon the irregular movements. His powers seemed to become exhausted by the violence of the paroxysms, and his pulse became so frequent and feeble that it could not be counted at the wrist. He died at 3.30 p.m., less than twenty-four hours from the onset of the disease. It may be a matter of some interest in studying the surroundings of this case, to give the thermometric record of the day. The tempera- ture of the atmosphere at 7 a.m. was 66° F.; at 2 p.m., 74° F., and at 9.15 p.m., 75° F. It was a clear and sunny day. The access of the disease was not therefore induced by anything unfavorable in the state of the weather. The second case was brought to me from the country in the person of a mulatto boy of 1G years, with the history that he had been bitten about a month previ- ously by a mad dog, and that he had been complaining of his head for twenty- four hours. lie was then suffering from general disturbance of the nervous sys- tem, with inability to swallow fluids. There was not such marked spasm of the muscles as in the boy whose case has been reported above, yet the symptoms ran such a course as to impress me with the characteristic features of hydrophobia. He was given ten grains of calomel, followed in two hours by a tablespoonful of castor-oil and a teaspoonful of oil of turpentine. After the bowels had been moved freely, a hypodermic injection of sulphate of morphine, gr. and sulphate of atro- pine, gr. -7*5-,was administered. Frictions with oil of turpentine were employed over the spine and epigastric region at frequent intervals. Carbonate of ammonium and camphor water were given internally, while enemata of lac assafcetidse were liber- ally used. My treatment was intended to be conservative, so that no harm should come from the remedies employed, and that the charge of killing the patient might not hold against me. It has been claimed that the desperate nature of this disease warrants the use of desperate means, and the most violent measures have in some instances been resorted to, even to the infliction of bites from ven- omous serpents, under the supposition of some antidotal influence. In this case, however, I determined to avoid all crucial medication, and left the patient k> succumb to the violence of his disease rather than to the toxic properties of drugs. He died from exhaustion on the second day of treatment, being the third after his attack, and thirty-three days after he had been bitten by the rabid dog. Here it may be noted that no attempt was made to cauterize the wounds, and that the period of incubation was only about one-half that observed in the case in which the nitric acid had been ordered, but per- haps not properly applied by the father of the boy. The third case which came under my observation was that of a young white man, about twenty years old, who had felt uncomfortable for a day and a night before I was called, nervous twitching with occasional spasmodic contraction of the limbs having supervened during the morning. There were periodic exacerba- tions of a convulsive nature observed during my first visit, and upon inquiry, it was learned that the patient had been bitten on the ankle by a small dog about two years previously. Neither he nor his friends had suspected at the time that this was a rabid animal, and they did not know what had become of it. The difficulty in swallowing water being notable, I made out the case as one of hydrophobia, and determined to rest my treatment upon frictions along the spine with camphorated oil of turpentine, and upon inhalations of ether, the use of which upon a towel, held over his mouth and nose, gave relief to the patient. HYDROPHOBIA. 135 As to the final effects of the employment of the ether in this case, urged from time to time so as to control the violence of the paroxysms, nothing was observed which should give encouragement to its repetition in similar cases. Having experimented with chloroform at the outset of the first case, and afterward with the nitrite of amyl, and now having tested the influence of ether, without securing any satisfactory result, I should be inclined to try some other class of medication if another case of hydrophobia should come under my care. The patient died on the morning after I first saw him, having had most violent paroxysms of irregular muscular contractions whenever the ether wras temporarily withdrawn. There was no evidence of any curative agency from its use, though his sufferings were lessened, and only for euthanasia is its employ- ment commendable. While administering the ether, my forefinger was caught between the teeth of the patient, and was lacerated so that the blood flowed from it at a point on the inside, near the nail. The wound was imme- diately bathed in oil of turpentine, and sucked by myself most energeti- cally, the finger being afterward enveloped in cotton saturated with turpentine. I had received the impression from writers on this disease as it occurs in man, that it was not communicable by the bites of human beings. But I considered that an abundance of caution in this case was called for, and hence acted promptly in preventing absorption by a firm grip around the finger with my other hand, until it had been washed with the oil of turpentine and thoroughly sucked. It gave me no con- cern afterward, and more especially as the bite had been inflicted through a fold of the towel held in the hand, did I feel relieved of all apprehen- sions. It has been proved since that the human virus may give the disease, and hence a bite should not be neglected. In compliance with a request of Mr. H. W. Grady, as already men- tioned, I made a visit to Social Circle in February, 1889, to get the facts connected with the death of a man in that neighborhood. It was reported currently that he had suffered from hydrophobia, and the object was to confirm or disprove that allegation. Mr. J. H. W., a white man of middle age who lived on his farm, was bitten by a cat on January 2, 1889, the weather then being very cold. The wound was on his left front finger, where there had been a bone-felon in former years. He went on with his ordinary duties without seeming to be concerned about the in- jury, and the wound healed kindly before the end of the month. On February 2, there had been pain in the part, and on the following day he had had chilly sensations. During the 4th, 5th, and 6th of February there were developed well-marked convulsions, with dread of water and great difficulty in swallowing fluids, while froth came from his mouth. On the third day of his disorder, he would be quiet a minute or two, and then a “spell ” would come on and he would jump up and run around the room, saying afterward that he was choking to death. He could say nothing while the “spell ” was on him. He attempted on the morning of the 5th to take milk through a quill, and got a little in his mouth, but could not swallow it. In the evening, however, he ceased running and hitting himself on the breast to get breath, after which he was able to swallow, and drank several dippers of water. The “ spells ” still, came on occasionally, but he seemed to be getting better for a time. But about midnight he changed for the worse again, and he would jump up three or four feet from the floor and beat himself with his fists. Those around him tried to hold him in bed, and he would clinch his jaws and grit his teeth, and gasp for breath. He died at 9 p.m. on Wednesday, February 6, after repeatedly 136 HYDKOPHOBIA. jumping up from the floor of the room in which he was kept under guard by his friends. When the symptoms in this case are taken in connection with the fact that the patient had been bitten by a cat which exhibited a pugnacious disposition, there is a strong presumption in favor of the trouble having had its origin in the bite. The disorder developed in a month after the injury to the finger, and ran its course with paroxysms of nervous and muscular disturbance, terminating in death after four days of acute suffering. The spasm of the throat which prevented the swal- lowing of water or other fluids, the general excitement, the incessant movement of the limbs, increased by contact of currents of air with the body, and the frothing of the mouth in the later stages of his disturbance, render it clear that the patient labored under hydrophobia. It was evident that his mind was not deranged in a way to affect his appreciation of passing events, but he manifested a disposition to do many things of an extraordinary character, including an inclination to bite those who came in close proximity to him. There were on those days exacerbations of the spasmodic movements, and his neck and face were disfigured by considerable swelling. lie seemed impressed with a conviction that death was near at hand, but did not give any intimation that he was aware of the nature of his disease. It may be stated that the cat was killed soon after biting this man, under the impression that it was suffering from rabies. There were a number of instances reported by the people in the neighborhood, in which dogs and cats had gone mad and had been killed. Some persons had been bitten by these animals, but no other case of hydrophobia had occurred. The “mad-stone,” so called, had been used in some of those bitten, but in others no sort of treatment had been employed. There is found in the stomach of the deer a concretion of a porous nature, which has been applied to the wounds inflicted by mad dogs, under the designation of “mad-stone,” and if it adheres to the part it is supposed that the poison is extracted. Any porous substance when moistened may, by capillary attraction, promote a discharge from a wounded surface to which it is applied, and it is claimed that the virus thus enters the interstices of the stone. In the cases now under consideration, a solid mass taken from a horse’s head, and hence inferred to be of an osseous nature, had been employed; but in other instances, when nothing of the kind had been used, the per- sons bitten escaped in like manner, without any serious consequences. It seems that substances derived from various sources have received the designation of “mad-stone,” and among the common people have been accredited, but there is no proof of their efficacy. With the light before us in regard to the efficacy of intensive inoculations during the period of incubation of hydrophobia, in the re- duction of mortality to \ of 1 per cent., those bitten by rabid animals should of course avail themselves of the Pasteur treatment. But there are many instances among those who are not informed of their danger until the onset of the disease, for whom antidotal measures might avail, if a true antidote should be discovered. Having observed the controlling influence of large doses of bromide of potassium and hydrate of chloral in the treatment of traumatic tetanus, I should be inclined to push 'this line of medication to the uttermost tolerance of the patient, should another case of hydrophobia come under my care. Let others deter- mine upon the course which seems most favorable for clinical expevimen- HYDROPHOBIA. 137 tation in this disease, and it is not beyond the range of probability that a trustworthy remedy for hydrophobia may yet be discovered. In regard to the treatment of hydrophobia when the disease is actu- ally present, there have been more definite results from the woorara than from any other of the many agents which have been employed. But the general principles of therapeutics have not availed for any definite rule of treatment other than to seek a corrective for the disordered nerve-centres. It is evident that no inference should be drawn in favor of the efficacy of measures applied during the period of incubation, as there is no sufficient ground, in most instances, to believe that the disease would have been developed. In view of the great fatality of cases in which hydrophobia has actually appeared, and of the very limited bene- fits derived from medication of any kind, there is open to the profession a wide field for experimentation on the canine species, to ascertain what course of treatment may prove efficacious in staying the lethal tendency at the earliest stage of the disease. In like manner heroic remedies should be tested early in the human subject by scientific investigation. SCROFULA AND TUBERCULOSIS. BY F. FORCHHEIMER, M.D., PROFESSOR OF PHYSIOLOGY AND OF CLINICAL DISEASES OF CHILDREN IN THE MEDICAL COLLEGE OF OHIO, CINCINNATI, OHIO. Etiology and Pathology. With the discovery of the cause of tuberculosis by Koch, in 1882, the whole subject has assumed a different aspect. The acceptance of the bacillus tuberculosis as the primary cause of all tubercular processes, it matters not as to their nature or their locality, has given us an entity which makes superfluous most of the theorizing for which this broad subject has been noted. The work of Koch in this direction has been so broad, so fundamental, and so thorough, that it has not been found necessary to take away from it or add to it one iota, and subsequent observers have been able to verify fully all that he has done. As a result of the labors of Koch and his followers, it can be truly said that there exists neither animal nor plant whose characteristics or proper- ties are better understood by scientists than those of the bacillus tuber- culosis. While admitting this, gratefully and freely, it must be as freely admitted that the chapter on human tuberculosis has by no means been written to its end. It seems strange to look upon a dis- covery made but eleven years ago as in the light of remote history, but so much has been done since that time that such a view is warrantable. In the justifiable enthusiasm of that period so much was done with the bacillus, and so little regard paid to the human being, that many con- clusions were offered and accepted which, in the light of subsequent and cooler observation, had either to be amended or dropped; so that many over-cautious members of the profession were apt to look upon the whole subject of the bacillary origin of diseases with distrust. At the time of writing, however, the proofs originally required by Koch have been accepted as adequate, and the bacillus tuberculosis is univer- sally looked upon as the cause of the tubercular process. Sufficient time has elapsed to test these views in practice, which is, after all, the best testimony as to the value of any discovery, so that one of the greatest achievements of science, in any age, can be attributed to this century. The purely technical portion of the subject need not be discussed here; in these days it has become common property, and has been treated of in works especially devoted to bacteriology. The diagnostic value of the bacillus tuberculosis is established, and no practitioner considers his 139 140 SCROFULA AND TUBERCULOSIS. diagnosis of a tuberculous process complete without a demonstration of the bacillus, which he can make for himself by methods well known and easily executed. The two etiological factors of the production of tuber- culosis in the human being are the bacillus and predisposition. The bacillus is a parasitic plant, rarely saprophytic, and the human being, the ruminants, with rabbits, guinea-pigs, and other animals, are its hosts, and from these, by means of infection, the process is transmitted to others. This is done in Ane of a great many different ways, but the tubercle bacillus, or its spore, is always introduced into the healthy animal. The fact that the spores of the bacillus elude detec- tion except by culture, gives rise to the possibility of deductions that may have to be revised in the future. Infection of the human being takes place either by way of a mucous membrane, from a lesion of the skin, or during intrauterine life, from either the male or the female. The hereditary form of tuberculosis has been a subject fruitful of dis- cussion. In the early days of the discovery of the bacillus, heredity as a factor in the production of tuberculosis was almost swept away. Not- withstanding the accumulated evidence of ages, the adherents of the bacillary nature of the disease felt themselves constrained to deny the existence of hereditary tuberculosis; the fact that the bacillus could be transmitted from parent to offspring did not enter into their calcula- tions as an additional evidence of the important role which it played. At the present day, Galtier has proven the existence of congeni- tal tuberculosis experimentally, and observations by Lucas, Schmorl and Birch-Hirschfeld, Baumgarten, Landouzy, McFadyean and others, make it imperative to accept this form of tuberculosis. In these cases the bacilli or their spores pass through the membranes of the placenta, and infection of the fruit takes place. The mucous membrane may become infected either by inhalation of the tubercle bacillus (respiratory tract), by the swallowing of infected food (gastro-intestinal tract), or by direct contact with the bacillus in other ways. The mode of infection seems to vary with age; in chil- dren we find the intestinal tract with its adnexa most commonly affected, in adults it is the respiratory tract. Milk is the most common carrier of infection for children; for adults it is the breathing in of dried tuber- cle bacilli. The fact that not all who breathe or swallow tubercle bacilli, proba- bly not the majority, become tubercular, and certain other facts, have led to the reacceptance of the idea of predisposition. When an enthusiast (Cornet) says that the human being is just as much predisposed to be- coming infected by the tubercle bacillus as a soldier in battle is predis- posed to being struck by a bullet, it marks a period in bacillary litera- ture characterized by acceptance of laboratory facts, regardless of clinical experience and medical tradition. As there are animals im- mune to the tubercle bacillus, so there are doubtless human beings in whom it would be impossible to cause the tubercle bacillus to grow. Predisposition is of two kinds: permanent and temporary. The first inherited, congenital, or dependent upon some peculiarity of structural or metabolic function not definable at the present time; the second usually produced by some disease, whooping cough, measles, syphilis, or, locally, by some inflammatory lesion. Again, there may be a local or a general predisposition; the local predisposition is probably most ETIOLOGY AXl) PATHOLOGY. 141 common, certain tissues, as bone and glands, being most remarkable in this respect. In some human beings tuberculosis may remain localized for a life-time, and yet, as has been shown in the treatment of lupus by tuberculin, a general predisposition may be created which may cause the patient to lose his life by the invasion of vital organs. Attempts are being made in civilized countries to prevent the spread of tuberculosis; this has been done as the result both of private and of state initiative. While it is, as yet, too early to speak of results, the next ten years must certainly show whether or not we'are on the right track. From a purely theoretical standpoint, prophylaxis may be obtained in two distinct ways—first, by preventing the contact of the bacillus with human beings; secondly, by making its contact harmless. As yet we are engaged with the solution of the first method. It has been the object to prevent contact by hunting up the source whence bacilli come, and then removing this source. It is needless to say that much has been insisted upon, in this di- rection, that will be deemed unnecessary in the future. Many sug- gestions have been made that, while perfectly just, are nevertheless absolutely impracticable: to change the breed of cows, to give up drink- ing milk or eating butter, etc., etc. As we know the sources whence tubercle bacilli come, all that seems necessary would be a careful con- trol of these sources; unfortunately, this is an undertaking of enormous magnitude, involving many questions, and not likely to be completed in the present condition of civilization. It involves competent inspection of food, scientific observation of cows supplying milk, and, lastly, the treatment of individuals affected with tuberculosis, as a source of infec- tion. It is unnecessary to dwell upon the latter feature; it will cer- tainly require much dissemination of knowledge before this can be ac- complished, and when it has been accomplished, let us hope that it will have been done in a manner less cruel and inhuman than seems necessary according to the directions insisted upon by extreme enthusiasts. The sober discussion by learned societies of the question, “ Should phthisical patients be allowed to marry?” although not new, shows the trend of modern opinion. At the same time it shows the Utopian plans of these purely theoretical people. When the time comes in which the proper authority can determine the breeding of human beings, the days of physical perfection will be at hand. The other method, that of ren- dering the tubercle bacillus innocuous, would seem more feasible in all directions. The tubercle bacillus is not ubiquitous, but comes from sources rather well known; for the present it seems more practicable to diffuse knowledge in this direction, and to do so is evidently the duty of every practitioner, however humble his station. For scrofula, matters are very much more unsettled than for tuber- culosis. The statement can be made without fear of contradiction that most cases of scrofula are really cases of tuberculosis; this has been proven by investigation both clinical and otherwise, and by the appli- cation of this view to therapy; indeed, many processes in glands and bones, formerly called scrofulous, are now unhesitatingly pronounced tuberculous, and can be proven such by careful examination. But there are a good many patients in regard to whom it would cer- tainly be wrong to speak of tuberculosis; the utmost that would be warrantable would be to say that these have a tendency to tuberculo- 142 SCROFULA AND TUBERCULOSIS. sis, that they are predisposed to tuberculosis. To this class belongs that large number in which we find a certain vulnerability of tissue with accompanying enlargement of lymph glands; in which the least irri- tant will produce an inflammation characterized by chronicity and lack of tendency to restitutio ad integrum. While the uncertainty of the nature of the process in this number must he continually reduced with increased research as to etiology, there will, of necessity, be left a cer- tain portion in which the cause must be sought for within the individ- ual. Here again, we shall find a local as well as a general predisposi- tion ; enlarged lymphatics predispose to those processes called scrofulous, impeded lymph-circulation will render tissues more vulnerable, it mat- ters not whether enlarged lymphatics are produced by local or general causes; a tubercular gland will therefore be a cause for so-called scrofula. A step farther will bring us to the conclusion that glands enlarged as a result of any cause, as simple as the presence of pediculi capitis, may act in the same manner. On the other hand, any general cause producing enlarged lymphatics will be followed by the same effects; tuberculosis, syphilis, the acute exanthemata, notably measles. If, then, we were to define scrofula as tuberculosis, we should be overshooting the mark, as in many cases we have no evidence that such is the case, or that there ever will be tuberculosis. But, on the other hand, if this is not ac- cepted, there remains no definition except that of a predisposition to many things, including tuberculosis. A careful view of the history of scrofula will show that many things were formerly accepted as scrofula which, with the advance of science, have been proven to be due to other •causes. Where formerly whole books (Lugol, Scharlau, Hufeland, Glover, Kortum, and others) were written upon scrofula, the subject can at the present time be satisfactorily dealt with in a chapter. The ques- tion naturally arises, Are we justified in making a diagnosis of a pre- disposition? Can such a diagnosis be put upon a scientific basis? It cer- tainly seems as if both questions should be answered in the negative. The diagnosis is not even one that is necessary; it is an obstacle to searching for the true cause of the condition; it therefore prevents in- vestigation and does the patient harm in that it is in the way of causal therapy. For the present, it is suggested that scrofula be dropped from our nosological table, to be reinstated when we can come to some defi- nite knowledge regarding its entity. In this connection, as well as in regard to the whole subject of tuber- culosis, it is of paramount importance to decide whether tuberculosis is constituted by the presence of the bacillus, or by the production of lesions by the bacillus, or by both together. It is a self-evident propo- sition that bacilli may be found without tuberculosis. It is not so easy to decide whether lesions may be found, tubercular in nature, in which the bacillus or even its spores may have disappeared, or may not be proven to be present by inoculation or culture. The prebacillary patho- logical definition of tuberculosis is no longer accepted, but it seems neces- sary to make a new definition which will include all those changes that may be due to the bacillus tuberculosis. For scrofula it has been pretty accurately determined that all the lesions, with the exception of those of the skin and mucous membranes, are usually due to tuberculosis. Some experimenters, however, have failed to produce tuberculosis by inoculating with scrofulous glands, and, as yet, it is too early to decide TREATMENT. 143 the question without the aid of pathological anatomy, a neglect of which is already beginning to show itself among the tendencies of the ardent followers of bacteria and immunities. Treatment. Next to the discovery of the bacillus, the treatment of tuberculosis has enjoyed the attention of the whole medical world more than any other division of the subject. The fundamental work of Koch had been so thoroughly done and so thoroughly accepted that when, at the tenth meeting of the International Congress at Berlin (1890), he intimated that he had found a remedy for tuberculosis, every physician consid- ered the whole matter more than half solved. This attitude was, however, quickly changed to expectancy by Koch’s first publication, which took place simultaneously in England, Germany, and the United States—so eager was every one to obtain details of the good news. The claims that Koch made for his remedy, afterward called tubercu- lin, were (1) That it made animals immune to tuberculosis and cured animals ill with tuberculosis; (2) That it was a diagnostic remedy ab- solutely essential; (3) That it was curative. Koch does not describe the method of obtaining the remedy, a procedure in which he is unfor- tunately upheld by some of the best German authorities, and one which cannot be too strongly condemned; but he tells where the remedy can be obtained, and advises the use of a new hypodermic syringe which is as cumbersome as it is unnecessary. Tuberculin, he claims, causes a specific effect upon tubercular processes; the diseased tissue is killed and is detached as a dead mass, or is fluidified; the bacilli are not killed, but the tissue surrounding them is affected. The diagnostic effect is observed in the form of a reaction, consisting essentially in a decided rise in temperature, accompanied by malaise, cough, vomiting, diffi- culty in breathing, preceded by a chill—one or more of these symptoms— but always the rise in temperature. For lupus, and for tuberculosis of glands, bones, and joints, he promises “rapid cure in fresh and mild cases, slowly progressive improvement in severe cases. ” In phthisis there is to be, first, increase in cough and expectoration, then diminution and disappearance of these symptoms as well as of the bacilli. “Incipient phthisis can be cured with certainty by means of the remedyrelapses are unimportant, as they also can be cured. Only where there are large cavities can little be expected. With all this promised by a man of Koch’s scientific reputation and trustworthiness, it is not to be wondered at that Berlin was looked upon as a Mecca, that both physicians and pa- tients flocked there from all parts of the world, that scientific societies were dragged into enthusiastic utterances,1 and that even German-hat- ing Frenchmen like Pasteur were converted {il y a, il n’y a pas a dis- cuter). In this period of enthusiasm every one, with few exceptions, was for the remedy; the subject was taken up by the German government, the Reichstag was interpellated (Dr. Graf): “ What will the government do to get the remedy and make it of service to Germany, if necessary to the whole world?” At the same time the lay press was doing its best to obtain every sensational element out of the situation, being assisted 1 Freie Vereinigung der Chirurgen Berlin’s, 16 Nov., 1890. 144 SCROFULA AND TUBERCULOSIS. therein by ambitious medical individuals, and what with the govern- ment, Koch and his followers, the patients, the doctors, and the medical and lay press, there ensued a period such as has never been seen before in medical history, but which resulted in a large number of experiments on human beings which must bring a certain amount of knowledge. During this period objections were raised to tuberculin by Leyden, Kaposi, Arloing, and Goldschmidt, as to its diagnostic value; Henoch and Litten warned against its use in tubercular meningitis; Ewald saw physical evidences of consolidation and even of cavities appear, and spoke of a death after injecting gm. 0.0002 in a case of lupus from disseminated catarrhal pneumonia in both lungs; Paul Guttmann stated that haemoptysis was a temporary contra-indication, but there were men of very good reputation who did not hesitate to speak of results after having used the remedy for three weeks. Thus did the printed matter increase, every country possessing its own Koch disciples and enthusiasts, until there seemed to be no end to tuberculin literature. It was left to the master-mind of Virchow to bring some order into this chaos, and, at the same time, to check the ever-increasing number of human experiments, by his authoritative statement from the post-mor- tem room. About three months after Koch's first publication, "Vir- chow made the following statements about tuberculin: It produced enormous hyperaemia; hemorrhage (one case died of haemoptysis from an old cavity); positive inflammation, especially at the edges of ulcera- tions and in the lymphatic glands (leucocytosis); oedema of the glottis, and phlegmonous retropharyngitis. In the lungs it might be followed by caseous hepatization and phlegmonous catarrhal pneumonia, in all prob- ability by fresh sub-miliary tuberculosis, which was not affected by the remedy. Again, all tubercles were not affected; those that were might give up their bacilli, producing secondary infection. He warned against the use of tuberculin, especially in ulcerative processes. This state- ment marked, as it were, the end of the period of enthusiasm, only inter- rupted by the second communication of Koch. In this communication Koch reported cures and repeated the claims of his first article. He now gave some information regarding the nature of tuberculin; it was a glycerin extract of tubercle pure cultures; the active substance could be precipitated by alcohol, but was not a toxalbumin, as it withstood high temperatures and could be dialyzed; about one-fourth per cent, of this was contained in tuberculin. We now come to the discussion of the second period in the history of this remarkable remedy; one in which sober thought, careful investi- gation, and criticism, took the place of blind faith and thoughtless fol- lowing of a great leader. In this second period not a single claim which Koch made in his first paper remained unchallenged, so that the query arises why Koch should have published as he did, and then have followed up his first publication by a second one amplifying the first and maintaining its supposed truths. Rumors of various sorts have been spread explaining the prematurity of publication; much ma}r be done to rehabilitate the confidence, now lost, in Koch, yet the fact re- mains that the medical profession of the world has been reduced from a condition of joy and happiness in the discovery of a remedy for tuber- culosis, to one of distrust and disappointment, much to the detriment of other discoveries that may be made. The effect upon the public has been TREATMENT. 145 incalculable as to the lack of confidence, natural to them, in the powers of medicine; but this will pass away in a comparatively short time, leaving those physicians who were not pulled along with enthusiasm, to share the humiliation with those who are in the habit of shouting loudest upon the least provocation. First, as to the prevention of tuberculosis in animals treated with tuberculin: all observers have shown that non-infected tissues may be- come tubercular during treatment, and that, in the rabbit, tuberculosis is not cured by the remedy (Baumgarten, Arloing, Rodet and Cono- mont, Popoff, Pfuhl, Gasparini and Mercati, Donitz, Ernst, Trudeau). Next, as to the chemical structure of tuberculin, Koch says that the active principle is not a toxalbumin; William Hunter has made a careful study of the fluid, and finds that it is made up of the following substances: (1) Albumoses—principally proto- and deutero-albumose, less hetero-albumose and, occasionally, traces of dys-albumose; (2) Alkaloid al substances, two of which can be obtained in the form of “hydrochlorate salts” of platinum compounds; (3) Extractives; (4) Mucin; (5) Inorganic salts; (6) Glycerin and coloring matter. He has succeeded in forming four modifications of the active princi- ple, all of which have to a greater or less degree one or more of the effects of tuberculin, and he finally comes to the following conclusions: Tuberculin owes its activity to at least three principles. Fever is absolutely unessential to its remedial action. Inflammation, too, is unnecessary, although it sometimes helps therapeutic action. The remedial substance and albumoses probably belong to the pro- teins, i.e., substances extracted from bacteria. To this most excellent observer 1 do we owe our knowledge of the chemical structure of tuberculin, expressed in terms conforming to our present knowledge of the albumins. If to this there be added the fact first pointed out by Korczynski, that all samples of tuberculin are not the same, the criticism may justly be offered from a scientific stand- point that pharmaceutical accuracy can hardly have been complied with when injections of tuberculin were made, and that empiricism was being indulged in, since it was impossible to state which cause produced the given effect. If we now examine the “specific effect upon tubercular processes” (Koch), as described before, many interesting things are found. That there is no specific effect has been shown by Roemer and verified by Buchner, in that chemical extracts from bacillus pyocyaneus and bacil- lus pneumoniae produce, practically, the same results as tuberculin. The changes themselves can be best summed up as has been done by Virchow, who shows that the remedy has very little effect upon tubercles, and that tubercles of mucous membranes seem to degene- rate more rapidly after its use, producing ulcers, the diseased tissue not being destroyed. Greater changes are observed in the surrounding tissue, necrosis being produced and resulting in the enlargement of cavities and in the perforation of intestinal ulcers. Ulcers, themselves, are cleaned. As regards its curative influence, Kluge and Burci have shown that tuberculin produces a positive ehemotactive effect; Gaertner and Roemer (chemical extract of tubercle bacilli) that it is a lymphagogue. In 1 British Med. Journal, July 25, 1891. 146 SCROFULA AND TUBERCULOSIS. this way can the remarkable changes which follow the use of tuberculin be partially explained: the leucocytoses, the oedema in various parts, the necrosis, possibly the inflammations. In this connection it is well to take up the views of Klebs, who says —not being in accord with any other observer—that tuberculin pro- duces two distinct effects upon bacilli: their destruction, and a retarda- tion in their growth. The action upon bacilli is without necrosis, but is a metaplastic one, due to a moderate infiltration of white corpuscles and fluid. He claims that there are two classes of substances in tuber- culin : one deleterious, producing necrosis and inflammation, the other destroying the bacilli; he has isolated the latter, and calls the sub- stance tuberculocidin. The diagnostic value of the remedy has been assailed almost from the beginning, when Leyden expressed his doubts in the matter; this was quickly followed up by the statement that patients with lepra (Kaposi, Arloing, Goldschmidt) and ulcer of the stomach (Oppenheim) did react, and that several with well-marked tuberculosis did not (Bar- deleben, Israel—case of lupus). It was also established that perfectly healthy individuals might react with small doses (Korczynski and Adamkiewicz), so that Leyden, in a later communication, felt himself warranted in saying that the practical diagnostic value of tuberculin was very limited, and that he had never had any assistance in diag- nosis from its use. It is now used by veterinary surgeons, and Eber, collecting a large number of cases from various sources, shows that it is diagnostic in over 8-1 per cent., which might make it valuable for cows, but hardly for human beings. All who have used tuberculin agree that, even for diagnostic purposes, its use is not devoid of danger; Henoch and Korte will not use it in tubercular meningitis, Henoch warns against emplojdng it in children, and many deaths are reported as resulting from its use. It is Virchow, again, who sums up its deleterious effects as: «, very great fluxionary hypersemia and oedema; b, hemor- rhagic processes; c, very intense inflammatory processes, especially in the lungs; cl, second eruptions of new and sub-miliary tubercles. In discussing the curative effects of any remedy in tuberculosis, much caution is required, in that we must not lose sight of the fact that a great many cases are cured spontaneously, or at least without the inter- vention of any remedy for which specific properties can be claimed. This is especially the case with phthisis, where so many patients have been cured by means of acting upon the individual as a whole; change of occupation, surroundings, climate, nutrition, etc. The great num- ber of publications during the early period of the use of tuberculin can Ue disregarded entirely, because they simply show that phthisical pa- tients have been benefited, as they would have been, and have been, by any remedy producing the great psychical effect that was produced by tuberculin. To verify this statement it is only necessary to look through the literature of the treatment of phthisis pulmonalis, and to see the great number of remedies that have been successfully used. More was promised in the treatment of local tuberculosis—lupus, and tuberculosis of the larynx—in which the astounding changes that take place in the tuberculous processes can be observed. While there could be no doubt concerning these changes, the question of cure could only be decided upon as a result of observation extended over a greater length of time TREATMEXT. 147 than had been employed in the beginning. For surgical tuberculosis, Konig and Bergmannsaid early that they had seen no cures; Virchow, that not a single case of any form of tuberculosis had been cured; Ewald was not sure but that the same good results would have followed any other form of treatment; Koehler declared that not a single case of lupus could be cured. The present state of opinion as to the tuberculin treatment can be best illustrated by a discussion in Berlin in connection with a paper read by Thorner.1 Leyden does not wish a new era of tuberculin treatment to be inaugurated; he has ceased using tuberculin, which is not a reli- able diagnostic remedy, even veterinary diagnoses being problematic, though these need not be as exact as in the human being, and therefore are not as important. He has had no therapeutic results; even in tuber- culosis of the larynx only one case has been cured, and this would prob- ably have recovered without the use of tuberculin. “ I consider it per- fectly correct that tuberculin should be dropped in the treatment of tuberculosis, and that its careful application should be permitted only now and then.” Ewald says that the end of the tuberculin period has been marked by the use of very small doses. Tuberculin has no specific effect upon tuberculosis, and therefore it has been given up by the great majority of German physicians. As it is in Germany, so it is everywhere; tuberculin has been tried and found wanting; its history has been described as occurring in Ber- lin ; as it was in Berlin so it was everywhere, as it is in Berlin so it is everywhere. There are still those who use tuberculin; they are in the small minority, but their number will not diminish until something new and more promising shall have been brought out. After Hunter’s work it is difficult to conceive how any one can still use the original fluid; but how some of his bodies (B and CB) may appeal to a physician can be readily understood, and an outcome from the tuberculin treat- ment may still be possible. If this should be the case it must surely come from the direction first followed by Hunter; the original fluid, the tuber culinum depur at urn, and tuberculocidin, are certainly things of the past, and mark an epoch in medical history as instructive as, up to the present day, it has been without practical value or compen- sation. Following close upon the use of tuberculin came Liebreich’s treatment by means of the cantharidates, good results being reported by various observers (Heyman, B. Frankel), and then Tranjen's with thymolo- acetate of mercury—both, however, meeting with very little favor and, apparently, being soon dropped by the profession. More recently, in connection with the modern ideas of serum-therapy for the purpose of immunization, dog and kid serum have been injected into human beings, and again excellent results have been reported. It would seem, however, that, in this connection, little can be hoped for in the treatment of tuberculosis, since the human being does not become immune to the tubercle bacillus. Indeed, it seems that the greater the number of tubercles present in the human being, the more likelihood of an increase. But we are anx- iously awaiting clinical testimony on the subject of serum-therapy in other diseases, and it may become possible to render a human being 1 Deutsche med. Wochenschrift, 14 Sept., 1893. 148 SCROFULA AND TUBERCULOSIS. immune to tuberculosis by artificial means, where internal immuniza- tion is not accomplished. While this article does not claim completeness in even mentioning all the remedies used for treatment since the previous volumes of this work appeared, it would be dereliction not to mention two remedies which have been accepted quite universally, creasote and iodoform. Creasote was first used by Bouchard and Gimbert in 1877 for the treatment of tuberculosis, and was reintroduced by Frantzel and Som- merbrod in 1887. The latter has made a “method” of the treatment in that he uses enormous doses, from 1 to 4 grammes daily, combined with cod-liver oil. It has been conclusively proven that creasote exerts no influence upon the bacilli; it must therefore act indirectly, posfeibly by influencing metabolic processes so that general nutrition is improved. It has been especially recommended in the treatment of phthisis pul- monalis and the so-called scrofulous processes. Even upon this subject do we find quite an extensive literature, and the evidence seems to be favorable to this method. It has seemed to me that the large doses of creasote are unnecessary; small doses of creasote with large doses of cod-liver oil do just as well. Care must be taken to have good speci- mens of both remedies. The active principle of creasote, the so-called guaiacol, has also been extensively used; after the statements of Kobei t, and in view of Wyss’s case of fatal poisoning by its employment, it may be found very advisable to limit its dose. Iodoform has been especially used in surgical tuberculosis, and with the best results, being injected into the affected parts in suspension. It has also been given internally in gastro-intestinal tuberculosis. The action of iodoform upon tubercle is not understood; it kills the bacillus in from two to three weeks, when in suspension (Troje and Tangl); but simultaneous introduction of iodoform and tubercle bacilli into an ani- mal has resulted in tuberculosis (Baumgarten, Kunz, Bodzing), and ex- perimental tuberculous abscesses are not cured in animals, as they are in man. Views vary as to the nature of its effect, whether upon the bacilli or upon the tissue, but all writers seem inclined to believe in the beneficial effects of the drug. The tendency to spontaneous cure of tuberculous processes, where the tissue is given the proper opportunity, has been abundantly proven by surgeons. Complete rest of a tubercular joint, which forms the basis of nearly all orthopaedic procedures in joint disease, with proper atten- tion to the general condition of the patient, shows that without active interference tuberculosis can get well. The same has been, in a measure, proven for the treatment of the internal organs; up to the present time, all those remedies which attack the tubercle or its surroundings have proven failures; the best results are obtained by acting indirectly upon the process. Even the brilliant results obtained in tuberculosis of serous membranes, by opening the cavity and exposing it to the air, cannot be looked upon as contradict- ing this statement. RACHITIS. BY J. LEWIS SMITH, M.D., CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK. Rachitis is a constitutional disease, but its most conspicuous ana- tomical characters pertain to the osseous system. The gross nutritive changes which it produces in the bones and cartilages, causing deform- ities, are well known to both physicians and public. In addition to these anatomical changes in the skeleton, typical cases exhibit a lack of tonic- ity along with stretching of the ligaments, causing the knock-knee and flat foot. They exhibit also weakness of the muscles, resembling paralysis, and sometimes mistaken for it in severe cases, reflex irrita- bility, rendering rachitic patients liable to laryngismus and tetany, un- due perspiration, anaemia, and proneness to catarrhal inflammations. Certain anatomical changes in the spleen and liver also occur in aggra- vated forms of the disease. These many and diverse anatomical and functional characters indicate the constitutional or general nature of rachitis. Therefore theories which restrict rickets to the osseous S3rs- tem are inadequate and erroneous. Antiquity of Rachitis.—Rachitis is probably an ancient disease. It is said that an old statue of AEsop, who was thrown from a precipice by the indignant Delphians 564 years before Christ, exhibited rachitic deformities; and Hippocrates, born 460 years before Christ, is believed to have alluded to this affection in his Treatise on the Articulations. Occasional expressions in the works of Celsus and Galen in the second century of the Christian era have led writers on rickets to believe that they also had observed the deformities produced by this disease. But rickets was first investigated in a scientific manner by Whistler, Glis- son, and their contemporaries in the middle of the seventeenth century. During the last few years many excellent monographs have been writ- ten on rachitis, and its causation, pathology, and treatment are better understood than formerly. Frequency.—Rachitis is widespread, but it is comparatively infre- quent in rural localities where families enjoy the hygienic requirements of pure air, sunlight, and a plentiful diet of good quality. It is most common in the crowded and badly fed families of the city tenement - houses where anti-hygienic conditions prevail. As pointed out in Vol. I., mild cases of rickets, not manifested by any prominent signs or 149 150 RACHITIS. symptoms, are often overlooked, so that the physician is not summoned, or, if he be summoned, and have not given particular attention to this disease, he, in not a few instances, does not detect its presence. In the absence of deformity which occurs late, the fretfulness, tenderness of surface, and perspiration, are likely to be attributed to other causes than the correct one. Hence, according to my observation, rachitis is more common in its milder forms in the asylums, dispensaries, and tenement houses of New York, and probably in other American cities, than is commonly believed by the public, and even by physicians who have given little attention to the disease. A few years since, in one of the New York asylums, my attention was directed to a rachitic child in whom the anatomical changes of rachitis had become so pronou ced that they attracted the attention of the nurses. Prompted by the occurrence of this case, which had developed during my attendance in the asy- lum, I made an examination of all the infants, and found, what I had previously not suspected, that about one in nine presented unmistakable signs of rachitis, though in a mild form and for the most part in its commencement. The late Dr. John S. Parry, of Philadelphia, stated that at least 28 per cent, of all the children, between the ages of one month and five years, who came under his ob- servation in the Philadelphia Hospital during the three years preceding the pub- lication of his paper in 1872, were rachitic.1 According to Dr. Gee, whose ob- servations were, however, made as far back as 18C7 and 1868, of the patients-- under the age of two years in the London Hospital for sick children, 30.3 per cent, were rachitic; and Hitter von Kittershain, whose observations were also- made several years ago, declared that of 1623 out-door patients under the age of five years brought to the clinic at Prague, 504, or 31.1 per cent., manifested this disease. Decently Professor Henoch, of the University of Berlin, has stated that he has seen many thousand cases of rachitis, and he adds that its spread in the large cities of Northern and Middle Europe is enormous. He says that his observations in regard to the frequency of rachitis in dispensary practice corre- spond with those of Hitter, as many as 31 per cent, being rachitic.2 In Man- chester, also, with its large number of operatives, Hitchie’s statistics show that of 728 outdoor patients 219 were rachitic.3 The curator of the New York Found- ling Asylum for the last ten years informs me that he believes, but without the- accuracy of statistics, that as many as 20 per cent, of the cases examined by him in the dead-house have presented the anatomical characters of rachitis, thought usually in a mild form. The recent large immigration from Europe of destitute families, living from choice or necessity in filth and degradation, who for the most part remain in the cities, occupying small, dark, and dirty7 apart- ments, and whose food is of the poorest quality and often insufficient, greatly increases the number of rachitic children in New York and probably in other American cities. In the outdoor department of Bellevue Hospital, to which many thousand immigrants from the lowest class of European society carry their sick children for treat- ment, rachitis is frequent, and the fact has been observed in this institution that a larger proportion of severe cases, attended by marked deformities, occurs in the Italian families than in those from other parts of Europe. In families of American parentage it is gen- erally7 admitted that rachitis is more prevalent in the negro than in the white race. 1 Amer. Jour, of Med. Sci., January and April, 1872. 2 Vorlesungen tiber Kinderkrankeiten. Berlin, 1892. 3 Medical Times and Gazette. 151 DIAGNOSIS. Although this disease occurs most frequently in the families of the destitute and poorly fed, nevertheless children of well-to-do families occasionally suffer from it, even in an aggravated form, in consequence, I think, usually of ignorance on the part of parents in regard to the dietetic requirements of young children. Merei, in his treatise on the Disorders of Infantile Development (London, 1850), says that in Manchester, where his observations were made, one child in every five in comfortable circumstances presented rachitic symptoms. In the United States rachitis is rare in well-to-do families, and when it does oc- cur, it can usually, as we shall see hereafter, be traced to dietetic errors. Diagnosis.—In preparing statistics relating to rachitis it is obviously important that the diagnosis of mild and incipient cases should be clear and unmistakable. What symptoms and anatomical characters indicate rickets? The fact that an infant has reached the ninth month with- out a tooth, is regarded by Sir Wrilliam Jenner as a reliable sign of rachitis. In order to determine to what extent dentition is retarded by rickets, and to what extent retarded dentition may be considered a sign of that disease, Dr. H. R. Purdy, Physician to the Outdoor Department of Bellevue Hospital, has made the following observations:— Table I.—Showing at what age 200 infants showing no signs of rachitis cut the first tooth. Cases consecutive. 3 cut first tooth at 2 months. 14 « u « “ 3 “ 16 “ “ “ “ 4 “ 20 “ “ “ “ 5 “ 24 u « « “ 6 “ 37 “ “ “ “ 7 “ 28 cut first tooth at 8 months. 20 “ “ “ “ 9 “ 14 “ “ “ “ 10 “ 15 “ “ “ “ 11 “ 8 “ “ “ “ 12 “ 1 “ “ “ “ 13 “ Table II.—Showing at what age infants exhibiting one oi' more rachitic symptoms cut the first tooth. Cases consecutive. Of these infants 132 were wet-nursed ; 68 bottle-fed. 2 cut first tooth at 4 months. 2 « « “ “ 5 « 3 “ “ “ “ 6 2 “ “ “ “ 7 5 “ “ “ “ 8 6 “ “ “ “ 9 7 cut first tooth at 11 months. 5 “ “ “ “ 12 6 “ “ “ “ 13 3 « « “ “ 14 1 “ “ “ “16 1 “ “ “ “ 18 Table III. — Thirty infants without teeth and with pronounced rachitic symptoms. In all these cases the rachitic rosary, enlarged subcutaneous veins, profuse perspirations, abnormal distention, and enlarged joints, icere pi'esent. Bottle-fed, 21; wet-nursed, 9. 6 aged 7 months. 10 “ 8 “ 1 “ 9 “ 1 aged 10 months. 4 “ 11 3 “ 12 “ 2 aged 18 months. 2 “ 14 1 “ 15 It is evident from these interesting statistics that dentition delayed until the ninth or even the tenth or eleventh month is not a certain sign of rachitis, but slow teething is common in the rachitic, and there- fore aids in the diagnosis. It is one of the diagnostic signs. In order to determine whether rachitis, incipient or of a mild form, be present, all the signs which characterize it should be considered—the fretfulness, free perspirations upon the head, neck, face, and chest, the tenderness of surface, anaemia, and general deterioration of health, de- layed dentition, swelling of the joints, craniotabes, bending of the long bones, rachitic rosarjq misshapen head, prominent frontal and parietal 152 RACHITIS. bosses, deformity of the thorax, with depression of the ribs and pro- jecting or misshapen sternum, prominent abdomen, and Harrison’s groove distinctly marked. All these signs and symptoms must be con- sidered before making a diagnosis in incipient or mild rachitis. In order to determine the diagnostic value of enlargement of the costo- chondral articulations, “the rachitic rosary,” I have examined these joints in three of the New York institutions in children supposed to be healthy or suffering from other ailments than rachitis. In many young children believed to be healthy, these joints are not apprecia- ble on palpation. In others a slight prominence can be felt in one or more joints. In order that the beading of these articulations be sufficient to indicate rachitis, it should, I think, be plainly detected by the fingers in most of these joints. Less than this I should not regard as sufficient evidence of rickets. Age.—In a large majority of cases rachitis manifests itself before the age of three years, and if it be first diagnosticated at a later date, it will usually be found on inquiry that its symptoms have bad an earlier commencement. Glisson, Portal, and Tripier say that they have seen it commence in children who were well on towards puberty, and Sir William Jenner says that he has seen children of seven or eight years who were only beginning to suffer from rachitis. The fol- lowing are the aggregate statistics of Bruennische, Von Rittershain, and Ritsche, relating to the age at which rickets occurs:— During the first half year, No. of Cases. . 99 “ “ second half of first year, . . 259 “ “ second year, . 342 “ “ third year, . 134 “ “ fourth year, . 31 “ “ fifth year, . 17 Between the fifth and ninth years, . 21 Aggregate, . 903 Treatment of Rachitis.—Hygienic Treatment.—The frequency of rachitis, especially in the cities, and the fact that inheritance is one of its recognized causes, and that manifestations of it appear early in life, render it very important that the parents during the procreative period should be, as far as possible, in a state of perfect health. The most common and potent cause of rachitis occurring after birth is some error in diet, or a disordered state of the digestive apparatus which usually results from improper feeding. As a preventive of rachitis the infant should if possible be wet-nursed until the age of twelve months. If this be impossible on account of ill health of the mother and consequent deficiency or poor quality of her breast-milk, and the parents be unable to provide a competent wet- nurse, food artificially prepared must of course be employed. During the age in which rachitis usually occurs, cow's milk, properly prepared, should after the weaning be used as a substitute for human milk. Cow’s milk contains five times as much casein as woman’s milk, and is slightly acid, whereas the latter is alkaline. Nevertheless, if properly prepared, cow’s milk is the most convenient and best substitute for woman’s milk. In the country, cow’s milk obtained fresh, and with 153 TREATMENT OF RACHITIS. proper attention to cleanliness in its manipulation, may not require sterilization by heat. But that received and used in the city, exposed more or less to an atmosphere containing numerous microbes, it is well to sterilize by subjecting it to a heat of from 105° to 167° F., for a period not exceeding twenty minutes. For infants with feeble diges- tion it may be well also to peptonize the milk by the use of peptogenic powder, in the manner well known to the profession. A properly pre- pared farinaceous substance mixed with the milk has not only nutritive properties, but by mechanically separating the particles of casein tends to prevent the formation of curds in the stomach. But as young in- fants digest starch with difficulty, a flour should be chosen, such as barley or oatmeal, in which the starch is to a great extent converted into dextrin, or better into grape sugar. The conversion into dextrin and into grape-sugar may be effected by the action of the diastase of malt. I am in the habit of employing barley flour subjected to the heat of boiling water seven days, and adding about ten drops of dias- tase to the gruel of one feeding. The gruel thus prepared, and mixed with sterilized or peptonized milk, is a suitable food for rachitic in- fants. The theory of Cheadle and others that the most common dietetic error which produces rachitis is a deficiency of fat, and that those rachitic patients do best who are allowed an increase of fat as well as of the proteids in their food, is sufficiently established to influence treat- ment. The upper half or third of the milk obtained from the bottle or can, is preferable to the lower portion, inasmuch as it contains more cream. Meat soups, properly prepared according to the age, are useful addi- tions to the diet. I have elsewhere stated that, in one of the institu- tions of New York, rachitis from being common was made to disappear almost entirely b}T allowing a more generous diet, a part of which was the daily use, but in moderate quantity, of beef tea. I have employed with apparent good results beef tea prepared as follows: Add half a pound of beef finely hashed to one pint of cold water, and add ten drops of dilute muriatic acid. Allow it to stand cold for half an hour, with fre- quent stirring; then place it upon the table in a pail or large pan of boiling water, so as to heat it without coagulating the albumin. In an hour it is ready for use. The beef should be carefully selected, so that it does not contain the germs of the tape-worm. The peptonized beef of the shops is» also a useful preparation. After the first year, the proportion of farinaceous food, employed with milk, a soft-boiled egg, and light meat-teas, may be gradually increased. In and after the second year, also, easily digested vegetables, well cooked, the juice of the orange, and succulent fruits such as the baked apple, or raw apple scraped and carefully separated from skin and seeds, may be allowed in moderation. In an address delivered at the meeting of the Section of Diseases of Children of the British Medical Association, August, 1888, Dr. W. B. Cheadle said: “The diet of a rickety child should be carefully examined to ascertain if it contain a due proportion of fat, proteids, and salt. It will be found that it is or has been defective, and it should be at once placed at the correct standard, so that the animal fat equals one-fourth of the total solids, the proteid one-third, the carbohydrates a little over one-third, and the salts about one-tenth. For a little infant these 154 RACHITIS. should be diluted to about the percentage which obtains in human milk. It is not enough to supply fat alone, if jiroteid and salts are likewise deficient.” The room occupied by the patient should be at about 70° F., of uniform warmth, and not exposed to draughts of air. The garments worn should usually be of woollen, thin and light in the summer, heavier and warm in the winter. Sponging and bathing with water at a temperature of 80° for young children, and from 70° to 75° for older children, the process occupying only a few minutes, and with precautions to avoid taking cold, are useful means of invigorating the system. A child with rachi- tis should be often in the open air when the weather permits, with pre- cautions always to prevent chilling of the extremities. Medicinal Treatment.—Medicines which aid the digestion and assim- ilation of properly selected foods, are sometimes useful. Irritability of the stomach, imperfectly digested stools, flatulence, colicky pains, etc., indicate faulty digestion, which may be improved by pepsin given with each feeding. Tonic remedies designed to improve the appetite and digestion, of a kind suitable for the age and condition of the patient, are often useful. In anaemia one of the readily assimilated prepara- tions of iron should be given. The complications which are so common require special treatment. The laryngismus stridulus, eclampsia, and tetany should be promptly treated. The bronchial catarrh to which rachitic infants are liable may be best treated by remedies like the following:— Ammon, chloridi, . . . . . . . . 3 i. Syr. tolutan., ( . . . f § ij. M. Dose, 15 drops every hour or two hours to an infant of from six to ten months. Ammon, chloridi, ) -- Ferri et ammon. citratis, aa i . Syrupi, f l i. Aquae f§iij. M. Give one teaspoonful from every two to every four hours to a child of one year. Some of the rachitic cases, with protracted bronchial catarrh, espe- cially those who also exhibit scrofula, may be most relieved by the s}rrup of the iodide of iron and cod-liver oil administered three times daily, with the inhalation of moist air containing the turpentine vapor. In the protracted intestinal catarrh of rachitic infants, I have ob- served the best results, as far as medicine is concerned, from the follow- ing prescription:— Subnitrate of bismuth, . . . . . . . 31 j. to iij. Essence of pepsin (Fairchild’s), . . . . . §i. Distilled water, . . . . . . . . . f ? ii j. Shake the bottle ; give from half a teaspoonful to one teaspoonful, according to the age,, every two hours. But a remedy is needed which will act promptly in the cure of rachi- tis, so as to prevent the evil consequences which its continuance is sure to produce. It is the opinion of many of the best clinical observers, who have had ample experience, that this has been discovered in the daily use of minute doses of phosphorus. Wegner fed young and growing animals (rabbits and fowls), for months, with small, non-poisonous, and easily assimilated doses of phosphorus, with the result, he believes, of expediting ossification TREATMENT OF RACHITIS. 155 and producing firmer bone. He says that under the influence of phosphorus the large marrow spaces diminish by the formation of true bone to the size of the Haversian canals in normal bone. According to Wegner, the administration for a lengthened period to the older fowls of finely divided, non-poisonous doses of phosphorus, produced, to a considerable extent, the conversion of cancellous into compact bone, having the normal chemical composition. Kassowitz has recently promulgated his views at some length on the pathology and treatment of rachitis. He says 1 that lime salts are not needed, since the ordi- nary food contains sufficient lime, and that the farinaceous foods should not be restricted. He adds that phosphorus in small doses restricts the formation of vessels in the growing bones of small animals. Hence it is useful as a means of overcoming the hypersemia. Kassowitz ad- ministers about y-g-g- of a grain in a teaspoonful of cod-liver oil, the dose of course varying according to the age of the infant. The distin- guished paediatrist of Vienna, Dr. Widerhofer, says of this remedy that its employment impresses him with the belief that it is not with- out benefit in the second year of life and upward. He thinks that it may be useful in the hardening of long bones, but he has not been able to obtain good results in craniotabes.2 Starker gives an analysis of 23 rachitic cases treated by Professor Thomas, of Freiberg, in his Clinic. He used the following formula: Phosphorus, 1 centigramme (about y grain); cod-liver oil, 100 grammes (about 3 fluidounces). A coffee- spoonful, probably about 1 fluidrachm, was administered twice daily, but variations in the dose according to the age are not mentioned in the report, the patients being between the ages of a few months and four years. Improvement occurred in the general condition in 18 cases, in the cranial development in 15 cases, in dentition in 14 cases, in the shapes of the epiphyses in 21 cases, and in locomotion in 17 cases; but strict attention was also bestowed upon the hygiene, and especially upon the diet. Soltmann says that good results occurred from the use of phospho- rus in 70 cases, which he had under observation, and in no instance were unfavorable effects noticed. W. Meyer obtained similar results in 42 cases. He regards phosphorus as a specific for rachitis. When properly given, it always, he says, produces positive results. Peterson has treated 200 cases with phosphorus, and regards it as a specific. Sigel concludes from the observation of forty cases in private practice that constitutional treatment is of the greatest importance, but instead of the administration of iron, lime, etc., phosphorus should be pre- scribed. Unruh also made many observations in the treatment of rachitic cases by phosphorus in the Dresden Hospital in 1885 and 1886, and considers it more efficacious than other remedies. Toplitz, of Bres- lau, treated 518 cases with phosphorus combined with cod-liver oil. No ill effects were observed, and in all the cases improvement occurred in the general condition. Of 208 cases of craniotabes, 176 were cured in eight weeks. In 58 cases of laryngismus stridulus the attacks ceased in from eight to fourteen days, after having continued for months under other forms of treatment. Dentition was also promoted.3 In America, 1 Wiener med. Wochen., Nov. 28, 1889. 2 Munch, med. Woch. 3 Dr. Yineberg, in New York Med. Jour., 1887. 156 KACHITIS. Dr. A. Jacobi, who has had a large clinical experience, also highly recom- mends phosphorus in the treatment of rachitis. The dose should be small, even minute, not more than from to yyy of a grain according to the age, three times daily. As regards my own observations, I am not able to express a positive opinion as to the value of the phosphorus treatment, for reasons which I think also apply to many of the cases embraced in the favorable statistics of the distinguished observers mentioned above, to wit, the simultaneous use of cod-liver oil, with im- provement in the diet and general hygiene. The following prescriptions may be employed: first, the oleum phos- phoratum, made according' to the following formula: Phosphorus, 1 part; ether, 9 parts; almond oil, 90 parts; one minim contains Ty¥ of a grain of phosphorus. Or, secondly, the following, known as “Thompson’s mixture:” $ Phosphori, gr. i.; alcoholis, tt|,cccL ; spt. menthse piperit., tt[x. ; glycerini, f § ij. M. Dose, 6 drops in- creased to 10, three times daily, to a child of from two to four years. Ten minims contain -yg-y of a grain, and thirteen minims contain of a grain. Phosphorus should, I think, be given after the meals, in order to prevent irritation of the stomach. Dr. H. H. Purdy, physician to the large class of children’s diseases in the outdoor department at Bellevue Hospital, has preserved statistics of the treatment of rachitis during a year. The cases which furnish the statistics were about 80, and he gives a resume of the results of treatment as follows:— Some were given cod-liver oil alone, some cod-liver oil with phosphorus, and others phosphorus alone, and of course all the mothers were given instruction in feeding and hygiene. Those infants that received only phosphorus were the slow- est to improve. Indeed, in several cases this method of treatment was abandoned because of the absence of signs of improvement. The group treated with cod- liver oil did the best. In fact, all of the infants that could tolerate the oil de- rived much benefit from it. The group that were given cod-liver oil with phos- phorus did very well, but seemingly no better than those that were given only cod-liver oil. The preparation that seems to be the most beneficial is one that is used at the Church Hospital and Dispensary. It is an emulsion of cod-liver oil made with the yolk of eggs. The formula for the emulsion is Yolks of eggs, No. x. Cod-liver oil, Oij. Syrup of wild cherry, ........ Oi. Sherry wiue, Oi. One or more teaspoonfuls should be given three or more times daily. In my opinion the treatment by phosphorus is still tentative, notwithstanding its rec- ommendation by so many distinguished physicians, and the old remedies, cod-liver oil and iron, should not be abandoned, although trial may be made of phosphorus at the same time. Care should be taken to prevent deformities while the bones are soft and yielding. The patient should not he encouraged to stand or use the limbs until they become firmer. He should lie upon a soft and even mattress. Uniform support of body and limbs is requisite in order to prevent curvature. In craniotabes the pillows should be soft, and care should be taken that the yielding parts of the cranium be not unduly pressed upon. The perspiration may be relieved by sponging TREATMENT OF RACHITIS, 157 with vinegar and water. The patient may he bathed in water a little cooler than the body, and rock salt may he added to the bath. The attacks of laryngismus stridulus, eclampsia, and tetany, which so frequently complicate rachitis, should be promptly treated by the rem- edies which are appropriate when they occur under other circumstances; constipation may be treated by enemata of glycerin and water, if not relieved by change of diet. The surgical treatment of rachitic deformities is sometimes impor- tant, but Professor Ogston, of the University of Aberdeen, and other surgeons who have given special attention to them, say that in young patients these deformities frequently diminish during growth, so as to cause little inconvenience in adult life. The measures employed by surgeons in order to cure or minimize the deformities are fully set forth in surgical treatises. ABSCESSES AND ULCERS. BY HENRY R. WHARTON, M.D., DEMONSTRATOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PRESBY- TERIAN, METHODIST AND CHILDREN’S HOSPITALS, ASSISTANT SURGEON TO THE UNIVERSITY HOSPITAL, ETC. Abscesses. Acute Abscess.—The almost invariable presence of certain infec- tions organisms in acute abscesses, staphylococci or streptococci, has led to the generally accepted opinion that this form of disease is directly dependent upon their presence, although Grawitz and Lemiere have shown by carefully conducted experiments that suppuration may be caused by the injection of irritating substances unaccompanied by micrococci or ptomaines. Lemiere recognizes the possibility of the for- mation of pus without the presence of micro-organisms, which form of suppuration he describes as chemical abscess, and differentiates this variety from that due to the presence of microbes. He says that in chemical abscesses, the cause being limited, the effect of pus produc- tion is limited to the time taken for the irritant to act, and that even if the chemical action be weak, the irritation may be sufficient to produce a barrier of newly formed cells which will encyst the abscess and pre- vent its spreading. On the other hand, abscesses due to micro-organ- isms are progressive, not limited, and the germ, when introduced into a favorable soil, can continue to proliferate and bring to the neighboring parts a new infection. For clinical purposes, I think it wise to regard all acute abscesses as the result of infective organisms. Treatment of Acute Abscess.—The treatment of an acute abscess con- sists in making a free incision to evacuate its contents. The only mod- ification in treatment which has been practised in recent years consists in the adoption of measures to make the abscess cavity aseptic, and in the use of such dressings as may maintain it in this condition. Before opening an acute abscess the skin surrounding it should be gently washed with soap and water, and finally with a 1-2000 bichloride of mercury solution; a free incision should then be made of sufficient extent to expose the cavity of the abscess and to permit the escape of its contents. The cavity should next be irrigated with water which has been boiled and cooled down to the proper temperature, or with a warm 1-2000 bichloride or 1-60 carbolic solution. When the cavity of the abscess has been thoroughly irrigated, and there is no further escape of pus with the injected solution, if not extensive or very deep, drainage will 159 160 ABSCESSES AND ULCERS. not be necessary; if, however, the cavity is large and deep, a perforated rubber drainage tube should be passed to its lowest part, and should be made to project at the most dependent point of the abscess, being secured by a safety-pin passed through its extremity on a level with the skin. In large or irregularly-shaped abscesses a number of tubes may be introduced in the same way, and their extremities may be brought out at different points. Glass drainage-tubes may also be employed, or a few strips of iodoform or bichloride gauze may be passed to the bottom of the abscess cavity, and brought out at the most de- pendent portion of the incision and used in the place of tubes. The line of incision is next covered by a strip of protective which has been sterilized by dipping it in a 1-2000 bichloride solution, and over this is laid a large pad composed of a number of layers of bichloride, iodo- form, or sterilized gauze, and the dressing is completed by the ap- plication of a number of layers of bichloride or sterilized cotton, the whole being held in position by a roller bandage or by adhesive straps. If the dressings become soaked with the discharges from the abscess cavity, they should be renewed at the end of twenty-fcur hours; if, however, the discharge is not copious, the dressings need not be changed for two or three days, when the drainage tubes or gauze drains may be removed. The subsequent dressing of the abscess consists in the application of a pad of gauze and cotton, applied as before described. After opening an acute abscess, it is often found useful, in order to cleanse the cavity thoroughly, to employ an injec- tion of peroxide of hydrogen, and to continue the injection until the effervescence in the escaping discharges ceases, when the cavity should be irrigated with the antiseptic solution as already described. It has also been recommended in the treatment of acute abscesses that the incision should be made so free as to thoroughly expose the cavity, and that the inner surface should be gently rubbed with a pledget of gauze held with forceps, so as to remove the lining membrane as far as possible, when the ordinary warm antiseptic irrigation and the dress- ings already mentioned may be employed. The only objection to this method is the free hemorrhage which the destruction of the walls of the abscess entails. If the cavity becomes filled with blood, a strip of protective should be placed over the incision, and a moist gauze dressing, covered by a layer of mackintosh and bichloride cotton, should he applied. If the cavity has been rendered thoroughly aseptic, it is possible that organization of the blood-clot may take place, and that cicatrization may result in this manner. The healing of an acute abscess, if the incision lias evacuated the contents freely, is usually very prompt under these methods of treatment. Chronic Abscess.—Chronic abscesses are generally of tubercular origin, and as long as they remain chronic do not contain cocci; the material with which they are filled, although it resembles pus in ap- pearance, is, by modern pathologists, not considered to be true pus, since it contains very few corpuscles and consists largely of broken-down and liquefied tubercle. This variety of abscess is classed by many writers as the caseous abscess. True chronic abscesses are occasionally seen in which the collection of purulent matter is surrounded by a dense capsule. ABSCESSES. 161 Treatment of Chronic Abscess.—Aspiration.—In dealing with large cold abscesses connected with disease of bone, it is often found satisfactory to employ aspiration, as by this means the contents may be removed, the vitality of the skin surrounding the collection be pre- served, and the shock which accompanies the use of an anaesthetic, or the method by free incision, be avoided. As the procedure is one prac- tically unaccompanied by pain, anaesthesia is not required, and the as- piration may be repeated as often as the fluid re-accumulates. The skin surrounding the point at which the aspirating trocar and canula are to be introduced should be washed with soap and water, and with a 1-2000 bichloride of mercury solution, the instruments being placed for a short time before being used in a 1-30 carbolic solution, or in boil- ing water. If the contents of the abscess have been evacuated by means of suction, the canula should be removed and the small puncture closed with a little sterilized cotton fastened to the skin with a scab of iodoform collodion. Incision.—Chronic abscesses may also be treated by free incision, and when this procedure is employed it is most important that precaution should be taken to render the skin surrounding the abscess cavity aseptic, and after the discharge has escaped the parts should be kept aseptic by the application of suitable dressings. The skin around the abscess having been thoroughly washed with soap and water and a 1-2000 bichloride solution, a free incision is made over the most de- pendent portion, and gradually deepened until the cavity of the abscess is freely exposed. The contents should then be washed out by irrigat- ing the cavity with a 1-2000 warm bichloride or a 1-60 carbolic solu- tion, or, before the use of these solutions, the cavity may be irrigated with peroxide of hydrogen, and the irrigation with carbolic or bichloride solution may subsequently follow. After all discharge has been thor- oughly washed out, one or more sterilized rubber drainage-tubes may be introduced and brought out at different points of the line of incision, being secured by means of safety-pins, or a few strips of iodoform gauze may be introduced to secure drainage in place of the rubber tubes. A piece of protective which has been sterilized by dipping in a 1-2000 bi- chloride solution should next be placed over the wound, and a large bichloride or iodoform gauze dressing, consisting of a number of layers, with several layers of bichloride cotton, should be placed over this, the whole being retained by a gauze bandage. If the dressings become soaked with discharge from the abscess cavity within a few hours, they should be removed and fresh dressings applied in the same man- ner; if the flow is not excessive, the dressings need not be disturbed for several days, and, when they are removed, if the discharge is slight and the cavity of the abscess seems to be aseptic, the drainage tubes may be withdrawn, an antiseptic dressing being again applied. Free Incision, with Curetting of the Walls of the Abscess-Cavity. —Another method of treating chronic abscess consists, after having rendered the skin covering the abscess perfectly aseptic, in making a free incision in the usual way and allowing the contents to escape, then irrigating the cavity to remove any discharge, and finally curetting its walls thoroughly and again irrigating it with a 1-2000 bichloride solution, or with warm water which has been sterilized by boiling. As this curetting is apt to be followed by quite free hemor- 162 ABSCESSES AND ULCERS. rhage, it is well after irrigation to pack the cavity firmly with strips of iodoform gauze, then applying a large gauze dressing with layers of bichloride cotton in the ordinary manner. As soon as the dressings have become soiled with discharge they are removed, and the gauze packing is also removed if it has become loose; but it will often be found that this will remain in place for a number of days, and if the wound is aseptic it need not be withdrawn until it has become quite detached. When it is finally removed, the cavity should be gently irrigated with a bichloride solution, or with warm sterilized water, and should be again gently packed with strips of iodoform gauze and the external dressing applied as before. By this method of treatment the cavity of the abscess fills up with granulations. Injection of Iodoform and Glycerin.—Another plan consists, after first sterilizing the skin covering the abscess, in passing a narrow- bladed bistoury through the tissues until its point enters the cavity; before the knife is removed a grooved director is introduced along its blade as a guide, the knife is then withdrawn, and the contents are allowed to escape along the groove of the director, their evacuation being facilitated by gentle pressure from the outside. When the cavity is empty, it is washed out with a warm 1-2000 bichloride, or a 1-60 carbolic solution, introduced through a syringe the nozzle of which enters the small puncture in the skin. This fluid is allowed to escape by again passing the grooved director into the small puncture, and the cavity is then filled up with an iodoform and glycerin emulsion, 1-10, intro- duced by means of the syringe. The surface of the skin should next be thoroughly irrigated, and a small compress of iodoform gauze placed over the puncture, and held in position a pad of bichloride gauze and cotton, with a bandage, or adhesive straps. Another method of using the iodoform emulsion consists in making a free incision into the abscess, irrigating its cavity with warm bichloride or carbolic solution, and then filling it with iodoform emulsion and bringing the edges of the incision together with sutures, applying a full antiseptic dressing. In many cases of chronic abscess, the removal of the contents is only one step toward securing healing; in cases arising from diseased bone, if it be pos- sible to remove the bone this should be done, even if very free and exten- sive incisions are required for the purpose. Antiseptic irrigation should then be practised, and free drainage should be secured by the intro- duction of drainage-tubes passed to the deepest portions of the cavity, which is packed with iodoform gauze, a large gauze dressing being ap- plied externally, and renewed as often as it becomes soiled. Ulcers. The treatment of ulcers differs little from that generally practised before the introduction of the antiseptic and aseptic methods of wound treatment, the same procedures as regards rest, mechanical support, and the use of constitutional remedies being employed, and the changes concerning only the treatment of the ulcerated surface itself. Healthy Ulcer.—This variety of ulcer has a tendency to rapid healing if the part upon which it is situated be kept at rest, and the 163 ULCERS. granulating surface be covered to protect it from injury and from the accumulation of foreign matters, although, even when the latter con- ditions are not present, we often see very rapid cicatrization, such as that which takes place under a scab made up of the dried discharge from the granulations and foreign matters brought into contact with them. This method of healing is takeii advantage of sometimes in small ulcers, where an aseptic scab is formed by dusting the surface with powdered iodoform or aristol. It is, however, a matter of com- mon experience that even healthy ulcers heal more promptly if kept perfectly clean and free from irritation. Treatment of Healthy Ulcers.—The skin surrounding the ulcer should be washed with soap and water, and shaved if hairs 'be present, the surface of the ulcer being then irrigated with a solution of boric acid, or with boiled water, and being covered with strips of protective which have been sterilized by dipping them in a 1-2000 bichloride solution, and then washed in one of boric acid. These strips should be large enough to cover the ulcer and extend a very short distance beyond its edges. Over them should be placed a pad of bichloride, iodoform, or sterilized gauze, consisting of at least a dozen layers, and large enough to extend in all directions a few inches beyond the edges of the ulcer; over this, again, is placed a layer of sterilized or bichloride cotton, a little larger than the gauze pad, and the dressing is held in position by the turns of a roller bandage, or by strips of adhesive or rubber plaster. This dress- ing need not be changed for some days, unless it becomes soiled, and in re-dressing the ulcer the same method should be adopted. The pro- tective prevents the adhesion of the gauze to the granulations, and be- ing applied in strips slightly overlapping each other, allows the dis- charge to find its way out and to be disseminated through the gauze. If for any reason another form of dressing is desired, good results may be obtained by use of an ointment consisting of carbolic acid til xvi., boric acid 3 ij., vaseline 5 i. This is spread upon a piece of lint, which should be fenestrated, and a little larger than the ulcer, and which, after the part has been cleansed and irrigated is gently laid over the granulat- ing surface and covered with gauze, cotton, and bandages in the way al- ready described. At the end of three or four days the dressing should be removed, and a new dressing applied in the same manner. If the granulations become exuberant, they should be touched with the solid stick of nitrate of silver. Inflamed or Phlegmonous Ulcer.—This condition may develop in a healthy ulcer either from accidental irritation, or from a change in the constitutional state of the patient. In this variety of ulcer the granulations at first become intensely red, and then dusky or gray* while a thin sanious discharge escapes from the surface; the surrounding skin and cellular tissue become involved in phlegmonous inflamma- tion, which gives the part a dusky red and glazed appearance. Treatment.—In the treatment of this form of ulcer it is important to put the part at absolute rest, and if possible to elevate it; if the ulcer be situated upon one of the extremities, so that it is possible to employ continuous irrigation, this will be found to be very efficient. The part containing the ulcer should be placed upon a rubber sheet so arranged as to carry off the water, and a piece of gauze composed of a 164 ABSCESSES AND ULCERS. number of layers and moistened in a weak carbolic solution, 1-80, or in boric-acid solution, should be laid over the ulcer and the inflamed surrounding tissues. Continuous irrigation is then practised by sus- pending over the part an irrigating bottle or can, filled with warm or tepid carbolic or boric acid solution, a small stream of the fluid being allowed to run continually over the gauze which covers the inflamed area. The constitutional condition of the patient should also receive attention, and the use of saline laxatives and of the tincture of chloride of iron is often followed by the best results. Usuall}" after the use of irrigation for a short time, twenty-four or forty-eight hours, it will be found that the inflammation of the surrounding tissues has subsided, and that the ulcer presents a healthy appearance, when the irrigation may be dispensed with and the ulcer dressed as a healthy ulcer in the way already described. If for any reason the treatment by irrigation is not feasible, a very satisfactory method consists in putting the in- flamed part at rest and covering it with a piece of lint spread with an ointment of ichtbyol and lanolin, one part of the former to four parts of the latter. The dressing is completed with a layer of cotton and a bandage. Under this treatment, combined with the use of constitu- tional remedies, the inflamed and unhealthy appearance of the ulcer and surrounding tissues rapidly disappears. Sloughing or Phagedenic Ulcer.—This form of ulcer is found m cachectic or ill-nourished individuals, and in addition to local treatment, the constitutional condition of the patient demands prompt attention. Treatment.—The surface of the ulcer should first be cleared from sloughs by a stream of warm carbolized water, or the sloughs may be removed by forceps and scissors. The surface should next be washed or sprayed with peroxide of hydrogen, 15-volume solution, and a wet dressing consisting of a number of layers of lint or gauze moistened in a 1-60 carbolic solution should be placed over the ulcer and covered with waxed paper or rubber tissue. This dressing should be changed at the end of twelve hours, the ulcer being irrigated with peroxide of hydrogen, and then with a 1-60 carbolic solution, and the wet dressing should be continued until the sloughs have separated. If, however, the sloughing process continues and tends to assume a pliagedsenic form, the surface of the ulcer should be thoroughly dried with absorb- ent cotton and touched with nitric acid applied by means of a swab, and after this, to arrest the further action of the acid, should be irrigated with lime-water. Powdered iodoform, or acetanilide, should then be dusted over the ulcer, this being covered by a pad of moist gauze. The cauterization often arrests the phagedsenic action, and when the sloughs separate, a healthy granulating surface is left. The constitutional treatment of a patient suffering with this variety of ulcer is also a matter of the first importance. He should be given stimulants, iron, and opium, the latter remedy, in doses of from one to three grains in twenty-four hours, seeming to exert a beneficial influence in many forms of gangrenous disease, as pointed out by Mr. Pollock. (Edematous Ulcer.—This variety of ulcer, which presents large, pale, flabby granulations, is often seen in cases in which wet dressings ULCERS. 165 or poultices have been continued for a long time, and is apt to occur in patients whose general health is defective. Treatment.—In this form of ulcer the application of a 20-grain solution of nitrate of silver, or of a 20-grain solution of carbolate of zinc, is often followed by a change in the character of the granulations. If, however, these project much above the surface of the ulcer, they should be freely touched with the solid stick of nitrate of silver, and after this boric-acid ointment may be applied on lint, with a compress of cotton and the support of a bandage. At the same time tonic reme- dies should be administered to correct the anaemic condition of the patient which often coexists. As soon as the granulations assume a healthy appearance, the treatment should be that of a healthy ulcer. Irritable Ulcer.—This form of ulcer differs from the healthy ulcer iu the fact that the granulations covering its surface are smaller and redder than those seen in the latter, while at the same time the ulcer is the seat of intense burning pain. Treatment.—The treatment consists in touching the surface of the ulcer with a 5 or 10 grain solution of nitrate of silver, dusting it with iodoform or aristol, and applying over the granulations a piece of lint spread with boric-acid oint- ment, a pad of sterilized cotton, and a bandage. As a depressed condition of health is often asso- ciated with this form of ulcer, tonics should be employed in con- nection with the local treatment. Varicose Ulcer.—The treat- ment of ulcers dependent upon or coexisting with a varicose condition of the veins, consists in the application of a stimulat- ing solution of nitrate of silver, 5 or 10 grains to the fluidounce, with a dressing of boric-acid ointment and a pad of gauze or cotton. This dressing should be combined with support of the venous circulation of the part, which is accomplished by the use of a firmly applied muslin or elastic bandage. Warty Ulcer of Cicatrices. —This is a very persistent form of ulcer, which is sometimes known as the warty ulcer of Marjolin, and which occurs in wounds which have only partly cicatrized, or which have broken down again after cicatrization. Some of the ulcers are non-malignant, being Fig. 1593. Warty ulcer of leg. 166 ABSCESSES AND ULCERS. of a fibro-cellular character, while others show by their structure that they are true epitheliomata. They are often associated with a carious condition of the bone in their immediate vicinity. I have seen a num- ber of cases which occurred in partially cicatrized gunshot wounds, often of many years1 standing, and in one case at least twenty years had elapsed before the patient came under my observation. The ulcer is usually covered by granulations having a papillary appearance, like condylomata, which often protrude above the surface of the surround- ing tissues. A typical case of warty ulcer, resulting from a gunshot wound received in the late war, is shown in Fig. 1593. This form of ulcer may cause little discomfort for a long time, but it gradually increases in size, the granulations becoming more exuberant and the patient ultimately experiencing intense pain at the seat of disease. The discharge from the ulcer is sometimes profuse and very offensive. Treatment.—The treatment of this form of ulcer consists in free ex- cision of the diseased structure, if this can be accomplished, with the removal of any carious bone that is associated with it; but in many cases, when situated upon the limbs, it is necessary to resort to ampu tation in order to completely remove the disease. There seems to be little tendency to recurrence if the morbid structures are freely removed by excision or amputation. I have in mind one patient, whose limb was amputated for this variety of ulcer, following an old gunshot wound, who ten years after the amputation of the limb had no evi- dence of any return of the disease. Indolent or Callous Ulcers.—These ulcers are generally situated upon the lower part of the leg, and are apt to affect persons who have passed the middle period of life. The surface of the ulcer is concave, and its edges are raised and indurated, the granulations being of a dull red color and covered by small grayish sloughs, while the secretion from them is thin and offensive. Treatment.—If it is possible, the patient should be confined to bed, as repair is much more rapid when the part upon which the ulcer is situated is at absolute rest; but as this form of ulcer is generally met with in persons of the laboring class, the patients have to go about at- tending to their ordinary vocations, and under these conditions, though the time of healing is longer, the final result is no less satisfactory. The skin surrounding the ulcer should be washed with soap and water, and hairs, if present, should be removed by shaving. The sur- face of the ulcer should next be irrigated or sprayed with peroxide of hydrogen, and, when effervescence has ceased, with a 1-2000 bichloride solution. A pad composed of several layers of lint wet in 1-60 carbolic- acid lotion should next be laid over the surface and covered by a sheet of rubber tissue, and over tins should be placed a pad of absorbent cotton and the turns of a roller bandage. This dressing should be changed every day for two or three days, and the surface of the ulcer on each occasion should be sprayed with the peroxide of hydrogen and irrigated with the 1-2000 bichloride solution. At the end of this time it will usually be found that the edges of the ulcer are much less in- durated, and that the granulations present a much more healthy ap- pearance. The dressing now employed should consist in strips of pro- tective, which have been dipped in a 1-2000 bichloride solution, slightly 167 ULCERS. overlapping each other, until the whole surface of the ulcer is covered. Over these strips is placed a pad of bichloride gauze, consisting of ten or twelve layers, large enough to extend beyond the edges of the ulcer in all directions, and freshly wrung out of a 1-2000 bichloride solution, while over this pad is placed another of bichloride cotton. The dress- ing is then held firml}7 in place by a bandage applied (in case of ulcer of the leg) from the toes to the knee. The bandage should be applied firmly, either as a spiral reversed bandage, or as a spica bandage of the leg, the latter retaining its place better than the former if the patient is compelled to walk about during the course of treatment. This dressing should be renewed every second or third day until the surface of the ulcer presents a healthy granulating surface and the discharge has no odor. After this time the use of bichloride irrigation may be omitted, and the ulcer may then be dressed as a simple or healthy ulcer. If there is a tendency for small sloughs to adhere to the surface, which are not removed by the action of the peroxide of hydrogen, the use of an acidulated solution of pepsin (pepsin 3 grains, hydrochloric acid 2 minims, water a fluidounce) will often liquefy them and cause their rapid removal. It is important that this solution should be in contact with the ulcer for some time, to accomplish the desired result. In some indolent ulcers, where the ulcerated surface is very extensive, even after the condition of the surrounding parts has been improved by the treatment above mentioned, it is impossible to obtain cicatrization, and in such cases some of the various methods of skin-grafting or skin-im- plantation may be employed with advantage; in other cases, where the extent of the ulcer is so great that repair cannot be expected under any form of conservative treatment, amputation of the affected part may be required. Skin-Grafting in Ulcers.—In the case of large ulcers such as occur after burns or scalds where there has been extensive destruction of the skin, we may have a broad surface covered by healthy granula- tions, and in such cases skin-grafting majT he employed with advantage. The skin-grafts may be taken from the thigh or arm of the patient, or from recently amputated limbs; the skins of frogs and birds, and the hairless skin of young animals, have also been employed. The surface of the ulcer should be irrigated with a warm solution of boric acid, or with a warm normal salt solution, 0.7 per cent., and the grafts, taken from a portion of skin 'which has been sterilized hv washing with soap and water and then with bichloride solution, are placed upon the granulating surface at a number of points, and are applied in lines transversely across the surface of the ulcer, so that a number may be covered by one strip of protective. Over each line of grafts a strip of protective, which has been sterilized and then dipped in boric acid or normal salt solution, is next laid, and a strip of isinglass plaster is fastened to the sound skin at one edge of the ulcer and is carried directly over the protective and fastened to the skin on the opposite side. This serves to keep the protective in place, and to press the grafts firmly upon the granulating surface. A number of these strips of protective and isinglass plaster are applied, until all the lines of grafts have been covered in. A pad composed of a number of layers of borated or sterilized gauze, and a few layers of borated or sterilized cotton, are 168 ABSCESSES AND ULCERS. next placed over the whole surface of the ulcer, and the dressings are held in place by a firmly applied bandage. This dressing is not dis- turbed for a week, and when it is removed the grafts are generally found fully vitalized. The surface of the ulcer is then irrigated with a warm boric or saline solution, and pieces of protective are re-applied over the grafts with layers of gauze and cotton as before. This second dressing is not disturbed for three or four days, by which time the grafts are so firmly attached that the dressing thenceforth differs in nowise from that of a simple or healthy ulcer. Thiersch's Method of Skin-Grafting.—To secure a favorable result by this method of skin-grafting, the surface of the ulcer, if it presents an unhealthy appearance, should be freshened with a curette, and then should be irrigated with normal salt solution, hemorrhage being con- trolled while the grafts are preparing by a compress wrung out of warm salt solution and applied directly to the part. The skin from which the grafts are to be taken should be thoroughly washed with soap and water, and then scrubbed with a solution of corrosive sublimate. The most convenient situation from which to obtain them is the arm or thigh. Long strips of skin are cut with a sharp razor, as wide as the part will allow; the subcutaneous fat should not be included, but the whole thickness of the true skin is necessary. Strip after strip, obtained in this way, is placed upon the raw surface and pressed firmly in position until the whole is covered. Narrow strips of protective, laid as a lattice-work over the grafts, should next be applied, and over these a compress wet with the salt solution, several layers of sterilized cotton, and a bandage. The external dressing, consisting of the cotton and compress, should be renewed after several days, but the protective need not be removed until the expiration of five or six days, when the grafts will usually be found to have formed adhesions. After their vital- ity is assured, the dressing of the ulcer should be simply a protective one. Transplantation of Large Skin-Flaps.—Krause recommends, in the grafting of ulcers, the transplantation of one or more large skin- flaps. The surface to which the flap is to be transplanted should be excised or thoroughly curetted, and the edges, if unhealthy in appear- ance, should also be removed. The wound is irrigated with normal salt solution, and the hemorrhage is controlled by the application of a compress of sterilized gauze, no ligatures being used. The skin to be transplanted must be disinfected by washing it with soap and water, removing any hairs which are present by means of a razor, and should be thoroughly scrubbed with ether. The flap is then dissected up, and is made as thin as possible, not including the fat, but simply the entire epidermis and cutis. It should be cut a little larger than the surface which it is to cover, if only one flap is used. The flap or flaps are next pressed firmly upon the raw surface, the blood acting as the best adhesive medium. When the entire surface of the ulcer is covered in an exact manner, the flaps are held in position with a five-per-cent, iodoform gauze pad, and over this is placed a large antiseptic dressing. The first dressing is removed in from four to five days, and if any blebs have formed between the cutis and epidermis, they should be opened. A similar dressing is again applied, and allowed to remain for a few days longer. It is often a matter of several weeks before the healing of the ulcer is accomplished under this method of treatment. ULCERS. 169 Tubercular Ulcer.—This form of ulcer results from a tubercular abscess of the cutaneous or subcutaneous tissues and lymphatic glands, and usually occurs in earty life. A tubercular ulcer presents very characteristic symptoms, its edges being undermined and presenting a dull-purple, congested appearance, while its granulations are dark-col- ored and flabby, and the discharge usually thin. Treatment.—The undermined edges of the ulcer should be trimmed away with scissors or knife, and the granulating surface should be thoroughly curetted. If the ulcer has originated in lymphatic glands which have broken down, the gland-tissue and the sheaths of the glands should be removed. It should then be irrigated with a 1-2000 bichloride solution, and the freshened surface should be well dusted with powdered iodoform, or should be covered with strips of gauze soaked in iodoform emulsion and glycerin (1-10), this in turn being covered with a pad of iodoform gauze and a few layers of bichloride cotton. Under this dressing, which should be renewed every two or three days, healing will often occur very rapidly. In addition to the local treatment, the patient should be given iodide of iron and cod-liver oil, and a nutritious diet; stimulants also are indicated in many cases. Syphilitic Ulcers.—Two forms of syphilitic ulcer are seen among the later manifestations of constitutional syphilis; the ulcer resulting from a broken-down gumma, and the serpiginous syphilitic ulcer; the latter is often preceded by the development of nodules in the skin. The ulcer resulting from a broken-down gumma may have clearly cut edges, or these may be undermined, if the destruction of the subcutane- ous tissue has been greater than that of the skin. The surface of the ulcer is usually covered by grayish sloughs. Treatment.—The ulcer should he thoroughly irrigated or sprayed with peroxide of hydrogen and washed with a 1-2000 bichloride solution, to cleanse it and remove as far as possible the sloughs. It should then be dusted with powdered iodoform or aristol, or the iodoform may he applied in the form of an ointment in the strength of 15-30 grains to the ounce of vaseline. The dressing should be completed by the ap- plication of a pad of iodoform gauze and a few layers of cotton. In this form of ulcer there is little chance of healing unless active con- stitutional treatment is instituted at the same time. The patient should be given iodide of potassium in full doses, and in many cases this drug is well combined with the hiniodide or bichloride of mercury, while sometimes, in addition to the above remedies, the use of iron and cod-liver oil is followed by the best results. The repair of syphilitic ulcers is usually very rapid under the use of these local and constitu- tional remedies. The serpiginous syphilitic ulcer is usually preceded by the develop- ment of nodules or tubercules in the skin, which are similar in their structure to the larger gummata. The tubercules break down, leaving ulcers which become serpiginous and may involve a considerable amount of tissue. Treatment of Serpiginous Ulcers.—The surface of the ulcer should be sprayed with peroxide of hydrogen to cleanse its surface, and the ulcer and swollen tissues surrounding it should be covered by an ointment consisting of 170 ABSCESSES AND ULCERS. Ung. hydrarg 3 iij. Acid, salicylic. ..... gr. xij. Ung. resinae 3 iv. M. This ointment should be spread upon soft kid and applied to the ulcer and infiltrated tissues, being renewed every twenty-four hours. Iodoform, in the form of either a powder or an ointment, may also be employed in this form of syphilitic ulcer. As a general rule, cauterization should be avoided in serpiginous ulcers, unless it be found that the ulcer is spread- ing rapidly, and then it is better to make one thorough cauterization with the acid nitrate of mercury, rather than to employ mild cauteriza- tion frequently; an iodoform dressing should be then applied. As a rule, however, the application first mentioned, combined with con- stitutional treatment, will be found most satisfactory. In this form of ulcer it is often found that small doses of iodide of potassium com- bined with mercury act better than larger doses, so that I usually employ the following combination: Potassii iodidi . . . . . . gr. v. -x. Hydrarg. biniodidi . . . . . gr. Elix. cinclionae . . . . . . f 3 i. M. One fluidrachm in water, three times a day, after meals. A certain amount of scarring is left after the healing of either of these forms of ulcer. GANGRENE AND GANGRENOUS DISEASES. BY E. M. MOORE, M.D., EMERITUS PROFESSOR OF SURGERY IN THE UNIVERSITY OF BUFFALO, ETC. Gangrene. The constitutional disturbance in gangrene is due to the absorption of toxines, which are the result of chemical changes produced by the action of microbes upon the tissues and fluids. When these are absent the dead tissue produces little or no effect upon the blood. It may be separated, or gradually absorbed and discharged through the emunc- tories, with no perceptible constitutional symptoms. The chemical construction of these toxines or ptomaines has thus far received slight elucidation, but something has been gained, and at this moment the field of inquiry is perhaps the most important in the range of chemical investigation. The surgeon recognizes the fact that life is often lost when only a small portion of tissue is invaded, and often saved when a whole limb as far as the knee is lost by gangrene. Indeed, it is now well under- stood that to no single microbe can the putrefactive changes be as- cribed. But the greater or less virulence of some well-known forms can be distinctly asserted. Thus we find that the staphylococcus and strep- tococcus pyogenes are sufficient to produce gangrene, as shown by their exclusive presence in the early stages of furuncle and carbuncle. But the virulence of the toxines resulting from the action of the bacillus of Rosenbach is vastly greater, although the extent of destruction of tis- sues may be the same in both cases. The ptomaines extruded into the tissues beyond the microbic colonies are capable of absorption. Varieties of Gangrene.—The two broad varieties of gangrene, moist and dry, have an important clinical and bacteriological signifi- cance. The tissues in the dry variety are not invaded by microbes, and therefore become mummified, producing very slight if any consti- tutional disturbance; but in the moist form the tissues become the nidus for various microbes, such as those producing pus, as well as the bacillus of putrefaction of Rosenbacli. The difference of prognosis in the two varieties has always been recognized by surgeons. Treatment of Gangrene.—But little can be added to what is already known. The discovery of the destructive microbes has added 171 172 gangrene and gangrenous diseases. but little to our therapeutics. Observation had anticipated what sci- ence has lately taught. The freer use and more careful application of antiseptics in the neighborhood of the living tissue has been somewhat advanced. But the method of employing bromine in hospital gangrene, and nitric acid in facial carbuncle, cannot be improved by any knowl- edge we now possess of the etiology of these diseases. Amputation in Gangrene.—The rule of waiting for the formation of the red line, which the long and universal experience of surgeons had fully justified until within a few years, has undergone much mod- ification. A better recognition of the pathological conditions present has determined marked exceptions to the former rule. These excep- tions will be stated below. Hospital Gangrene.—When we regard the peculiar method of in- vasion by the microbes, it would seem as if the cause of hospital gan- grene must be specific. Thus far, however, no special form has been discovered, the bacillus of Rosenbach and the cocci of suppuration be- ing those that are found. Happily the disease is one that will seldom be seen again. The antiseptic mode of treating wounds will bar the development of hospital gangrene. Like scurvy, its horrors will be his- torical. The antiseptic treatment of this form of gangrene had already been learned, and no improvement in its therapeutics has been added since the discovery of its cause. Senile Gangrene.—The course of this disease is, as has been stated above, usually slow. But it has a tendency to the development of throm- bosis, the occurrence of which will suddenly change the whole aspect of the case. The gangrene may have been confined for weeks to the toe, but suddenly it travels in three days up to the knee. This can only be caused by thrombosis, resulting in complete obstruction of an artery. The question of amputation, as regards the proper time of its perform- ance in this special form of gangrene, has always puzzled surgeons. The red line has been waited for, but even when pretty well established the disease will extend beyond it, and thus destroy the hope of relief by amputation. There is difficulty and, perhaps, impossibility of diag- nosis as regards the exact point of occlusion in the artery, and the amputation may not be high enough. The operation is in itself a severe one, and the disease occurs in old age. There is to be considered also the depression arising from the disease while waiting for the formation of the line. Even if there be no recurrence of the gangrene, the life may still be lost. In view, however, of the diminished danger of .amputation since the use of antiseptic measures, it is often better to perform the operation before the red line forms, especially if the course of the gangrene is more rapid than usual. The loss of a limb is of greater importance in early than in later life. Less risks to save a limb should be taken in the old than in the young. To be assured of get- ting above the obstruction in this form of gangrene, it will be wise to amputate above rather than below the knee. GANGRENOUS diseases. 173 Gangrenous Diseases. Bed-Sores.—But little can be added to what has been said in the article on Gangrene in Vol. I. The habit of rubbing the back, and es- pecially the parts that are excessively pressed on, has become such an established usage in nursing, that the danger of bed sores forming is less than it was formerly. Local applications of acidulated water, to neutralize the alkaline secretions, possess a definite power. The acetate of aluminum is a favorite drug for this purpose, and even after the skin has broken and pus has formed, it is relied upon by Dr. Senn as the safest and most reliable antiseptic in these cases. Noma.—The cause of this disease is regarded by Lingard as a spe- cial bacillus of unusually large proportions, which makes its way through the mucous membranes. This gives opportunity for the entrance of the cocci of suppuration, and also of the saprophytes of putrefaction. Symmetrical Gangrene.—To what has already been said, I may add that Morven’s disease is sometimes a cause of this form of gan- grene. Much obscurity still hangs over the etiology of this affection. Morven refers its seat to the spinal cord, but also admits that it may be one of the manifestations of peripheral neuritis. It appears at first on one side, but is apt to become symmetrical, attacking the fingers and toes, producing felons in the first stage and necrosis afterward. The condition is a chronic one. Diphtheritic Gangrene.—Of this form we may say that the de- struction of tissue is not deep. It may be regarded as due simply to the Klebs-Loeffier bacillus. No special treatment other than what is called for in the treatment of diphtheria has thus far been brought out. Perhaps the peroxide of hydrogen has the greatest power in arresting this form of gangrene. Ergotism.—Of this disease little need be said. Like hospital gan- grene and scurvy, it will probably, in future, only be known in history. It has been suggested that a persistent spasm of the arterioles in ergot- ism is the cause of such a diminished circulation as to produce gan- grene. Embolic Gangrene.—Among the causes of embolism may be the formation of a thrombus from the rupture of the intima of an'artery by violence. Thus a rough spot gives an opportunity for the formation of a fibrinous mass that may break away and furnish the plug. Besides careful attention to the maintenance of the temperature of the part af- fected, and favoring the circulation, as already recommended, little is to be done. The return circulation is often established, but if gangrene of the extremity occur, amputation should be practised, and we should not delay for the formation of the red line. If we can discover pulsa- tion of the main artery in the limb, the amputation should be at the point at which such pulsation is detected. 174 GANGRENE AND GANGRENOUS DISEASES. Furuncle.—The bacteriologist finds in the fluid of furuncle the position of the pathogenic cocci. That most usually found is the staphylococcus pyogenes aureus. But all the other varieties of pus- producing cocci may be present. There can be but little doubt that they make their entrance through the sebaceous glands. We have in furuncle the evidence of the power of these microbes to produce gan- grene unaided by any of the putrefactive bacteria. Carbuncle.—This disease should no longer be called anthrax, which name should only be used to designate malignant pustule. The two diseases are entirely distinct, as proved by their special microbic origins. Both render the part susceptible to the invasion of saprophytes after their special development. As stated before, two opinions have been held with reference to the cause of carbuncle, one that it is spe- cial and unknown, the other that it has the same origin as furuncle, or, in other words, that carbuncle is an aggregation of furuncles. The latter view seems now to be established by conclusive experiments and reliable clinical observations. Modern surgery seeks in the treatment of carbuncle the destruction of the invading microbes as the first indi- cation. It will be seen, however, that as the result of clinical observa- tion alone, most surgeons have for a long while carried out this plan more or less perfectly. The points of suppuration in the hair follicles and their appendages are shown early in carbuncle, and are numerous. Some of these enlarge more rapidly than others, and present a circular opening resembling that of a furuncle. Whether we employ the expectant plan, or make crucial incisions, the destruction of the central portion of the skin is almost certain. If the microbes are destroyed early, the skin may be largely saved. To attain this object, I know of no better treatment than that proposed by a friend, the use of carbolic acid and glycerin, one part to five. Though of poisonous strength, this preparation becomes harmless when properly used, while if less strong it is inefficacious. In employing this remedy a piece of absor- bent cotton is saturated with the mixture and then drawn out and twisted. This movement expels most of the fluid and renders the cot- ton nearly dry. The openings of the carbuncle are enlarged by crucial incisions, each half an inch in length. The cotton rope is then pushed in with a probe and well packed at various points. The inflam- mation and swelling rapidly subside, and the skin is preserved. The end of the rope being left out of the opening, it is easily removed, and the dressing is renewed each day. Biedel has very recently urged the use of free incisions as the best means of preserving the skin. ANESTHETICS AND ANESTHESIA. BY ALBERT I. BOUFFLEUR, B.S., M.D., PROFESSOR OF PRACTICAL ANATOMY IN THE NORTH-WESTERN UNIVERSITY WOMAN’S MEDICAL school; lecturer on anatomy in the rush medical college; surgeon TO COOK COUNTY HOSPITAL, CHICAGO. The statement made by Professor Lyman, in the article on Anaes- thetics and Anaesthesia in Volume I. of this work, that “it is impossi- ble to employ any anaesthetic agent without in some small degree, at least, approaching the confines of danger,” has been supported by the results of experimental research upon animals, and by clinical experience upon man, during the past decade. While the relative safety of the different anaesthetic agents has not been changed, many phenomena have been carefully investigated, conclusions have been harmonized, the value of some danger signals seems to have been conclusively set- tled, and the treatment of serious conditions has been changed from a mere general routine to a more rational method of practice. From an historical standpoint, recent evidence shows conclusively that the honor of the first use of the principal anaesthetic substances— ether and chloroform—belongs to two American physicians. The data presented by Dr. L. B. Grandy 1 seem to prove beyond a doubt that to Dr. Crawford W. Long, of Jefferson, Ga., belongs the honor of having first used sulphuric ether for surgical anaesthesia, while a committee of the Chicago Medical Society, after a thorough investigation of the subject, decided, for reasons given in its report,2 that Dr. Samuel Guthrie, of Sackett’s Harbor, N. Y., was the first user of chloroform. The agreeable odor, concentration, rapidity of action, rarity of bad after-effects, and ease of administration of chloroform are so much in contrast with the usual effects of ether, that practically all experi- mentation and observation have been conducted with the hope that, with a full knowledge of its effects, means of fortification or restora- tion would be developed which would enable the surgeon to employ this potent substance with comparative safety. Three of the most impor- tant series of experiments have been conducted under the direction of Surgeon Lieutenant-Colonel Lawrie, for the Yizamof Hyderabad, to de- termine the phenomena and dangers attending the inhalation of chloro- form. The conclusions of the two Hyderabad chloroform commissions may be summarized as follows:— Inhalation of chloroform freely diluted with air causes a gradual fall of blood- pressure—providing the animal is not prevented from breathing. 1 Virginia Med. Monthly, 1893. 2 Annual of Universal Medical Sciences, 1892 ; Hare, Practical Therapeutics. 175 176 ANAESTHETICS AND ANAESTHESIA. The absorption of the residual chloroform in the lungs causes the fall to con- tinue after inhalation has been stopped. Struggling increases inhalation and, therefore, produces more rapid fall, and if associated with gasping may lead to dangerous depression. Slowing or temporary stoppage of the heart is not dangerous (providing respira- tion is undisturbed). The temporary exhaustion of the vagi following stimulation produces danger. Operations cannot produce syncope. Chloroform tends to prevent danger of shock. Chloroform always arrests respiration before the heart’s action. Chloroform, in itself, does not endanger life in cases of fatty heart, but slight exertion may cause death in patients so affected. Hemorrhage has no effect upon the narcosis. Ether cannot cause aneesthesia unless air is excluded.1 The third series of experiments, made by Drs. Hare and Thornton, confirms in the main the foregoing,2 These writers hold, however, that depression of the circulation occurs with the inhalation of an excessive dose, which effect is chiefly due to centric vasomotor depres- sion and final depression of the heart muscle. They believe that death practically always results from respiratory failure, provided the heart is healthy. In discussing the second Hyderabad Commission’s report, Alexander Wilson, anaesthetist to the Manchester Royal Infirmary,3 holds that the respiration indicates the amount of chloroform inhaled, while the pulse indicates the way in which it is being utilized by the circulation—a slow pulse allowing free administration of concentrated chloroform vapor, while with a full-bounding pulse even dilute vapor may be dangerous. He says that the results of the Commission’s experiments justify watching the pulse as well as the respiration. Buxton 4 presents the results of his extensive clinical experience with anaesthetics on man —and such must be admitted to be of more practical value than the conclusions formed from experiments upon animals—and believes, as McWilliams seems to have demonstrated,6 that inhalation of chloro- form is attended with cardiac dilatation from the first, and that this is from the direct effect of the substance upon the heart muscle. Unger6 and others conclude from their investigations that the prolonged inhala- tion of chloroform produces fatty degeneration of the heart muscle. The extensive cross-circulation experiments of Gaskell and Shore 7 are very ingenious, and, could they be taken without reserve, w7ould indicate direct action of chloroform upon the heart substances. But the oppor- tunities for error, and the highly artificial conditions produced, render the results thus obtained almost useless to the practising physician. Hare and Thornton,8 in their conclusions, practically admit that both cardiac and respiratory death can take place, but that respiratory failure occurs first wdiere the heart is healthy. If the heart is diseased and the depression of chloroform is added, sudden arrest may occur without any premonitory disturbance of either respiration or pulse. It is evident that all the phenomena attending the inhalation of chloroform have not been definitely settled, and until the results of ex- ’Lancet, 1890; Therapeutic Gazette, 1893; Annual of Universal Med. Sciences, 1891. 2 Therapeutic Gazette, Oct. 16, 1893. 3 Manchester Medical Chronicle, 1890. 4 British Medical Journal, 1892. 5 Ibid., 1890. 6 Centralblatt fur Chirurgie, 1887. ’Lancet, 1893. 8 Therapeutic Gazette, Oct. 16, 1893. 177 A DM I NISTRATION OF ANESTHETICS. periments upon animals have been practically verified upon man, they should be accepted with some reservation. From all the facts and ob- servations now before us, we may draw the following practical conclu- sions:— 1. The inhalation of any anaesthetic substance is not entirely free from danger. 2. Chloroform is a safe anaesthetic when skilfully administered. 3. Death is usually from respiratory failure, providing that the heart is physically and functionally healthy (a condition which is not unfrequently indeterminable). 4. Death from circulatory depression—vasomotor or cardiac, or both—may occur, but is usually preceded by disturbance of respiration. 5. Both the respiration and circulation should be watched, hut of the two the former is probably the better criterion. 6. Prolonged, profound, or oft-repeated anaesthesia may produce seri- ous changes in the nervous system and also in the myocardium, which may he manifested, either definitely or indefinitely, for days or even weeks after anaesthesia is recovered from. Administration of Anesthetics. Preparation of Patient.—From a medico-legal standpoint it is best to inform the patient or his friends, in the presence of a third party, that the inhalation of any anaesthetic is attended with some danger. A careful examination of the heart, lungs, and urine should be made before the anaesthetic is selected. The patient should not take any food, excepting beef-tea or clear bouillon, for at least six hours before an anaesthetic is given. Feeble and nervous patients, as well as drunkards, should be given some stimulant, or morphine with atropine hypodermi- cally, within one-half hour before inhalation is begun. The patient’s clothes should be loose, and so arranged as to admit of ready exposure of chest and abdomen. The patient should be told what sensations to expect. The eyes should be covered with a damp cloth to prevent irri- tation of fluid or vapor. If chloroform is to be used, the face may be protected by simple cerate or vaseline. Fear should at all times be al- layed by kindly reassurances, and by the avoidance of all reference to the operation until complete anaesthesia is obtained. Anesthetist.—Whatever the agent, the anaesthetist should be, if possible, one skilled in its use, and he should give his whole attention to its administration. Ether should be preferred to chloroform unless the anaesthetist is skilled in the use of the latter. In addition to having a pure anaesthetic, he should have, at least, a pair of forceps, a hypoder- mic syringe, solutions of strychnine and atropine, tincture of digitalis, or digitalin, aromatic spirits of ammonia, and whiskey. It is well also to have an additional anaesthetic substance at hand. Ether.—It is necessary to exclude all air to produce complete anaes- thesia with ether, and hence a cone with impervious walls should be used. Glover’s, Allis’s, Ormsby’s, and other inhalers are excellent in construction, hut are, as a rule, cumbersome and often not at hand. 178 ANESTHETICS AND ANAESTHESIA. An extemporized cone of pasteboard, or any firm substance, surrounded by a towel so as to leave a space for evaporation, is efficient, clean, and always readily made. At first, the cone should be held several inches from the patient's face, but after the nasal and faucial mucous mem- branes have been anaesthetized, its close application should be allowed, when rapid inhalation of concentrated ether vapor can be secured, thus producing narcosis quickly and safely.1 After complete anaesthesia has been produced, the inhaler should be removed during every sixth or eighth inspiration and expiration.2 Death occurs from paralysis of respiration; therefore the respiration and the color of the face should be watched, and since the diaphragm is the first respiratory muscle to stop acting, it is advisable to notice the abdominal movements. Com- plete anaesthesia is indicated by a contracted pupil3 and the absence of the act of deglutition.4 Etherization by the rectum is, to say the least, a dangerous method, and as yet is most unsatisfactory.5 Chloroform.—This must always be greatly diluted with air. Even five per cent, of chloroform is dangerous. The air surrounding the patient should be dry, and the temperature should he above 60° F.° The stages of narcotism are prolonged, and syncope is more fatal, in a moist atmosphere.7 Chloroform should be administered by the open method, and very slowly at first. The simple inhaler of Esmarch (Fig. Fig. 1594. SHARP & SMITH Esmarch’s Inhaler. 1594), which consists of a wire frame with a gauze covering, or the canvas cone of Lawrie/is the best, as the apparatus itself does not re- quire attention, and always admits a large amount of air. Any possi- ble interference with respiration should be prevented by loose clothes, position, etc. Struggling, choking, and holding the breath should be avoided by holding the inhaler farther from the face.9 The inhaler should be removed during an act of gasping following struggling, etc., as a dangerous dose might be taken in at such a time. After tolerance is acquired and the first stage past, the administration should be pushed quickly into the third stage of anaesthesia. The more bounding the pulse, the more rapidly is chloroform absorbed, and, hence, less is required. When administered near a gas flame, I as well as others10 have noted that chloroform becomes decomposed and causes irritation 1 Medical Record, 1889. 2 Buxton, Anaesthetics. 3 La France Medicale, 1887. 4 Practitioner, 1887. 5 Buxton, Anaesthetics. 6 Asclepiad, 1892. 1 Ibid., 1892. 8 Therapeutic Gazette. 9 Ibid. 10 Lancet, 1889; Medical Press and Circular, 1889; Berliner klin. Woch., 1889; Practi- tioner, 1889. ACCIDENTS OF ANAESTHESIA. 179 of the nose and throat in all who are present, and sometimes produces nausea and serious disturbances of respiration. Complete anaesthesia is indicated by an insensitive cornea, stertorous but rhythmical breath- ing, or muscular relaxation. The presence of either should cause stop- page of inhalation.1 We should watch, (1st) the rhythm and depth of respiration, preferably the abdominal, (2d) the pulse, and (3d) the pupil. Anaesthesia should be complete before the operation is begun, so as to lessen the liability to syncope from reflex inhibition of the heart. Additional evidence has been presented that anaesthesia can some- times be produced in children during sleep.2 Nitrous Oxide.3—1. Have the mouth or face piece fit accurately, and hold the nose, so as to exclude all extraneous air. 2. The patient should take a few deep inspirations before the gas is turned on. 3. To avoid struggling and the use of large quantities of gas, and to promote profound narcosis, turn the gas on toward the end of a long expiration. 4. Slight pressure on the bag facilitates the action of the gas. 5. Drop- ping of the chin indicates full narcosis. Hillisher4 has administered nitrous-oxide gas with from ten to fifteen per cent, of oxygen to 2901 pa- tients, producing peaceful sleep for a long time, and he considers it the ideal amestlietic. He has devised an apparatus for the definite mixture of the gases, and claims to have eliminated the necessity of pressure, which according to the extensive experiments of Paul Bert was essential. Bromide of Ethyl.—This should be administered on an open inhaler, in drop doses for the first few seconds, and then the full dose should be applied close to the mouth. Anaesthesia usually occurs in from fifty to sixty seconds. Accidents of Anaesthesia. Asphyxia.—Asphyxia may result from the following causes: 1. Muscular rigidity of the jaws, which can be overcome by forcibly hold- ing the mouth open. Spasm of the respiratory muscles probably never leads to a fatal result.6 2. Mechanical closure of the laryngeal opening by the epiglottis,6 or falling backward of the tongue, which may best be relieved by flexion of the neck, with moderate extension of the head and elevation of the jaw by means of the fingers placed behind its angles.7 3. Accumulation of mucus, which must be removed by sponges, or by turning the head to one side. 4. Presence of foreign bodies, as, for instance, teeth, blood clot, masses of new growth, sponges, etc., which should be removed, if possible, through the mouth, but other- wise by tracheotomy. Blood may be removed by suction with a suit- able syringe. 5. Respiratory paralysis from over-dosage. If the face is flushed and cyanotic, the failure is respiratory and the head should not be lowered, while if the face is pale, the failure is primarily cardiac and the head then should be lowered.8 1 Lawrie, Therapeutic Gazette. 2 Buxton, Anaesthetics; Medical Record, 1890. 3 British Medical Journal, 1892. 4 Allg. Wien. med. Presse, 1889. 6 McCallum, Medical News, 1892. 6 Buxton, Anaesthetics. 1 Martin and Hare, Annual of Univ. Med. Sciences, 1890. * Hare, Practical Therapeutics. 180 AN.ESTIIETICS AND ANESTHESIA. Artificial respiration should be carefully performed by Sylvester’s or Kelly’s method,1 at the rate of from sixteen to twenty movements to the minute, and it should invariably be commenced by an expiratory effort,2 so as to avoid further absorption of the anaesthetic, or, if possible, the vapor should be sucked out of the lungs before inspiration is per- formed. Artificial respiration should be maintained for at least forty-five minutes, as patients have recovered after being apparently dead for an hour.3 During the attempt at restoration the respiratory tract should be maintained unobstructed as directed above. A dash of cold water, or better ether, on the abdomen and chest may cause reflex inspiration,4 as may the general application of the electric current to those surfaces.5 Other forms of irritation, and especially dilatation of the internal anal sphincter, be successfully employed at times. The hypodermic use of strychnine and atropine, and, if the emergency be great, the use of ammonia by intravenous injection of the weaker watery solution (Aqua ammonise U. S. P.) into the leg, are very useful. Frictions and hot applications are also indicated. Syncope.—Syncope rarely occurs during etherization, but does some- times occur during chloroform inhalation, (a) In the first stage, it is suddenly manifested by fluttering or stopping of the pulse, extreme pallor, sudden wide dilatation of the pupils, and cessation of respira- tion. It is usually fatal. (b) In the taler stage, there is usually more warning given, by disturbed respiration, pallor, weakened pulse, cessation of hemorrhage, and dilatation of the pupils. When syncope is threatened or has occurred, the surgeon should remove the inhaler, lower the head, and, if necessary, maintain artificial respiration as above described. Direct compression of the heart by pressing the hand deeply under the costal cartilages seems to have been efficient,0 and is easily performed during artificial respiration. Deep and rapid pressure in the precordial region has proven successful in several instances, with or without artificial respiration.7 Strychnine is probably the best stimu- lant to administer under these circumstances. Ether may be used hypodermically with advantage, at times, as may also whiskey, digi- talis, and ammonia, but if the circulation has stopped their employment appears useless. Nitrite of amyl is positively contra-indicated,8 except in the later stages of narcosis, or after great loss of blood, when a single whiff may do some good.9 Auto-transfusion, by elevating the limbs and applying constrictors for from three to five minutes, has been of use.10 Babroff 11 recommends very highly the injection of from 25 to 225 grammes of a 6-1000 saline solution into the subcutaneous tissues, as soon as any evidence of respiratory or cardiac embarrassment occurs. The greater the loss of blood or the anaemia, the larger the amount to be injected. Heat and sinapisms to theprecordium are useful. Punc- ture of the heart, as proposed by Watson,12 faradization and galvani- 1 British Medical Journal. 2 Murray-Aynsley, Annual of Univ. Med. Sciences, 1893. 3 Hare, Practical Therapeutics. 4 Muncliener med. Woch., 1889; Medical Age, 1889. 5 Hare, Practical Therapeutics. Iliffe, British Medical Journal, 1892. 1 Konig, Berliner klin. Woch., 1892; Sinclair, British Medical Journal, 1892. 8 Babroff, Kirurgitcheskaia Latopis. 9 Hare, Practical Therapeutics ; Buxton, Anaesthetics. 10 Babroff, Kirurgitcheskaia Latopis. 11 Ibid., 1891. 14 New York Med. Journal, 1887. ACCIDENTS OF ANESTHESIA. 181 zation of the heart and of the phrenic nerves, and the injection of ether in ether narcosis, are unscientific and deserve condemnation.1 Epileptic Seizures.—Nothing can be done during such seizures ex- cept to protect the patient’s tongue, and restrain him from doing him- self an injury. After-Effects of Anesthesia.—Temperature.—This is appreciably lowered by etherization, and hence it is advisable to supply artificial heat and to keep the patient well covered. Nausea and Vomiting.—These conditions often prove troublesome, and sometimes intractable. No specific treatment has as yet been de- vised, but the following measures have been found most useful. The patient should maintain the recumbent position and abstain from food for three or four hours after anaesthesia. Hot water in teaspoonful doses is frequently useful. Small quantities of ice, and also iced cham- pagne, are quite generally used. Ice with small doses of aconite is advised by Hare.2 Dr. Ochsner, of Chicago, has had nearly uniform success in controlling vomiting after anaesthesia by administering an ounce of castor oil in the foam of ale. It is important to give only the foam of the ale, the carbonic acid gas of which probably acts as a local anaesthetic until the oil removes the mucus from the stomach. Sina- pisms applied over the epigastric region are sometimes beneficial. In plethoric, bilious persons, small doses of calomel are occasionally useful. Nausea alone can be relieved by minim doses of tincture of nux vomica, given in hot water every ten minutes.3 Britton4 recommends four or five drops of spirit of chloroform, with two or three drops of the vinegar of opium, as the most efficient remedy in ether nausea. Hiccough.—This may be relieved by an infusion of mustard (3i. added to f 3 iv. of boiling water) taken in teaspoonful doses.5 Mor- phine hypodermically is also useful. Hysteria.—Hysterical seizures may occur, but are of short duration and do not require treatment. Insanity.—Various forms of insanity may follow anaesthesia in pre- disposed persons,6 and should be treated upon general principles. I had once three cases within a single month, in which insanity developed after anaesthesia for herniotomy, on the fourteeenth, twelfth, and fourth days respectively. The last two cases recovered under general treatment, and the first underwent improvement. Jaundice.—This condition occasionally follows chloroformization, and should be treated as catarrhal jaundice. Albuminuria and Glycosuria.—These conditions may follow both ether and chloroform anaesthesia, and while usually temporary after the latter, they may prove serious when caused by the former, and should be treated upon general principles. 1 Hare, Practical Therapeutics ; Buxton, Anaesthetics ; Babroff, Ivirurgiteheskaia Latopis, 1891 ; Annual of Universal Med. Sciences, 1893. 2 Practical Therapeutics. 3 Buxton, Anaesthetics. 4 Annual of Universal Med. Sciences, 1892. 5 Buxton, Anaesthetics. 6 Savage, Brit. Med. Journal, 1887; Bull, Annual of Univ. Med. Sciences, 1888; Bro- phy, ibid., 1888; Boston Med. and Sura:. Journal, 1889; American Journal of Med. Sciences, 1890. 182 ANESTHETICS AND ANESTHESIA. Mortality from Anesthetics. In addition to the statistics given by Lyman, in Yol. I., it may be said that Hunter McGuire1 states that be saw 28,000 chloroform adminis- trations during the War of the Rebellion, without a death, and that Lawrie2 reports 45,000 administrations, also without a death. T. Brown Henderson,3 on the other hand, gives the statistics from St. Bartholomew’s Hospital, as follows: Chloroform, 12 deaths in 17,666 administrations (1 in 1472); ether, 1 in 7493; gas and ether, 1 in 12,807. Julliard4 collected 524,507 chloroform administrations, with 161 deaths (1 in 3258), and 1 death in 14,987 etherizations. Mac- ewen, Macleod, and Buchanan, of Glasgow,6 record 34,000 chloroform administrations with but three deaths (1 in 11,000), while Ollier6 re- ports 29,500 etherizations without a single fatal result. Giirlt,7 of Berlin, reported to the last German Surgical Congress the statistics from 62 operators, showing 109,196 cases of anaesthesia, with 39 deaths, or an average of 1 in 2800, divided as follows: Chloroform, 94,123, with 36 deaths (1 in 2614); ether, 9431, without a death; ether and chloro- form, 2891, with one death; ether and alcohol, 1381, with no death; bromoform with ethyl-bromide, 2151, with one death; pental, 210, with one death. In the Medical News of October 29, 1892, an extensive array of statistics is presented, comprising reports from 42 sources and show- ing 638,461 administrations of chloroform, with 170 deaths (1 in 3749), and 300,157 etherizations, with 18 deaths (1 in 16,675). It isalso re- ported that Dr. Rabotz has administered ether 150,000 times, without any death. Several deaths and a large number of cases which presented serious symptoms have occurred from the hypodermic use of cocaine. It should be noted that the reports of McGuire, Nussbaum,8 and Law- rie, comprising 113,000 chloroformizations without a single death, were, in the first and second instances, of administrations in military practice, which should he received with some reserve, as it is very diffi- cult to fairly weigh all the causes of fatal results under such circum- stances, while in the last instance they were in a hot, dry climate, under conditions most propitious for the safe administration of chloro- form. Statistics compiled, as lias been the custom, from so many sources, are at best unreliable, and since hut a comparatively small pro- portion of the deaths and even a smaller proportion of the administrations are ever recorded, their practical uselessness is apparent. To be of value, the cases for the administration of the different agents should be carefully selected, and the anaesthetic should he used by skilled and unbiased operators. Even then it should be remembered that the results will naturally vary considerably. The Scotch and German statistics are undoubtedly the most reliable at hand, and the difference in the ratios given is probably best accounted for by different methods of administra- tion. We are informed that the Germans are given to pushing chloro- form narcosis, which may account for their high mortality rate; while the ratio of the leading Scotch surgeons (1 in 11,000) was doubtlessly 1 Journal Amer. Med. Assoc., 1887. 3 Glasgow Med. Journal, 1890. 6 Ibid. 1 Centralblatt fur Cliirurgie, 1892. 2 Lancet, 1890. 4 Buxton, Anaesthetics. 6 Revue de Chirurgic, 1893. 8 Bulletin de l’Acad. de Med. de Paris. CHOICE OF ANESTHETICS. 183 attained by very careful selection and administration, and is probably the most favorable award that can be made to chloroform. The ratio of fatal ether narcosis as given by Lyman in Vol. I. (1 to 23,000) is, according to Julliard and Buxton,1 probably too low. It should be remembered, however, that the vast majority of deaths from ether narcosis have occurred in cases of strangulated hernia, carcinoma with starvation, etc., conditions in which the power of resistance has been very greatly reduced. The statistics of the other substances, either alone or in combination, are so meagre and unreliable that it is impossi- ble to express their comparative dangers, excepting that it should be remembered that nitrous oxide has been administered millions of times with less than ten recorded deaths, and that the hypodermic use of cocaine for local anaesthesia is attended with considerable danger. Choice of Anesthetics. The choice of an anaesthetic depends upon the condition of the patient, the necessities of the operation, and the safety of the agent. No argu- ment has been advanced to successfully change the judgment heretofore expressed as to the relative safety of ether and chloroform. We must, therefore, conclude that generally ether is the safest anaesthetic, and especially as far as the immediate effects are concerned. The condition of the patient and the exigencies of the operation must, however, al- ways be taken into consideration. Ether.—Ether is generally to be preferred under the following con- ditions: 1. When the operator must employ an unskilled anaesthetist. 2. In collapse or extreme prostration, as in cases of prolonged suppura- tion with a hectic or anaemic state, collapse following loss of blood, etc., since it stimulates the heart and but little of the anaesthetic is required.2 3. In heart disease the dangers of any anaesthetic are increased, but ether is to be preferred to chloroform. In uncomplicated mitral regur- gitation, ether can be given as in any ordinary case.3 4. In persons who are free from pronounced pulmonary or renal disease. Chloroform.—While chloroform is more dangerous than ether, it is comparatively safe when skilfully administered to persons not affected with organic or functional cardiac incompetency. It should be pre- ferred in the following conditions: 1. In hot climates, where ether is usually inapplicable, and where a free circulation of dry and warm air increases the safety of the patient. 2. When a large number of persons are to be anaesthetized. 3. In cases of Bright’s disease. 4. In cases of aneurism and marked atheroma of the blood-vessels, where the struggling and vascular stimulation of ether might cause rupture. 5. In cases of obstruction in the respiratory tract, or acute or pronounced pulmonary disease, as bronchitis, pneumonia, phthisis, or any other condition productive of dyspnoea. 6. In cases requiring the use of the thermo-cautery about the head, or in operating near an open fire. 7. When the circulation is not disturbed by fatty degeneration or valvular disease of the heart. 8. Only when a competent anaestlietizer is at hand. 1 Buxton, Anaesthetics. 2 Ibid. ; Lancet, 1888. 3 Ibid., 1889. 184 anesthetics and anesthesia. 9. In children and adults who already have bronchitis or are known to hear ether badly. 10. In weak and sickly persons, who, as a rule, take chloroform with less danger than the strong and robust, because they struggle less, making the strain on the heart less. 11. In patients who have taken food within four hours. 12. In obstetrical cases.1 Nitrous Oxide.—This agent is especially useful in dental surgery and in minor operations requiring anaesthesia for but a few moments, and also in the extremely weak. Its administration preparatory to the use of, or in combination with, ether, will avoid the struggling and ex- citement caused by that agent, but as the combined administration requires a special and somewhat cumbersome apparatus,2 its use in this manner must of necessity be limited to hospital practice. Ethyl Bromide.—This agent is indicated in short operations, hut its instability, impurities, and frequent substitution by ethylene bromide, which is very dangerous, render its effects uncertain and its use unsafe.3 It is, however, held in favor by a number of prominent European surgeons,4 and by a few Americans.5 Selection of Anaesthetic for Special Departments of Sur- gery.—Brain Surgery.—Chloroform, with morphine either before or during anaesthesia, is to be preferred, as ether causes too much vascular excitement in the brain. The morphine will prolong the anaesthesia with very little chloroform, Ophthalmic Surgery.—Cocaine is very extensively used. Ether and chloroform are also extensively employed; the former seems the safer, but the latter facilitates the operation by producing absolute immobility of the patient. About the Mouth, Jaivs, and Respiratory Tract.—Chloroform is the most satisfactory, since the inhalation of a small amount at intervals suffices to maintain complete anaesthesia. By extending or turning the head to one side, the entrance of blood or other substances into the larnyx can be prevented. Senn and some other surgeons prefer to operate about the mouth during partial—“talking”—anaesthesia, secured by the administration of morphine with whiskey to semi-intoxication, when the patient will spit out the blood, etc., when commanded so to do. Dented Surgery.—Nitrous oxide gas alone or with ether is the safest and most convenient anaesthetic. Thoracic Surgery.—The choice will depend upon the symptoms and general condition of the patient (see Ether and Chloroform). Abdominal Surgery.—Chloroform should generally be preferred, be- cause it relaxes the abdominal walls most completely, and because the liability to coughing, struggling, and vomiting is not as great as with ether, which, however, is preferred by many operators.6 After the in- cision has been carried through the parietes, only a small degree of nar- cotism is required. Rectal Surgery.—The narcosis must be very profound and, as a rule, ether is considered the safest anaesthetic. 1 See Lyman, in Vol. I. 2 See Fig. 39, Yol. I., page 417. 3 Lyman, Yol. I. ; Annual of Univ. Med. Sciences, 1890. 4 Annual of Univ. Med. Sciences ; Vrach, 1891 ; Zeitschrift fur Therapie. 6 Medical News, 1892. 6 Buxton, Anaesthetics; British Med. Journal, 1892. ANAESTHETIC SUBSTANCES. 185 Hypnotism.—The following operations have been reported as having been performed during hypnosis: Amputation of the breast, by Cloquet, in 1829; amputation of the leg, by Loysel, in 1844; of the arm, by Joly, in 1845; of the thigh, by Guerineau, in 1859.1 More recently Mesnet2 has performed anterior colporrhapliy during hypnosis, and Roth has reduced a dislocation of the humerus;3 Hafftner is reported4 to frequently produce this state by holding the mask before the pa- tient’s face, and soothingly directing him to go to sleep. Anaesthetic Substances. Trimethylethylene—C5H10—Pental.—This is an impure amylene,5 the use of which has been revived within the past two years. Giirlt records 210 administrations with 1 death, while Hollaender6 reports 000 narcoses by its means for minor operations with no fatality. While re- garding it as the best anaesthetic for short operations, he admits the occurrence of dangerous symptoms, and does not produce any evidence to show its superiority over older and safer anaesthetics. Wood and Cerna,7 and Chalab,8 consider it very dangerous. Dichloromethane—Methylenic Chloride, Methylene Bichloride.— Favorable reports are occasionally received of the use of this agent. Trelat9 declares that the methyl chloride of Sir Spencer Wells is a mix- ture of chloroform and methylic alcohol, 4 to 1, and that it does not decompose b}T exposure to air or light. Used by means of a spray, methylene chloride produces local anaesthesia, which is probably due to freezing of the part by rapid evaporation.10 The danger of sloughing may be prevented, according to Bardet,11 by painting the surface with glycerin. Chloralamide—C6H502N.—This is a colorless, crystalline, and slight- ly bitter substance, with a melting point of 115° C. (239° F.). It is a compound formed by the addition of formamide to anhydrate of chloral. It is soluble in 9 parts of water and parts of alcohol, and does not decompose in either solution. Its action is similar to that of chloral, being a cerebral and spinal depressant, but it does not so considerably depress the circulation. In addition to being a potent hypnotic, it is credited with being an efficient analgesic. It is administered in from ten-grain to thirty-grain doses, and the resulting sleep usually lasts from five to eight hours. •- Paraldehyde—C2H40.—This is a colorless liquid, having a disagree- able odor and burning taste, with a boiling point of 124° C. (255° F.), and a sp. gr. of 0.998. It is readily soluble in cold water and alcohol. It acts as a nerve sedative, and is principally used as an hypnotic and 1 Practitioner, 1889. 2 Bulletin de l’Acad. de Med. de Paris, 1889; Practitioner, 1889. 3 Provincial Med. Journal, 1889 ; Correspondenz-Blatt fur Schweizer Aerzte, 1889. 4 Correspondenz-Blatt fur Schweizer Aerzte, 1889. 5 Hare, Practical Therapeutics. 6 Dental Cosmos, 1893. ’Ibid., 1892. 8 International, klin. Rundschau, 1892. 9 Bulletin de 1’Acad, de Med. de Paris, 1889; Cincinnati Lancet-Clinic, 1889. 10 Asclepiad, 1889. 11 Annual of Univ. Med. Sciences, 1890. 186 ANAESTHETICS AND ANESTHESIA. antispasmodic. Death from its use occurs by respiratory failure. It is administered in large doses (from 30 to 60 grains) well diluted, and it is necessary to repeat the dose at short intervals. Tribromomethane—CHBr3—Bromoform.—This substance is analo- gous to choloroform and has similar anaesthetic properties. It boils at from 147° to 151° C. (296.6° to 308.8° F.) and is soluble in alcohol and ether. It is produced by the action of bromine upon equal parts of methylic alcohol and caustic potassa. It is a colorless, limpid liquid, with a sweet taste and an agreeable odor. When applied locally it is a potent antiseptic. It is an antispasmodic and analgesic. Its use as an anaesthetic has been limited. Giirlt reports 2151 administrations of bromoform with ethyl bromide, with one death. Wlrtm given by the mouth it should he diluted with alcohol, or suspended in syrup of acacia. Diethyl-Dimethylmethane—C7H10S2O4—Sulphonal.—This is a col- orless, odorless substance, melting at 125° C. (257° to 259° F.). It is made synthetically by the interaction of anhydrous mercaptan and anhydrous acetone in the presence of hydrochloric acid gas. It is solu- ble in alcohol and ether, and sparingly so in cold (1 to 100) and hot water (1 to 20). Its chief property is that of an hypnotic, and as such it is administered in from fifteen-grain to thirty-grain doses. Its action is probably exerted upon the higher nerve centres.1 Local Anesthetics. Cocaine.—Cocaine is the alkaloid derived from the erytliroxylon coca. When administered in medicinal doses it is a respiratory, car- diac, and cerebral, as well as muscular stimulant. In poisonous doses it produces cerebral convulsions and cardiac failure. When applied locally it paralyzes the sensory nerves. The hydrochlorate of cocaine is principally used, in the strength of from a two-per-cent, to a ten-per-cent, solution, which if prepared with boric acid and distilled water remains unchanged for a long time. About the eye and the mucous membrane of the nasal and pharyngeal cavities, a two-per-cent, or four-per-cent, solutionis efficient, while in the vagina and rectum a ten-per-cent, solu- tion is necessary. It is especially useful in ophthalmic and nasal sur- gery, in amputations of fingers, and in other minor operations where the circulation can be controlled. It is not readily absorbed by the skin or by a bleeding surface, and must he used hypodermically when such parts are concerned. In operations about the fingers a constrictor should be placed about the part, so as to interrupt the circulation, either before or preferably just after the injection of a solution of from four to eight per cent. When the operation has been completed the ligature should be intermittently relaxed, so as to prevent the drug from entering the circulation suddenly; this may also be accomplished by encouraging slight bleeding from the wound. Cocaine has been successfully used in a number of major operations,2 such as amputation, lithotomy, 1 Hare, Practical Therapeutics. 2 Boston Med. and Surg. Journal, 1890; China Medical Missionary, 1890; New England Med. Monthly, 1892. local ANAESTHETICS. litliolapaxy, herniotomy, laparotomy, etc., but since several deaths have occurred from its use, it should be looked upon as a dangerous anaesthet- ic, unless the drug can be confined and its entrance into the circulation graduated. Its effect upon different individuals varies greatly, and it should therefore be used cautiously, and the patient should be watched for some time after its systemic diffusion. In operations in- volving the skin, the drug should be injected into the derma itself, and not beneath it. Schleich 1 suggests a 1 to 10,000 solution in a two-per- cent. salt solution for intradermal injection, and declares that it is effi- cient and absolutely safe. Tropa-Cocaine (Tropsin).—Under this name Chadbourne2 calls attention to a new coca base.' It is a benzoyl-pseudo-tropein, made syn- thetically, and is a powerful anaesthetic. A three-per-cent, solution of the liydrochlorate in a weak saline solution is employed, and it is claimed that it is more active, less irritating, more stable, and less than half as toxic as cocaine. Cocaine Plienate.—This combination was produced by Von Oefele,3 and has been favorably reported upon by Veasey.4 The employment of these preparations has not been sufficiently extensive to enable one to form any definite opinion as to their merits. Ethyl Chloride.—When this substance is sprayed upon the surface of the body, it produces local anaesthesia by freezing. It is kept in a compressed form, sealed in glass tubes. Other Local Anesthetics.—Many substances* have been added to the list of local anaesthetics during the past few years, but upon careful investigation most of them have been proven to be either inert, less efficient than cocaine, or too irritating for use, or to be proprietary preparations in which cocaine is found. Stenocarpine, or Gleditschia triacanthus, is an efficient local anaesthetic which belongs to the last class.6 Dr amine, proposed as efficient, was found absolutely inert by Ogston.6 Erythrophlcein produces anaesthesia of the cornea, but its mode of action is in dispute. It does not produce anaesthesia when in- jected.7 Anaesthesia has been produced by instilling from two to three drops of an aqueous solution of strophanthus8 into the eye. The action is slow, but the effect quite prolonged. Intraocular pressure is greatly increased. Many other substances have a local anaesthetic effect upon the tissues,9 as, for instance, ammonium bromide and sulphate, iron salts, acetate of lead, resorcin, antipyrine, drugs of the digitalis group, and the es- sential oils; the latter act by destroying the nerve ends and by causing adjacent irritation. Styptics and caustics are, as a class, anaesthetic, as are salt solutions and even distilled water. 1 La Semaine Medicale, 1892. 3 Merck’s Bulletin, 1891. 6 Ibid., 1887. 1 Annual of Univ. Med. Sciences, 1889. 1 British Med. Journal, vol. ii., 1892. 4 Medical News, 1893. 6 British Med. Journal, 1887. 8 Ibid., 1888. 9 Ibid., 1889. 188 ANESTHETICS AND ANESTHESIA. Note to Page 182. Gurlt1 reports for 1893 and 1*894 52,384 inductions of anaesthesia with 21 deaths (1 in 2494), divided as follows: Chloroform, 33,080 ad- ministrations with IT deaths (1 in 1946); ether, 11,668 administrations with 2 deaths (1 in 5834); and Pictel’s glacial chloroform, 3182 admin- istrations with 2 deaths (1 in 1591). These statistics added to those of the preceding three years, as quoted on page 182, give chloroform a ratio of 1 death in 2647, and ether of 1 in 13,160. 1 Verhandlungen der Deutschen Gesellschaft fur Cliirurgie. AMPUTATIONS. BY JOHN ASIfflURST, Jr., M.D., BARTON PROFESSOR OF SURGERY AND PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PENNSYLVANIA HOSPITAL, ETC. Operation and Dressing of the Stump. Since the appearance of the Article on Amputations in the first volume of this work, I have, in common with other surgeons, adopted what is known as the “antiseptic method,” in a simplified form, in the dressing of stumps, and during the last seven }rears have employed this method in all the amputations which I have had occasion to perform, as well as in other operations. I have not used the antiseptic spray, and indeed it is now, I believe, universally abandoned, and I have not for several years used antiseptic irrigations during the progress of the operation, believing them to be quite unnecessary, and not unattended with danger from the risk of increasing the shock by chilling the patient’s surface, since even warm solutions by evaporation reduce the bodily temperature. Indeed, I attribute much importance to the maintenance of heat during the operation, and in cases, as of multiple amputation, in which there is likely to be much depression, I have hot cans or hot-water bags placed on the operating table in proximity to the patient’s trunk, and am confident that I have saved lives by the adoption of this precaution. For the same reason (the fear of chilling the patient) I object to the use of ether in the preliminary cleansing of the part on which the opera- tion is to be performed; it is quite sufficient to have it carefully shaved, rubbed with oil of turpentine, and thoroughly scrubbed with hot soap- suds, and finally well washed with a hot 1-2000 solution of corrosive sublimate. The operation is then proceeded with, and no further washing or irrigation is necessary until the vessels have been tied and the surgeon is ready to close the wound. In this view I am sustained by the recent utterances of Sir Joseph Lister himself, who declares that no fear need be entertained of germs that may be in the air, and that those only are deleterious which are on the surface of the patient’s body, or which may be introduced by the surgeon’s hands or instru- ments. The inventor of the antiseptic method has latterly returned to his first love, and relies for the cleansing both of the patient’s body and of the operator’s hands upon a five-per-cent. (1-20) solution of car- bolic acid, and declares that by its employment it is sometimes possible even to dispense with soap and water; but, for my own part, I prefer the sublimate to the carbolic solution, except for use with the instru- 189 190 AMPUTATIONS. ments, sutures, etc., and while I do not practise the complicated wash- ings recommended by some surgeons both at home and abroad—wash- ings which in their multiplicity and complicated character surpass those of the ancient Pharisees—yet I believe in the necessity of ordinary as well as of antiseptic cleanliness, and have an old-fashioned respect for soap and the nail-brush. During the operation the limb to be am- putated is kept surrounded with towels wrung out of antiseptic (1-2000 sublimate) solution, hut these are kept from chilling the patient by being spread over blankets protected by India-rubber sheeting. I have not any changes to suggest in the technique of the operation of amputation in general, except that in employing catgut ligatures, which I prefer to silk under ordinary circumstances, I find that the first turn of the reef-knot is apt to slip before the second can be tied down upon it, and I therefore begin with a surgeon’s knot (see Fig. 139, Vol. I., p. 582), which keeps its place very well, and then secure it by a second knot which fixes it permanently. This cannot be done with very thick catgut, and with that is unnecessary, since then the first turn of the reef-knot can be drawn so tightly as to prevent slipping; but with the thickness of gut employed for ordinary ligatures this modified knot will be found very satisfactory. For ligating the ma- jority of vessels in an amputation I use catgut prepared with juniper- oil and alcohol, but for the main artery in a large amputation—as through the thigh, or at the shoulder-joint—chromicized catgut is pref- erable because more enduring. For suturing the stump I still employ a metallic stitch, usually of silver wire, which for large wounds I prefer to any other material; for small amputations, as of the fingers, I some- times use silkworm gut, or even fine black silk. Drainage-tubes of India-rubber are, I think, of great value in the treatment of stumps, though I feel bound to say that in an amputation of the thigh which Professor Esmarch did at my Clinic some years ago by his circular, single-incision. (einschnitt) method, and in which he closed only the centre of the wound, leaving both ends open, with- out drainage-tubes, healing took place as rapidly and as perfectly as could be desired. But I think the use of the tube is a safe precaution, and I commonly place one of large calibre (one is usually sufficient) across the face of the stump, cutting it on a level with the skin, and securing both its extremities by safety-pins. In circular amputations I sometimes bring out one or both ends of the drainage-tube through perforations of the cuff above the level of the incision, which is then closely sutured. For the dressing of stumps I employ protective, a deep and a super- ficial dressing, a moderately thick layer of cotton, and a roller bandage. The use of iodoform in a fresh wound I think objectionable as being both unnecessary and frequently irritating. I do not pretend to say that the particular form of dressing which I am about to describe is better than those employed b}r other surgeons, and indeed I believe that if the principles of asepticism—that is, perfect cleanliness—and if the avoidance of irritation are carried out, the special articles used are a matter of indifference; but this dressing is simple and easily applied, and I can recommend it as entirely satisfactory. The protective (Lis- ter’s) should be large enough to cover the entire line of the wound, with a margin at each end and on both sides of at least three-quarters OPERATION AND DRESSING OF THE STUMP. 191 of an inch, and before being applied is dipped in the 1-2000 sublimated solution; it should be closely adjusted, and slit at its extremities to en- able it to be fitted around the ends of the drainage-tube, below the safety-pins. The object of the protective is to keep the deep layers of gauze from adhering to the wound, and to protect the latter from the irritating effect of the corrosive sublimate with which the gauze is im- pregnated. The deep dressing consists of at least eight layers of sub- limated gauze, of ample dimensions, wrung out of the hot 1-2000 solu- tion, not that it may be used as a wet dressing, but simply that its aseptic quality at the moment of application may be insured ; it is care- fully folded around the stump in the manner described in Yol. I., page 605. The superficial dressing contains an equal number of layers of gauze, cut of still larger size, and is applied dry; between its outer layers is inserted a sheet of mackin- tosh cloth, or some substi- tute, which again is wrung out of the hot 1-2000 solu- tion immediately before adjustment. In hospital practice, I employ instead of the mackintosh, from mo- tives of economy, a tough water-proof paper, made for the packing of butter for transportation, which becomes soft and flexible when dipped in the hot so- lution, and which answers the intended purpose in every respect satisfactorily. The object of the mackin- tosh or water-proof paper is not, as is sometimes sup- posed, to keep the dressings moist, but to prevent blood or serum from the wound soaking through to the ex- terior — where it would come in contact with the air, and might undergo putrefaction—by interposing an impermeable barrier which forces the effused fluids to turn upon themselves, as it were, and saturate the whole thickness and extent of the dressings before they can reach the surface, and then only marginally and at a considerable distance from the wound. The superficial dressing is en- tirely surrounded with sublimated cotton. which, besides being antisep- tic, serves to protect the stump from mechanical injury, and the whole is then secured with a firm and slightly compressing bandage which consolidates the various portions of the dressing, and keeps everything close and snug. This dressing may usually be allowed to remain un- disturbed for five or six days, and sometimes much longer. Fig. 1595. Recovery after triple amputation. From a patient in the University Hospital. 192 amputations. Statistics. In the Article in Vol. I., pp. 598 and 619,1 gave statistics of multiple and single major amputations occurring in my own practice. Since the publication of that article 1 have with my own hands done 153 single, 2 triple, and 10 double amputations, some particulars of which I have included in the annexed tables. An analysis of these shows that the death-rate of my operations has slightly diminished in the single amputations, and has been materially less in those of a mul- tiple character. This will appear from the following summary:— Part Involved. First Series. Cases 1-100. Second Series. 101-153. Cases Both Series. Recovered. 0) 5 Total. Mortality Per cent. Recovered. Died. Total. Mortality Per cent. Recovered. ___ Died. Total. Mortality Per cent. Wrist 1 0 1 0.0 i 0 1 0.0 2 0 2 0.0 Forearm 13 5 18 27.7 14 0 14 0.0 1 27 5 32 15.6 Elbow 1 0 1 0.0 2 0 2 0.0 I 3 0 3 0.0 Arm 15 G 21 28. G 17 3 20 15.0 32 9 41 21.9 Shoulder 8 2 5 40.0 6 0 6 0.0 9 2 11 18.1 Ankle 2 0 2 0.0 3 0 3 0.0 5 0 5 0.0 Leg 22 3 25 12.0 35 9 44 20.4 57 12 69 17.4 Knee and knee-joint 2 2 4 50.0 8 9 17 52.9 10 11 21 52.4 Thigh 12 8 20 40.0 27 15 42 35.7 39 23 62 37.0 Hip 1 2 3 66.6 1 3 4 75.0 2 5 7 71.4 Aggregates 72 28 100 28.0 114 39 153 25.4 CO GO 67 253 26.4 Table Showing- Results of 253 Cases of Single Major Amputation. Table Showing Results in 23 Cases of Multiple Amputation. Double amputation amputation Aggregates O 4*. Recovered. First Series—11 Cases. O -3 Died. (-*■ O H-t Total. 63.6 63.6 0.0 Mortality Per cent. GO Recovered. Second Series—12 Cases. CO Died. to (—*• to o Total. 33.3 30.0 50.0 Mortality Per cent. to (—*• Recovered. Both Series—23 Cases. h-*- M H*. H-i O Died. to CO to to >-*. Total. 4^ 00 47.6 50.0 Mortality Per cent. These figures show for the single amputations a diminished death- rate of somewhat less than three per cent., and for the multiple am- putations a gain of no less than 30 percent. This great improvement I attribute to the general introduction into Philadelphia during this period of the ambulance system, which enables persons seriously injured bv railway or machinery accidents to be put promptly under treatment and transported without risk of hemorrhage, and has thus been the means of saving many lives. Among the single amputations the greatest gain has been in operations in the upper extremity, with a slight im- provement in the thigh amputations; but on the other hand the death- rate in amputations through the leg and at the knee and hip-joints has been greater than in my first series. 193 No. Date. Sex, Age, and Occupa- tion. Nature of Case. Nature of Operation. Result. Hospital. Remarks. 101 Jan. 13, 1894 F. Adult. Laun- I. Amputations at the Wrist. Right hand burned and crushed by 1 Oval method Recovered 1U niversity Secondary. 102 May 17, 1884 dress M. 30. Operative steam mangle II.—Amputations thr Right hand split by circular saw ough the Forearm. Circular amputation, Recovered University Primary. 103 Oct., 1885 M. Adult. Brake- Left forearm crushed by railway train lower third do., upper third « U Primary. Died 3 months 104 Oct. 21, 1886 man M. 35. Brakeman Right hand and wrist crushed between do., lower third “ after operation from perinephric abscess communicating with pleura and bronchi. Primary. 105 March 26, 1887 F. 80 railway cars Sarcoma of right hand do. U U For disease. 106 J une 24, 1887 M. Adult. Quarry- Right hand blown off by explosion of do., middle third “ Pennsylvania Primary. 107 Dec. 19, 1888 man M. Adult. Laborer dynamite Left hand blown off by explosion of do., lower third a University « 108 July 23, 1889 M. 30. Operative blast Right hand and wrist crushed between do., middle third « Pennsylvania 109 March 26, 1890 F. Adult cog-wheels Gangrene of right hand from burn re- Posterior flap amputation a U Secondary. 110 June 2, 1890 M. 25 ceived by falling against stove in epileptic tit Right hand and wrist crushed between Circular amputation, u u Primary. 111 July 8, 1890 M. 66. Laborer railway cars Right hand crushed by fall of barrel middle third do., lower third a u « 112 March 29, 1*891 M. 21. Boxmaker of sugar Gunshot wound of left forearm ; radial do., upper third « u U 113 April 4, 1891 M. 30. Operative and ulnar arteries severed Left forearm lacerated by carding ma- do. « a 114 Oct. 16, 1891 M. 16. Operative chine Right hand crushed and lacerated by do., lower third a Children’s u 115 Feb. 17, 1894 M. Old machinery Chronic disease of right wrist do., middle third u University For disease. statistics. Table Showing Results of One Hundred and Fifty-Three Consecutive Cases of Single Major Amputation.1 1 In continuance of Table in Vol. I., page 618, Tbe cases are numbered continuously. * 194 amputations. Table Showing Results of One Hundred and Fifty-Three Consecutive Cases of Single Major Amputation.—Continued. No. Date. Sex, Age, and Occupa- tion. Nature of Case. Nature of Operation. Result. Hospital. Remarks. 116 June 28, 1888 M. Adult. Train- III. —Amputation Right forearm crushed between rail- S' at the Elbow. Amputation by anterior Recovered University Primary. 117 March 9, 1892 hand F. Young way cars Osteo-sarcoma of forearm and posterior flaps Circular amputation « Pennsylvania For disease. Died in 2 118 Oct. 23, 1882 M. 30. Train-hand IV.—Amputations throu Right arm crushed by railway train gh the Upper Arm. Circular amputation, Recovered University months after opera- tion from secondary intrathoracic growth. Primary. 119 June 7, 1883 M. 25. Train hand Right arm crushed by railway train middle third . Modified circular amputa- 120 Sept. 13, 1883 M. 24. Brakeman Secondary hemorrhage following com- tion, upper third do. Died « Secondary. Death in 4 121 Dec. 17, 1884 M. Adult. Brake- pound fracture of right arm from railway injury Traumatic gangrene of left arm fol- Circular amputation, up- Recovered u hours from shock and hemorrhage. Intermediate. 122 April 1, 1886 man M. 19. Telegraph lowing crushing injury by railway train Compound fracture of left humerus per third Modified circular amputa- U u Primary. 123 Nov. 27, 1886 Operator M. Young adult by railway injury. Rupture of brachial artery and vein Recurrent caries after excision of el- tion, upper third Circular amputation, Died M For disease. Death in 124 Nov. 27, 1886 M. 45 bow. Tuberculosis Contracted and painful condition of middle third Modified circular amputa- Recovered U 8 days from tuber- cular meningitis. For deformity. 125 Dec. 9, 1886 M. Adult. Brake- right arm from an old burn; limb useless Right arm crushed by railway train tion, upper third Circular amputation, Primary. 126 Dec. 18, 1886 man M. Adult Right arm crushed by railway train upper third Modified circular amputa- U a U 127 Feb. 1, 1887 M. 20. Train-hand Right arm crushed between railway tion, upper third do. u a U 128 Jan. 16 1888 M. 12 Crush of left arm do. « a U 195 statistics. Table Showing Results of One Hundred and Fifty-Three Consecutive Cases of Single Major Amputation.—Continued. No. Date. Sex, Age, and Occupa- tion. Nature of Case. Nature of Operation. Result. Hospital. Remarks. IV.—Amputations through the Upper Arm.—Continued. 129 Feb. 24, 1888 M. 15 Compound dislocation of right elbow Circular amputation, Recovered University Primary. and crush of forearm by railway in- middle third 130 Feb. 29, 1888 F. Elderly j uiy Gangrene of left arm from embolism Modified circular amputa- “ Pennsylvania Secondary. following reduction of dislocated shoulder tion, upper third 131 A pril 28, 1888 M. 81. Laborer Sloughing of right arm from erysipe- do: U University 66 las following injury 132 June 8, 1888 M. Adult Sloughing and suppuration after frac- Elliptical amputation, u Pennsylvania u ture of left radius and ulna with rupture of brachial artery lower third 133 April 27, 1889 M. 42. Railway Crush of right arm by railway injury Modified circular amputa- Died University Primary. Death in 8 conductor tion, upper third hours from heart-clot. 134 Feb. 8, 1890 M. Middle-aged Cysto-sarcoma of right elbow Circular amputation, Recovered 66 For disease. middle third 135 April 9, 1892 F. 45 Sarcoma of right humerus Modified circular amputa- “ “ U tion, upper third 136 May 31, 1893 M. 12 Incurable encircling ulcer following Circular amputation, “ Pennsylvania Secondary. lacerated wound of right forearm ; muscles destroyed. lower third 137 March 21, 1894 M. Young Crush of right arm Circular amputation, U “ Primary. middle third V.—Amputations at the Shoulder. 138 Jan. 10, 1883 M. 30. Brakeman Left arm crushed by railway train ; Larrey’s method Recovered University Primary. vessels injured 139 March 14, 1883 M. 16 Necrosis of right humerus do. “ “ For disease. 140 May 13, 1886 M. 10 Left arm crushed by railway train do. 66 66 Primary. 141 Feb. 4, 1888 M. 15 Right arm rushed by machinery do. “ Pennsylvania 142 Feb. 20, 1888 M. 25. Brakeman Left arm crushed by railway train do. “ “ 143 Jan. 6, 1894 M. 12 Peripheral sarcoma of left humerus do. (Wyeth’s pins) u University For disease. amputations. 196 Table Showing Besults of One Hundred and Fifty-Three Consecutive Cases of Single Major Amputation.—Continued. No. Date. Sex, Age, and Occupa- tion. Nature of Case. Nature of Operation. Result. Hospital. Remarks. VI.—Amputations at the Ankle. 144 Feb. 18, 1882 F. Young Chronic disease of right ankle from hereditary syphilis Syme’s method Recovered University For disease 145 March 31, 1890 M. Adult Crush of left foot by railway injury do. Pennsylvania Children’s Primary. 146 Nov. 5, 1890 M. 7 Caries of left tarsus; os calcis previ- ously excised VII. —Amputations do. through the Leg. For disease. 147 Oct. 15, 1881 M. 40. Laborer Caries of left foot following old injury with extensive sloughing and ery- sipelas Modification of Lee’s me- thod, upper third Recovered University For disease. 148 Oct. 22, 1881 M. 35 Re-ulceration after compound fracture of leg with great shortening ; limb useless Modified circular method, upper third 149 Nov. 17, 1881 M. 25. Bridge- builder Right leg crushed by blow from heavy stone External flap method, up- per third U “ Primary. 150 Jan. 20, 1882 M. 42. Train-hand Right leg and foot crushed by railway car do. Died Primary. Death from gangrene on 5tli day. 151 Feb. 17, 1882 M. 19. Train-hand Left leg crushed by railway car. In- jury of pelvis followed by luematu- ria, etc. Crush of left foot and ankle by rail- way injury; limb severed Circular method, middle third U Primary. Death on 5th day front pelvic in- jury- 152 May 24, 1882 M. 30 External flap method, up- per third Recovered u Primary. 158 Oct. 5, 1882 M. 16 Left foot crushed by railway car Modified circular method, lower third u *' 154 Oct. 9, 1882 M. 45 Secondary hemorrhage and sloughing after amputation at left ankle one week previously do. Died u Intermediate. Death after 2 days from re- current. hemorrhage. 155 Nov. 11, 1882 M. 45 Painful and ulcerated stump after am- putation of left leg two years previ- ously Right leg crushed by railway car External flap method, up- per third Recovered Reamputation. 156 Nov. 27, 1882 M. 52 Antero-posterior flap me- thod, upper third Died u Primary. Death on 6th day from delirium tremens. 157 Oct. 29, 1883 M. 25. Train-hand Right leg nearly severed by falling telegraph wire by which was caught while riding on top of car External flap method, up- per third Recovered Primary. STATISTICS. 197 Table Showing Results of One Hundred and Fifty-Three Consecutive Cases of Single Major Amputation.—Continued. No. Date. Sex, Age, and Occupa- tion. Nature of Case. Nature of Operation. Result. Hospital. Remarks. VII.—Amputations through the Leg.—Continued. 158 Feb. 23, 1884 M. 30 Painful and ulcerated stump after am- putation of left leg ten years previ- ously External flap methed, up- per third Recovered University Reamputation. 159 March 22, 1884 M. 51 Warty ulcer of left leg following gun- shot wound received twenty years previously do. Died For disease. Death on 6tli day from gan- grene. 1(50 Fob. 16, 1885 M. 19 Gangrene following cuneiform osteot- omy for inveterate club-foot Modified circular method, lower third U Intermediate. Death on 7tli day from sep- ticaemia. 161 May 23, 1885 M. 10 Caries of left ankle Internal flap method, lower third Recovered For disease. 162 April 17, 1886 M. Adult. Engine- driver Deformity of left foot from burn External flap method, lower third For deformity. 163 Dec. 4, 1886 M. 25 Ulcerated stump after previous am- putation of left leg Modified external flap method, upper third Reamputation. 164 Jan. 1, 1887 M. Adult Left leg crushed by railway train do. a “ Primary. 165 May 13, 1887 M. 62 Left foot crushed by railway injury Modified circular method, lower third u Pennsylvania 168 June 9, 1887 M. Adult. Laborer Right leg crushed by railway train External flap method, up upper third u University 167 Sept. 24, 1887 M. Adult Caries of right tarsus ; astragalus pre- viously excised Modified external flap method, middle third U For disease. 168 Oct. 29, 1887 M. 57. “ Engine - boss " Crush of left foot and ankle by rail- way train ; fracture of ribs do. Died Primary. Death on 11th day from urae- mia ; granular kid- Secondary. [neys. 169 Dec. 3, 1887 M. Adult Right leg crushed by railway train. Refused amputation till twelfth day do. Recovered u 170 March 3, 1888 M. 25 Ulcerated stump after previous ampu- tation of right leg do. u Reamputation. 171 June 13, 1888 M. Adult Conical stump after previous amputa- tion of left leg do. Pennsylvania 172 July 14, 1888 M. Adult Ulcerated stump after previous ampu- tation of left leg do. University 173 July 19, 1888 F. 60 Compound fracture of right leg by falling downstairs do. Pennsylvania Primary. 198 AMPUTATIONS. Table Showing Results of One Hundked and Fifty-Three Consecutive Cases of Single Major Amputation.'—Continued. No. Date. Sex, Age. and Occupa- tion. Nature of Case. Nature of Operation. Result. Hospital. Remarks. VII.—Amputations through the Leg.—Continued. 174 Jan. 26, 1889 M. 20 Ulcerated and conical stump after pre- Modified external flap Recovered University Reamputation. 175 Jan. 26, 1889 M. 26 vious amputation of right leg method, middle third Ulcerated and conical stump after pre- do. U “ U 1889 M. vious amputation of left leg 176 March 23, 14 Sarcoma of left tibia do., upper third “ U For disease. 177 June, 1889 M. Adult Ulcerated stump after previous ampu- do., middle third “ Pennsylvania Reamputation. 178 July 23, 1889 M. tation of right leg 20 Crush of right leg by fall of iron cast- do., upper third Died U Primary. Death on 3d 179 1890 M. Young adult mg day from prostration. March 29, Caries of left ankle do., lower third Recovered University For disease. 180 July 28, 1890 M. Adult Caries of right ankle, recurring after do., middle third “ “ excision 181 July 30, 1890 F. Adult Caries of right ankle, recurring after do. “ U U excision 182 Oct. 11, 1890 M. Adult Compound fracture of right leg. Re- do. a U Secondary. 1891 fused amputation at first 183 Jan. 17, M. 25 Ulcerated stump after previous ampu- tation of left leg do., upper third u Reamputation. 184 Jan. 31, 1891 M. 30 Compound fracture of right leg by do. Died Pennsylvania Intermediate. Death mining explosion ; vessels injured from sloughing and 185 Nov. 14, 1891 M. 10 Right foot crushed by railway train do., middle third Recovered Children’s secondary liemor- Primary. [rliage. 186 Feb. 9, 1893 M. 18 Left leg crushed by railway train do. “ University 187 March 18, 1893 M. Young adult Conical stump after amputation of do. a U Reamputation. right leg in childhood 188 June 19, 1893 M. 50 Suppurating arthritis of right ankle do., lower third a Pennsylvania For disease. 189 March 3, 1894 M. 53 Dry (embolic) gangrene of right foot and ankle do., upper third u University 190 June 15, 1894 M. Adult Old injury of left foot; ulceration and do. “ Pennsylvania “ anchylosis VIII.—Amputations at the Knee and Knee-joint. 191 Nov. 12, 1881 M. Adult Compound fracture of right leg from Amputation by long an- Died University Secondary. Death on fall, followed by diffuse suppuration terior and short pos- 9th day from heart- • and necrosis terior flap at knee joint clot. STATISTICS. 199 Table Showing Results of One Hundred and Fifty-Three Consecutive Cases of Single Major Amputation.—Continued. No. Date. Sex, Age, and Occupa- tion. Nature of Case. Nature of Operation. Result. Hospital. Remarks. 192 Jan. 27, 1883 M. Adult VIII.—Amputations at the Knee Syphilitic necrosis and ulceration of and Knee-joint.—Continued. Amputation by long an-i Died University For disease. Death on 19B Oct. 20, 1883 M. 45 left leg, of more than twelve years’ duration Warty ulcer following gunshot wound terior and short pos- terior flap at knee-joint Antero-posterior flap me Recovered U 7th day from cardiac thrombosis and em- bolism of pulmonary For disease. [artery. 194 Feb. 28, 1885 F. 60 of left leg twenty years before Recurrent sarcoma of right leg thod, through condyles of femur Anterior and posterior Died U For disease; consecu- 195 March, 1885 M. Child .... Necrosis of left tibia flaps at knee-joint do. Recovered u tive hemorrhage. Death from heart-clot and exhaustion. For disease. 190 July 17, 1885 M. 44 Compound comminuted fracture of Antero-posterior flap me- Died “ Primary. Death on 6th 197 Dec. 12, 1885 M. 64 left leg and lacerated wound of thigh Incurable ulcer of right leg thod, through condyles do. U u day from traumatic gangrene. For disease. Death on 198 Oct. 20, 1886 M. 56 Crush of right leg do. Recovered « 2d day from beart- Primary. [clot. 199 July 29, 1887 M. Adult Gunshot wound of left leg followed do. “ Pennsylvania Intermediate. 200 July 29, 1887 M. Adult. Train- by gangrene (incipient) Crush of right leg by railway injury Anterior and posterior University Primary. 201 Oct. 16, 1887 hand M. Adult. Hod- Crush of right leg by railway injury ; flaps at knee-joint Antero-posterior flap me- « « « 202 Jan. 12, 1888 carrier M. 34. Merchant lacerated wounds Crush of right leg by railway injury thod, through condyles do. Died U Primary ; delirium tre- 208 June 25, 1888 M. 4 Crush of right leg by railway injury do. Recovered Pennsylvania mens, and secondary hemorrhage. Death on 36th day from septicaemia. Intermediate. 204 May 31, 1890 M. 25 followed by gangrene Gunshot fracture of right leg, vessels do. Died « Primary. Death on 2d 205 May 30, 1891 M. 50 divided Warty ulcer following gunshot wound Anterior and posterior Recovered University day from heart-clot. For disease. of left leg twenty-six years before flaps at knee-joint 200 AMPUTATIONS. *53 52 .S O I O »—i H -< H P Pm ■**1 & o •-s VH W m3 o y; w Pm O m W 03 o w t> l-M H P> a w a> o O w w P3 w Eh I tH H Pm MM PH G <1 a w o & t> W w fc O Pm O m H G ►3 m W Pm O fc t-M Is o w CZ2 w h—" pc ears to be especially common, cases having been reported by Volk- mann, Konig, Kelsey, Bockel, Arnd, and Lovinsohn, of recurrence at intervals varying from three to eleven years. Cancer of the tongue also appears to offer a bad prognosis in this respect, recurrences after an interval of more than three years being reported from Billroth’s and Volkmann’s clinics, while Kocher had the misfortune to see a return in two of his cases ten and twelve years after operation. The same sur- geon saw return of the disease in the scar, after laryngectomy, three years after the operation in four cases, and Billroth and Fischer had a similar experience in one case each. Metastasis has usually been supposed to show itself very soon after the primary operation, but there are some cases on record which go to prove that it also may fail to declare itself for some years. In one of Poulsen’s cases of mammary cancer the patient died of cancer of the stomach over five years after the operation on the breast, and three other patients died with signs of some internal recurrence in from three to six years. Schmidt reports a case of death by cancer of the lungs and liver seven years after removal of the breast, and Dietrich one of cancer of the uterus four years after a similar operation; in neither case was there any local return. Lovinsohn reports a case of cancer of the rectum in which the disease did not return in loco, but in which the patient died four years afterward of metastasis in the liver. The last case is perhaps not so very remarkable, for the liver infection might itself have been secondary to disease in the lymphatic glands, and thus might not have been very much longer in developing than usual. Some of the other cases can be explained as the growth of entirely indepen- dent tumors, and I should certainly so interpret the cases of late appear- ance of the disease in the other breast and in the pylorus. But there still remain some cases of recurrence in the lungs and liver which ap- pear to be true late developments of secondary tumors. It is therefore self-evident that the limit of two years set by the ear- lier writers is altogether too short to assure a cure, and it may be questioned whether even the limit of three years can be allowed to stand. It is true that the total number of cases recurring three years and more after the operation is very small, compared with the total number of operations for malignant disease; but it should be remem- bered that the proper basis of comparison is not the number of opera- tions, but the number of patients who have been operated upon and 298 TUMORS. yet remain alive and free from disease three years or more afterward, and that number is comparatively small. Thus my lists show 180 pa- tients alive and free from recurrence for three years or more after re- moval of the mamma for carcinoma, but they also show 93 cases in which there was a relapse after that period, or eleven per cent, of the cases observed over three years. For the rectum, the tongue, and the larynx, a four years’ interval of freedom should certainly be re- quired before a patient can even relatively be said to have been cured. Taking all these facts into consideration. I have in this article required three years’ freedom from recurrence before allowing that a case is cured, and for the tongue and the rectum I have set the limit at four years. After the facts which I have been obliged to record of late return of the disease either in loco, or as the result of metastasis, and of repeated return after operations, it is necessary to throw a little more emphasis on the cheerful side of the picture by noting the comparatively large number of cases in which a cure has been established after a second or even several secondary operations. Plicque has put on record 97 such cases collected from various sources, but unfortunately I have been un- able to obtain his thesis for study. But Poulsen records three cases in which two or more recurrent mammary carcinomata were removed in the first year or eighteen months, and yet the patients remained well from eight to nine and a half years after the last operation. He also mentions two cases in which recurrent growths, appearing one three and the other five and a half years after the first operation, were suc- cessfully removed, and in which the patients continued well respectively two and three and a half years subsequently. Gouley relates two cases of very late recurrence of carcinoma of the breast (20 and 25 years af- ter the first operation), in which the patients remained well five years after the last operation; and adds a similar case of sarcoma. Parker records a case of amputation of the thigh for sarcoma recurring after amputation at the knee, in which the patient was well seven years after the second operation. Michael saw an epithelioma of the skin of the thigh recur twice, and the patient finally remain well nine years after the last operation. Similar cases of carcinoma in the rectum are recorded by Turner, Volkmann, Sihle, and Arnd. I have met with a personal experience which is very interesting in this respect. In January, 1890, I removed a slow-growing epithelioma from the floor of the mouth, in a man forty-nine years of age, removing at the time all the mucous membrane of the lower surface of the tongue, and all the tissues be- tween the mouth and the skin under the jaw, leaving only the tongue above and the skin below. The hone was not affected at this time, hut before he left the hospital a small growth had to be curetted from its inner surface. In December of the same year the patient returned with the lower jaw involved, and with a mass as large as a hen's egg over the great vessels of the neck on the same side. I found a large gland adherent to the internal jugular vein, and excised with it over an inch of that vessel; otherwise the mass was not adherent, and two weeks afterward, when the wound had healed, I removed the right half of the body of the lower jaw with the diseased tissues attached. He made a good recovery, and now, four years after the last operation, still remains perfectly well. RESULTS OF TREATMENT IN CARCINOMA. 299 Such are the results of the operative treatment of cancer. In spite of the general and great improvement over those of former times, it must be acknowledged at the outset that even free removal is no sov- ereign remedy. It may be said with truth that if the disease is attacked in time it can be cured by a radical operation, but that single limita- tion prevents the’ universal success of operative treatment, for there must always remain the internal cancers which do not give symptoms until they are too far advanced to be completely eradicated, and also a large proportion of external tumors which, owing to the carelessness or ignorance of their victims, are not observed until it is too late for successful interference. As Winter puts it, supposing that cne case in four of uterine cancer can be cured by operation, and only one case out of four which come to the surgeon is suitable for operation, we can save only one woman in sixteen of those attacked by the disease. We must therefore still desire a remedy which may cure the disease in any stage and in any situation, without damage to the surrounding parts, in some such way as mercury and potassium iodide act upon the lesions of syphilis. As we have seen in speaking of sarcoma, there appears to be some ground for hoping for an advance in this direction, since the experiments of Fehleisen, Spronck, and Coley have shown that at least in some cases it is possible to check the progress and even cause the absorption of malignant tumors by inoculation with the germs of ery- sipelas, or even by hypodermic injection of the sterilized products of cultures of these germs. In the mean time, let us hold the advantage we have gained and try to increase it, as may undoubtedly be done. The first step toward the improvement of operative results must come through the family phy- sician—the general practitioner. Not until he is fully convinced that an operation will cure the disease if attacked in the early stages, and not until he is able to make an early diagnosis, can we secure the full value of this method of treatment. On him depends the entire ques- tion. Winter interrogated 56 patients with uterine cancer who applied at the Frauenklinik in Berlin, and found that 47 of them had first had advice upon their symptoms, which were often vague enough at the beginning, from their family physicians, and that only one-third of the number reached the clinic in time for satisfactory operations. The reason was evident on closer questioning, for in only one-half of the cases had the attending physician made any immediate examination of the parts, and in one-third no examination whatever. It is not sur- prising, therefore, that of every fifteen only three were found suitable for an attempt at operative treatment. The same holds true of carcinoma of the breast. In a very consider- able proportion of the cases which I have seen, the patients have told me that their physicians had examined the tumor in the breast, and had declared that it was of no importance, that it would pass away, or would not grow larger, or had even given that commonly offered false explanation, “It is the change of life.” Nowit appears improbable that all of these physicians were so ignorant or so negligent as not to consider the possibility of cancer, and I believe that the chief reason for delay and neglect in such cases is the lack of faith in operative treat- ment, which not only prevents the physician from urging early opera- tion, but acts indirectly by leading him to neglect the proper study of 300 TUMORS. a disease which he considers incurable, or at least to slight the exam- ination and diagnosis of the cases in which he suspects its existence. That this state of affairs is improving has also been shown by Win- ter, who says that, whereas in 1883 only 19 per cent, of the cases of uter- ine cancer seen by him Avere considered to have enough chance of cure to make an operation Avorth while, in 1891 37 per cent, of the cases were operated upon, and solely because the patients came at an earlier period of the disease. But it requires much further improvement be- fore the results can be made much better. The delay on the part of the physician occurs most often in A\raiting to his diagnosis made certain—waiting for evidence of groAvth in a tumor, or for glands to en- large—before he has the courage to suggest an operation. As a matter of fact, his attitude should be the reverse, and whenever he is not ab- solutely certain that a tumor is innocent, he should recommend opera- tion, or should at least seek the adAuce of those experienced in such cases. Now that we are able so easily to remove small portions of a growth and have an authoritative opinion upon its structure, a positive diagnosis can usually he made comparatively early, and the physician should remember that the very symptoms for which he waits in order to make a diagnosis are usually such as indicate that the case has already passed the favorable time for treatment; invoked glands do not indeed contra-indicate operation, but they show that the disease has probably gone so far that the chances of cure are greatly dimin- ished. The ignorance and timidity of the public will of course always limit our efforts to obtain more favorable conditions for really curative oper- ations, but improvement in this respect is also largely in the hands of the profession, whose power and duty it is to educate their patients, and to s1aoav them the importance of having competent advice and prompt treatment for all swellings, tumors, Avarts, ulcers, and slow-liealing wounds, no matter Iioav painless or trifling they may appear. BIBLIOGRAPHY.1- Abbe, Annals of Surgery, Jan., 1894, p. 58; Ahlfeld, Arcliiv fur Gynakologie, 1880, Bd. xvi. S. 135; Albarran, Tumeurs de la Yessie, Paris, 1891 ; Alsherg, Deutsche medicinisclie Wochenschrift, 1887, No. 46; Arnozan, Dictionnaire encyclopedique des Sciences medicales, “Pancreas;” Ascii, Centralblatt fur Chirurgie, 1889, No. 16. Babes, Ziemssen’s Handbucli der speciellen Pathologie und Therapie (1884), Bd. xiv. ; Baker, St. Bartholomew’s Hospital Reports, 1866, vol. ii. ; Barker, Transactions Pathological Society, London, vol. xxxvii., p. 478 (traumatic cyst of hand) ; Id., Medico-Chirurgical Transactions, London, 1883, vol. lxvi., p. 229; Id., Transactions Clinical Society, London, vol. xxiv., p. 68 (dermoid) ; Bartels, Deutsche Zeitsclirift ftir Chirurgie, 1884, Bd. xx., Heft 1 ; Barth, Deutsche medicinisclie Wochenschrift, 1892, Bd. xviii., S. 531; Baumgarten, Arcliiv f. pathologisclie Anatomie, Bd. cvii., S. 515; Bayer, Deutsche medicinisclie AVoch- enschrift, 1887, No. 9, Bd. xiii., S. 174; Bazy, Progres medical, Paris, 1886, No. 30; Berg, Arcliiv f. klinische Chirurgie, Bd. v., S. 190; Berger, Bulletin de la Societe chirurgicale, Paris, t. xi., p. 293; v. Bergmann, Berliner klinische AVochenschrift, 1887, No. 47; Berliner, Dissert., Centralblatt f. Chirurgie, 1890, S. 309; Bessel Hagen, Arcliiv f. pathologisclie Anatomie, Bd. xeix. (sarcoma of jejunum) ; Id., Arcliiv f. klinische Chirurgie, Bd. xli., S. 444 (multiple osteoma) ; Bidder, Arcliiv f. pathologisclie Anatomie, 1890, Bd. cxx., S. 194; Bierfreund, Arcliiv f. klinische Chirurgie, 1891, Bd. xli., S. 1; Billroth, AViener klinische Wochenschrift, 1890, No. 48 (transplantation of carcinoma) ; Id., AATener medicinisclie 1 The names of some authors referred to in the text have been omitted from this Bibliog- raphy, because the references to their works can easily be found in the papers of more recent writers on the same subjects who are mentioned in the same paragraph. BIBLIOGRAPHY. 301 Wochenschrift, 1888, No. 20 (thyroid) ; Id., Wiener klinische Wochenschrift, 1891, No. 34, S. 625 (stomach) ; Id., Archiv f. pathologische Anatomie, Bd. xvii., S. 78; Blanc, Gazette medicale, Paris, 1888,7 s., t. v., p. 148; Blascliko, Archiv f. pathologische Anatomie, 1891, Bd. cxxiv., S. 175; Blum et Duval, Archives generales de medecine, Aug., 1883; Bocker, Deutsche medicinisclie Wochenschrift, 1886, No. 43; Bonde, Dissert., Centralblatt f. Chir- urgie, 1885, S. 695; Id., Archiv f. klinische Cliirurgie, Bd. xxxvi., S. 207, 313; Borck, Archiv f. klinische Cliirurgie, 1890, Bd. xli., S. 94l ; Bosworth, Wood’s Medical and Surgi- cal Monographs, New York, 1891, vol. xi. ; Bottcher, Archiv f. pathologische Anatomie, Bd. civ., S. 1; Bouisson, Progres medical, 1887, No. 13; Bramann, Archiv f. klinische Cliirurgie, Bd. xl., S. 101; Brandi, Dissert., Centralblatt f. Cliirurgie, 1887, S. 942; Braun, Archiv f. klinische Chirurgie, Bd. xlv., S. 186 (epithelioma of scalp) ; Id., loc. cit., Bd. xliii., Heft 1, S. 196 (endothelioma) ; Bremer and Carson, American Journal of the Medical Sciences, Sept., 1890, p. 219; Brissaud, Bulletin de la Societe anatomique, Paris, 1876, t. 11., p. 608; Brossard, Archives generales de medecine, Sept., 1884; Bruce, Transactions Pathological Society, London, vol. xix., p. 288; Bryant, quoted by Poland, Brit, and For. Med.-Chir. Review, 1872, No. 98; Busachi, Gazzeta degli Ospitali, 1891, No. 67; Butlin, St. Bartholomew’s Hospital Reports, vol. xxiv., p. 83; Id., British Medical Journal, 1889, vol. i., p. ”'77. Chambard, Annales de Dermatologie et de Syphiligraphie, t. iv., No. 2; Chavasse, Medico-Chirurgical Transactions, London, vol. lxxiii., p. 81; Chevalier, These de Paris, Centralblatt f. Chirurgie, 1892, S. 291 ; Chiari, Prager medicinisclie Wochenschrift, 1885, No. 50; Coats. Transactions Pathological Society, London, vol. xxxviii., p. 399; Coats, Glasgow Medical Journal, Dec. ,1891, vol. xxxvi., p. 420 ; Cohn,Zeitsclirift f. Geburtshalfe und Gynakolo- gie, Bd. xii.,S. 14; Colmheim, Archiv f. pathologische Anatomie, Bd. lxviii., S. 547 (thyroid tumor) ; Coley, Reference Handbook of the Medical Sciences, Supplement, vol. ix., “Sarcoma”; Condamini, Lyon medical, 1887, t. lvi., p. 103; Conner, Annals of Surgery, 1888, vol. viii., p. 110; Cornil, La Semaine medicale, June 24, 1891 ; Councilman, Boston Medical and Surgical Journal, 1893, April 20; Crawford, Lancet, London, 1892, vol. i., p. 795; Creighton, Medico-Chirurgical Transactions, London, 1882, vol. lxv., p. 53; Cripps, St. Bartholomew’s Hospital Reports, 1878, vol. xiv., p. 287 (heredity) ; Id., Transactions Pathological Society, London, 1881, vol. xxxii., p. Ill (transplantation) ; Cristiani, Revue de Chirurgie, 1892, No. 1 (traumatic epithelioma of forehead) ; Id., Journal de 1’Anatomie et Physiologie, 1891, t. xxvii., pp. 249, 444 (congenital tumors) ; Cullingworth, British Medical Journal, 1877, vol. 11., p. 253; Curtis, Medical Record, New York, 1888, vol. i., p. 605 (metamorphosis) ; Id., loc. cit., 1894, vol. i., p. 225 (results of treatment) ; Czerny, Centralblatt f. Chirurgie, 1886, Beilage S. 38 (epithelioma of breast) ; Id. (und Rindfleisch), Beitruge zur Chirurgie (Billroth’s Fest- schrift), Wien, 1892, S. 423. Demarquay, Maladies chirurgicales du penis; De Ruyter, Archiv f. klinische Chirurgie, Bd. xl., S. 98; Dieterich, Archiv f. klinische Chirurgie, Bd. xxxv., Heft 2, S. 289; Diet- rich, Deutsche Zeitschrift f. Chirurgie, Bd. xxxiii., S. 471 ; Dittrich, Prager medicinische Wochenschrift, 1889, No. 48; Djakonow, Dissert., Centralblatt f. Chirurgie, 1889, S. 461; Doran, Medico-Chirurgical Transactions, London, 1885, vol. lxviii. p. 235; Dowd, Medical Record, New York, 1892, vol. i., p. 434; Dreyfuss, Archiv f. pathologische Anatomie, 1888, Bd. cxiii., S. 535; Duhn, Journal of Cutaneous and Venereal Diseases, 1886, vol. iv., No. 5; Duncan, Edinburgh Medical Journal, 1885, vol. xxxi., part 2, p. 1127. Edgren and Quenset, Hygeia, Centralblatt f. Chirurgie, 1891, S. 178; v. Eiselsberg, Wiener klinische Wochenschrift, 1890, No. 48 ; Eschweiler, Deutsche Zeitschrift f. Chirurgie, Bd. xxix., S. 355; v. Esmarch, Archiv f. klinische Chirurgie, Bd. xxxix., Heft 1 (etiology) ; Eve, Transactions Pathological Society, London, 1888, vol. xxxix., p. 295. Feigel (Russian), Centralblatt f. Chirurgie, 1892, S. 24;Fenger, Journal American Medical Association, 1888, vol. xi., No. 6; Fenwick, Transactions Pathological Society, London, 1888, pp. 171, 172; Fink, Zeitschrift f. Heilkunde, Bd. ix., S. 453; Fischer, Deutsche Zeit- schrift f. Chirurgie, Bd. xxix., S. 581; Id., loc. cit., Bd. xxv., S. 313 (sarcoma of penis) ; Flothmann, Centralblatt f. Chirurgie, 1890, S. 934; Forgue, Gazette des Hopitaux, Paris, 1890, p. 335; Franke, Archiv f. pathologische Anatomie, Bd. cxxi., S. 444; Friedhinder, Fortschritte der Medicin, 1885, Bd. iii., S. 307; Friedreich, Archiv f. pathologische Ana- tomie, Bd. xxv., S. 465. Ganghofner, Zeitschrift f. 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Haberern, Arcliiv f. klinische Cliirurgie, Bd. xliii., S. 352; Hahn, Berliner klinische Wochenschrift, 1887, No. 47, and 1888, No. 21, S. 413 (transplantation) ; Id., Arcliiv f. klinische Cliirurgie, Bd. xxxvii., S. 522 (larynx) ; Hall, Medical News, Philadelphia, Oct. 31, 1885, p. 478; Hamburger, Hospitalstidende, Centralblatt f. Cliirurgie, 1892, S. 301 ; Hanau, Fortschritte der Medicin, Bd. vii., S. 321 ; Hardaway, American Journal of the Medical Sciences, April, 1886, vol. xci., p.511 ; Hauser (Monograph), Centralblatt f. Cliirurgie, 1891, S. 740; Haviland, Lancet, London, 1888, vol. i., pp. 314, 365, 412, 467; Hawkins, Ogle, Transactions Pathological Society, London, 1855, vol. vi. ; Hayes, Alabama Medical and Surgical Age, 1891 ; Ileclit, Dissert., Centralblatt f. Gynakologie, 1891, No. 38; Heid- cnhain, Arcliiv f. klinische Cliirurgie, 1889, Bd. xxxix., S. 97; Hericourt, Revue de Mede- cine, 1885, t. v., p. 54; Herczel, Beitrage zur klin. 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S. 29; Wheeler, Boston Medical and Surgical Journal, Dec. 24, 1885; Hale White, Transactions Pathological Society, London, vol. xli., p. 283; Whitehead, Lancet, London, 1891, vol. i., p. 1032; Williams, Transactions Pathological Society, London, 1887, vol. xxxviii., p. 460 (vege- table tumors) ; Id., British Medical Journal, May 31, 1884 (heredity) ; Id., Lancet, London, 1891, vol. ii., p. 607 (contagion) ; Id., loc. cit., 1888, vol. i., p. 713 (classification) ; Id., Annals of Surgery, Oct., 1891, p. 265 (lipoma) ; Id., Middlesex Hospital Reports, 1889 (statistics) ; Id., Medical Press and Circular, Dec. 4, 1889, vol. i., p. 461 (tongue and lips) ; Winter, Berliner klinische Wochenschrift, 1891, S. 809; Witzenshausen, Beitrage zur klin- ischen Chirurgie, Bd. vii., S. 571 ; Worner, Beitrage zur klinischen Chirurgie, Bd. ii., S. 129; Wyss, Archiv f. pathologische Anatomie, 1886, Bd. xxxv., S. 394. Yersin, Archives de Patliologie normale et pathologique, 1886, 3 s., t. vii., p. 428. Zahn, Deutsche Zeitschrift f. Chirurgie, Bd. xxii., Heft 3 und 4; Zarubin, British Medi- cal Journal, Epitome, Aug. 1, 1891; Zausch, Dissert., Centralblatt f. Chirurgie, 1889, S. 534; Zizold, Munchener medicinischer Wochenschrift, 1889, Bd. xxxvi., S. 89,110. VENEREAL DISEASES: GONORRHCEA. BY J. WILLIAM WHITE, M.D., PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE UNIVERSITY, PHILADELPHIA AND GERMAN HOSPITALS, PHILADELPHIA. Nature of Gonorrhcea. The pathological and experimental arguments in favor of the speci- ficity of gonorrhoea now far outweigh the clinical evidence heretofore adduced. While they fall short of actual demonstration of the invaria- ble association of a definite micro-organism—the gonococcus of Neisser —and the symptoms of the disease, and while, further, the same micrococci, or others indistinguishable from them, have been found in various normal secretions, yet the almost constant presence, in acute urethritis of high grade, of large numbers of gonococci, and the fact that Bumm, Anfuso, Wertheim, and Gebhard have produced the disease by inoculation of pure cultures, would seem to show a definite relation. The medico-legal value of this relation is, however, impaired by the fact that Lustgarten, Mannaberg, Legrain, Poney, and others have shown that the normal urethra may contain diplococci identical in all respects with Neisser’s gonococci, found like them in epithelial and lymphoid cells, and having the same peculiarities as to staining, etc. Pathology of Gonorrhcea. Brewer 1 describes as follows the pathological processes in an ordinary- case of gonorrhoea: A small amount of purulent material containing gon- ococci is deposited during the sexual act upon the mucous membrane of the fossa navicularis. These living organisms penetrate the epithelial covering of the mucous membrane, and, finding their way through and between the superficial cells, eventually reach the upper stratum of the subepithelial connective tissue. The irritation caused by this microbian invasion results in an acute hypersemia of the part, with dilatation of the capillary vessels and exudation of serum. There is also an in- creased glandular secretion with epithelial exfoliation. Subsequently, an abundant transudation of leucocytes takes place from the dilated capillary vessels. These, during their outward passage through the epithelial layer, absorb and carry with them large numbers of gonococci. If the urethra is examined at this time, the mucous membrane will be 1 Morrow’s Cyclopedia of Genito-Urinary Diseases, p. 151. 305 306 VENEREAL DISEASES: GONORRHCEA. found to be thickened, deep red in color, and covered with an abundant muco-purulent or purulent secretion. The orifices of the mucous folli- cles appear as deeply injected, slightly elevated spots. Epithelial ero- sions and sometimes areas of genuine ulceration are present. The pro- cess begins in the fossa navicularis and gradually extends downward, reaching the bulbo-membranous junction about the twentieth day. When the wandering leucocytes have succeeded in removing the micro- organisms from the sub-epithelial tissue, the symptoms begin to subside. The hypersemia diminishes, the sub-epithelial round-cell infiltration is absorbed, the erosions and ulcerations receive a new cellular covering, and the disease is at an end. Resolution takes place more slowly in the glands, which often continue to secrete pus long after the process has ceased in other portions of the mucous membrane. Posterior Urethritis. In many cases, either with or without the complications of the sec- ond stage, the disease will pass into the third or subsiding stage; In others, however, the inflammation, previously confined to the pendu- lous urethra, extends backward so as to involve that portion of the ure- thra between the bulbo-membranous region and the bladder. The compressor urethrae muscle may act as a bar to this backward exten- sion, but it is thought that a more rational explanation of the not in- frequent escape of this region is to be found in the fact that the mem- branous urethra is less vascular and less richly supplied with glands and follicles than other portions of the canal. It hence offers a less favorable ground for the development of micro-organisms. The symp- toms of this accident are those associated with the accompanying pros- tato-cystitis. The complications are inflammations of Cowper’s glands, of the prostate, and of the bladder. Abortive Treatment of Gonorrhcea. The increasing evidence in favor of the view that the gonococcus is the chief cause of gonorrhoea would naturally lead one to anticipate much benefit from the employment of antiseptics both as abortive and as curative agents. The latter question will be considered elsewhere. As to their efficacy in aborting the disease, there is thus far not much clinical evidence that is encouraging. Unfortunately, the results of culture experiments and of the influence of parasiticides upon gonococci external to the body do not afford satisfactory evidence as to the effect of the same agents when applied to the same germs embedded in the depths of an inflamed urethral mucous membrane. Bumm’s investi- gations appear to show that, at first, these multiply by preference in the papillary layer, and find their way to the surface only during the latter part of the purulent, and during the subsiding (or muco-puru- lent) stage, and Finger uses this as a theoretical argument against the early administration of either astringents or antiseptics. Enough is known, however, to enable us to state with certainty that the agents which are effectual against the microbes of suppuration are not equally ANTISEPTIC TREATMENT. 307 destructive of the gonococci, several competent observers having noted the fact that antiseptic solutions, when applied to gonorrhoeal secre- tions outside of the body, have seemed to exert but little effect upon the gonococcus, even when strong enough to destroy pus-cells almost immediately. Antiseptic Treatment. When the ardor urinse of the earliest stage of gonorrhoea has some- what subsided, the time has arrived when the use of antisepsis is es- pecially indicated. Clinically, we may assume that at this stage, in the majority of cases of urethritis, gonococci, the microbes of suppuration, and other bacteria will be found intermingled, and that successful treatment by germici- dal agents will involve the destruction of all the different varieties present. Dismissing theoretical considerations, we may inquire what drugs, if any, belonging to the class of antiseptics have a curative effect upon the essential symptom of urethritis—the blennorrhoea; restricting our inquiry to those cases in which the disease is comparatively acute, and in which it is limited to the pendulous urethra; in other words, to the ordinary cases of uncomplicated gonorrhoea which present them- selves in one’s office for treatment during the first few days after its appearance. The treatment of “ posterior” urethritis need not be dis- cussed in this relation. Considering topical remedies first, and excluding a large number which have little or no claim to occupy time or attention, we may di- vide the remainder into three classes: 1. Those which when strong enough to exert a sufficient germicidal action, are locally so irritating as to be harmful or unbearable. This class includes nitrate of silver, carbolic acid, chloride of zinc, iodine, chloral, potassium permanganate, salicylic acid, and creasote, all of which have been faithfully tried in many cases and by competent sur- geons, the concurrent testimony being, that when used in sufficient strength to sterilize the discharges they produce an amount of local irritation and swelling, ardor urinse, chordee, and even exceptionally urethral ulceration, that far outweighs any advantage to be -derived from their antiseptic properties. 2. Those which are such feeble antiseptic agents that they cannot be depended upon to destroy all the bacteria found in urethral discharges. Among these may be mentioned resorcin, thallin, quinine, the sulphate and acetate of zinc, lanolin, sulphur waters, tannin, alum, hydronaph- thol, and cadmium sulphate. Both clinical and experimental evi- dence coincide as to most of these drugs. Each has had its more or less enthusiastic advocates, but when given a wider trial has been found disappointing, while bacteriologists have shown that its germicidal action is either limited to a very few varieties of bacteria, or is slow and uncertain. 3. The third class includes a number of agents which, while open to the same objection of too feeble or too limited antiseptic action, have the additional drawback of insolubility in ordinary media, and of occa- sionally becoming mechanically irritating from the formation of con- 308 VENEREAL DISEASES: GONORRHOEA. cretions. Among these are iodoform, calomel, bismuth subnitrate, oxide of zinc, and other insoluble powders. It must not he supposed that this list is intended to be even approx- imately complete. It might be increased literally a hundredfold, and nothing could better demonstrate the blind absurdity of empirical methods than the dozens of ridiculous formulae and the hundreds of useless drugs which have from time to time been recommended for use in the various forms of urethritis. So far, however, as they are antiseptics, they would be found in one or the other of the above classes. There are certain agents which I have purposely omitted from this classification, but which, as ordinarily employed, might have been in- cluded with considerable propriety. These are corrosive sublimate, the sulpho-carbolate of zinc, boric acid, peroxide of hydrogen, and the salicylate of bismuth—the five drugs which in various combinations are, in my opinion, of the most practical value in attempting by topi- cal treatment to secure asepsis in an inflamed urethra. Corrosive sub- limate was used in the last century and in the early part of this century by Musitanus, Malow, Gardave, Benjamin Bell, John Hunter, Gutauer, and Swediaur. It then fell into disuse, but was revived again in 1846 by Mueller von Berneck, and was employed spasmodically and unsystem- atically by a few surgeons until Neisser’s discovery of the gonococcus gave the drug an extraordinary vogue. The records of its effects in different hands have thus far been most contradictory. While on the one side we have Leistkow, Lewin, Eichsbaum, Grandin, Chameron, Paul, Louissot, Keyser, and Macrae advocating its employment, on the other we have Diday, Wyeth, Dujardin-Beaumetz, Lewis, Finger, Auspitz, Bardezzi, Du Castel, Dreyfous, and Fournier, who either recognize no advantage from its use, or who record positively unfavorable experi- ences. Its employment by the method of irrigation in solutions vary- ing in strength from 1 in 60,000 to 1 in 10,000 has been popularized by the excellent work of Curtis, Halsted, Vanderpoel, and Brewer, and their published results seem to warrant its further trial, especially in hospital and dispensary practice. The method of deep irrigation or retrojection involving the use of a catheter has always been unsatisfactory in my hands in private prac- tice. It involves too much expenditure of time on the part of both patient and surgeon, and in a genuine acute inflammatory urethritis is certainly objectionable on account of the irritation produced by even the softest instrument. Keyes and others have met with cases of cys- titis, prostatic abscess, epididymitis, and other complications which seem to have been produced by this treatment used early in attacks of urethritis. Palmer has called attention to its inapplicability to pri- vate practice, and I can add my testimony to that of these writers, though I am aware that in forty-six cases treated by retrojection Dr. Brewer claims to have met with no difficulty. I find it much more satisfactory to order frequent injections from a large syringe employed with moderate force, using the strongest solu- tions that can be given without causing pain, and preventing the liquid from passing too deeply by instructing the patient to sit upon a folded towel during the injection, so as to occlude the membranous urethra. My results as to sublimate were, however, disappointing as long as I INTERNAL REMEDIES. 309 used this drug alone. In a certain proportion of cases, by no means a small one, any solution, however weak, seemed to irritate, giving rise not so much to pain at the time of injection as to subsequent increased ardor urinse. I11 others the treatment was well borne but had no in- fluence upon the discharge; in others it aggravated this; and those in which it caused very decided improvement were in the small minority. Rigid dietetic and hygienic directions were always given at the same time, and were, as a rule, fairly well followed, as most of the patients were of good social position. Boric acid, recommended long ago by Hyndman, of Cincinnati, and tried by Chameron, Du Castel,- and others with unfavorable results, was used by me in a considerable number of cases six or eight years ago, and and was dropped on account of the general negative character of its ef- fects. It has been shown to have little effect on the gonococcus, but it is quite unirritating, and can be used in sufficiently strong solution to de- stroy many of the weaker forms of vegetable life. Its germicidal action is slow but continuous. I shall allude hereafter to its internal employ- ment. I certainly improved my results when I added it to the bichloride injection in the proportion of about fifteen grains to the ounce. I felt, however, the additional need of an astringent, and for a long time employed the sulphate of zinc, for which I afterward substituted the sulpho-carbolate (from two to ten grains to the ounce of the mixture). By adding a ten or fifteen per cent, solution of peroxide of hydrogen in varying strengths, I then found that I had a formula which, both clini- cally and experimentally, showed excellent antiseptic qualities. In ex- ceptional cases of profuse catarrhal secretion the addition of bismuth salicylate was also of advantage. The formula which I now employ is as follows: R Hydrarg. bicliloridi gr. tV Acid, boric 3 i. — 3 iss. Zinci sulpho-carbolat gr. xviij. - 3 S3. Liq. hydrogen, peroxid f§i.-f|iij. Aquae ros q. s. ad f 3 vi. The rigid application of the antiseptic principle by means of these drugs, used in this way, has undoubtedly brought about a distinct gain in my results; complications are fewer, and the time required for cure is shorter, than when I was content with employing sedatives and astrin- gents and with endeavoring to meet symptomatic indications, but there is still much to be desired. Internal Antisepsis.—In quite a large proportion of cases it is not possible to use this injection, or any modification of it, for some days after the disease has reached its height. Under these circumstances, boric acid combined with potassium bromide and belladonna in a solu- tion of potassium citrate, while it never has any very marked effect upon the amount of discharge, usually moderates the ardor urinse, chor- dee, and vesical tenesmus of the inflamatory stage. Internal Remedies. There can be little doubt that the beneficial action of cubebs, copaiba, and oil of sandalwood, as well as that of their congeners, gurjun, kava 310 VENEREAL DISEASES: GONORRHOEA. kava, eucalyptus, and the various terebinthinates, is chiefly due to their antiseptic powers, which not only deprive the altered and partially ster- ilized urine which contains them of many of its harmful properties, but cause it to exert a positively curative effect upon the suppurating mucous membrane. This statement is borne out by a number of microscopic observations upon specimens of urine before and after the administra- tion of these drugs, and by culture and inoculation experiments. I have been led by the publications of Dreyfous,1 Sahli,2 Bouchard,3 Lane,4 and Nencki (quoted by Bouchard) to add salol to the drugs em- ployed in the routine treatment of gonorrhoea. Dreyfous’s paper contained the results of his observations in seven cases in which salol Ijad been administered in full doses both with and without admixture with cubebs and copaiba. Sahli had shown that the resultants of the intestinal decomposition of salol were salicylic and carbolic acids, which were eliminated by the kidneys. He had exposed to the air for some weeks the urine of a patient under the influence of salol without the least decomposition occurring. Nencki had made the same observation. Bouchard called attention to the value of the simultaneous employment of several anti- septics by internal administration. Lane reported excellent results in fifty cases of gonorrhoea in which he had used salol in doses varying from 5 to 30 grains three times daily. I have not succeeded in getting quite such good effects from this drug as have been reported by others, but I am satisfied that its use has been of unmistakable benefit to my patients, diminishing the average duration of the cases, reducing the discomfort and suffering, and lessen- ing the frequency of complications. I have given it almost invariably in the form of a capsule in combina- tion with cubebs and copaiba: Salol 5 to 10 grs. Oleoresin of cubebs 5 grs. Para balsam of copaiba 10 grs. Pepsin 1 gr. The conclusions at which I arrived after a preliminary trial of anti- septics, locally and internally,5 are justified by my later experiences and are as follows:— 1. The results of antiseptic treatment are not so uniformly suc- cessful as might be expected, on account of, a, the anatomical and physiological peculiarities of the male urethra; b, the difficulty of ap- plying sufficiently energetic local antisepsis; c, the necessarily inter- mittent character of such applications, and, d, the failure to combine with the topical treatment appropriate internal medication. 2. No one antiseptic agent can be depended upon, in the strength at which it can be borne by the inflamed urethral mucous membrane, completely to sterilize the discharges and the suppurating surfaces. A judicious combination of several antiseptics, if not essential to success, is at least of considerable value. 3. The internal administration of salol in conjunction with copaiba 1 Gaz. Heb'd. de Med. et de Chir., 4 et 11 Janv., 1890. 2 La Semaine Medicale, 7 Avril, 1886. 3 Ther. des Maladies Infectieuses, 1889: Antisepsie, p. 247. 4 Lancet, March 22, 1890. 6 Medical News, June 14, 1890. TREATMENT of posterior urethritis. 311 and cubebs renders the urine aseptic, and probably antiseptic, so that it acts as an exceptionally thorough and efficient antiseptic injection, shortening the duration of the disease and diminishing the frequency and severity of its complications. Treatment of Posteror Urethritis. “ Posterior” urethritis requires for its treatment, as a rule, the use of full-sized steel sounds and the instillation into the prostato-membranous urethra of solutions of silver nitrate varying in strength from 1 to 5 per cent. These combined measures rarely fail to effect a cure, but occasionally other injections or irrigations may be used with advantage. Sulphate of thallin in the strength of from 3 to 24 per cent, has been strongly recommended by Goll, of Zurich, and by Keyes, but I have had no experience with it. VENEREAL DISEASES: THE SIMPLE VENEREAL ULCER OR CHANCROID. BY F. R. STURGIS, M.D., OF NEW YORK. Varieties of Chancroid. Dr. Fernand Lavergne, in the Annales de Dermatologie et Syphili- graphie for 1883, calls attention to a variety of the simple venereal ulcer which he has styled the papular chancroid. Its peculiarity con- sists in being slightly elevated instead of depressed beneath the tissues, and it closely resembles a syphilitic papule. The diagnosis is based in part on the coexistence upon the same subject of other varieties of chancroid, and it is found in both men and women. Lavergne calls at- tention to the fact that in the museum of the St. Louis Hospital there is a specimen of simple papular chancroid of the vulva. Inoculability of the Chancroid and of Chancroidal Buboes. At the International Congress of Dermatology and Syphilography, held in Paris in 1889, Ducrey read a paper in which he arrived at the following conclusions:— 1. That the chancroid is possessed of a specific and definite poison; 2. That this virus has not yet been artificially cultivated, although it has been produced by inoculation in man; it corresponds with a micro- organism which has not yet been artificially developed in the usual nu- tritive materials; and 3. That this micro-organism, which up to the present time has been regarded as the cause of the chancroid, and which is not easy to cul- tivate, appears not to be identical with the microbe which is the real cause of the chancroid. For some time very little was heard about this question of the microbe, until Welander published in the Arcliiv fur Dermatologic unci Syphi- lographie, 1889, a paper in which he claimed to have found the bacilli in the pustules of inoculation, though they were not found in all speci- mens, and when present were present in very small quantities, whence he did not regard them as of great pathological importance. In 1891, Krefting, in the Norcliskt Medicinskt Arkiv, published the result of a 313 314 VENEREAL DISEASES: SIMPLE VENEREAL ULCER OR CHANCROID. series of inoculations made upon fourteen patients. He found the re- sults much the same as Ducrey had found, to wit, that in pustules pro- duced by successive inoculations the presence of a microbe similar to that found by Ducrey could always be demonstrated. The attempts to cultivate this microbe were negative. He found, on examining sec- tions of excised chancroids, that he was unable to demonstrate the presence of these microbes, and the difficulty he thought existed in the fact that these bacilli could not exist in alcohol, even if very much diluted, and that they were very difficult indeed to color by any of the then known methods. Jullien, in 1892, communicated to the “Societe de Dermatologic et Syphiligraphie, ” at Paris, the fact that he had made experimental inocu- lations after the manner of Ducrey and Krefting, and had been led to be- lieve that the chancroids which he had used were not very virulent, and that inoculation would not go beyond the third generation. In 1892, in the July number of the Monatshefte fur praktische Dermatologie, Unna showed that, by using a method of coloration consisting of a mixture of glycerin and ether, he had demonstrated the existence of a bacterium which he called the streptobacillus of the soft chancre. Unna did not positively state that this bacillus was identical with those which Ducrey and Krefting had discovered, but he noted that these bacilli, during their period of increase, formed in the tissues more or less elongated chains, and that they were nearly always found in the lymphatic inter- spaces of the cellular tissue. He never found any fnigratory cells. Krefting, again in 1892, in the Archiv fur Dermatologie und Sypliilo- graphie, Erganzungsliefte, showed that in subsequent researches he had always been able to find the same bacillus, and also had found this bacillus in a virulent bubo which had been opened under cover, as well as in the pustules which were produced by inoculation of the pus from this bubo both before and after it had been opened. The attempt at culture, however, of either variety of pus, whether of inoculation or from the bubo, gave a negative result. In making his experiments Krefting first used for the purpose of discoloring his sections Unna's mixture of glycerin and ether. This, however, he afterward gave up for a preparation of the oil of anilin and xylol, for the purpose of dis- coloration, while for staining he used the alkaline solution of borax and methyl blue indicated by Unna, and in the preparations of chancroid thus made, he found bacilli in more or less numbers seated about the borders of the ulcerations, and in many instances penetrating through a zone of infiltrated cellular tissue surrounding the ulceration, and encroaching upon sound tissue. As Unna has pointed out, these bacilli are more frequently disposed in more or less elongated chains, but nevertheless they are sometimes found as small rods, which latter, however, do not always present the rounded extremities which were found in the bacilli derived from the chancroidal secretion as distinct from the tissues of the ulceration. His conclusions with regard to this question of the microbe of the chancroid are, that its presence is demonstrable in the pustules of inocu- lation, and in the secretions of virulent buboes as well as in the arti- ficial inoculations made with the pus from such buboes, and that it is moreover found in great numbers in sections made of excised chan- croids. Although there is very little doubt that a peculiar microbe has virulence OF CHANCROIDAL BUBOES. 315 been found in the secretion and in the tissues of the chancroid, it is yet too soon to determine absolutely its relative importance as regards the question of inoculation. Virulence of Chancroidal Buboes. Within the last few years very various opinions have been expressed with regard to the question of whether the buboes which occur with the chancroid are virulent by absorption, or virulent by subsequent inocu- lation, and upon this question M. Straus, in the Annales de Derma- tologie et Syphiligraphie for 1885, published his views in full. The conclusion at which he arrives is that there are not two kinds of bubo, accompanying the soft chancre, but only one, and that this bubo is never originally virulent, but only becomes so by secondary inoculation after the bubo is opened. He instances Ricord's experiments made from 1831 to 183T, in which out of 338 cases of bubo he obtained 271 successful inoculations. In 42 of these the pus of the bubo inoculated the day it was opened proved to be virulent. In 229 others positive results were only obtained by inoculation of the pus taken from one to several days aftpr the opening of the bubo, and in these cases the inoculations made at the time of the opening of the bubo were negative. This view of M. Straus was vigorously combated by M. Horteloup at the “Societe de Dermatologie, ” in December, 1884, as reported in the Annales de Der- matologie et Syphiligraphie. He considered that M. Straus had been very fortunate in his clinical experience with the bubo, but at the same time thought that he was a little premature in absolutely denying the existence of the chancroidal variety, and cited evidence in favor of the existence of the chancroidal bubo, which he thought invalidated the theory of M. Straus. The case occurred in a hospital patient who entered for a bubo fol- lowing a chancroid of the frenum. This chancroid had lasted for fifteen days. At that time the patient had noticed upon the right side of the frenum a little pustule which became denuded and converted into an ulceration. Three days after having observed this ulceration a phimo- sis occurred. On the 18th of November a sharp pain was felt in the right groin, and on the next day a swelling was observed at that point. Upon the patient’s entry into hospital it was noticed that there was a complete phimosis which prevented the glans penis from being thorough- ly exposed, and that there was besides an inflammatory swelling of the foreskin, together with a tender point on a level with the frsenum and a sanio-purulent discharge. In the right inguinal region there was a tumor of large size, the skin covering which was of a purple hue and very thin. Fluctuation throughout its substance was complete, but there was no peripheric induration. The case was diagnosticated as one of chancroid of the frsenum, and in accordance with the clinical char- acteristics of the bubo itself, its sudden appearance, its rapid march, its peculiar coloration, and the thinness of the skin, this latter was con- sidered as a chancroidal bubo. Under treatment the phimosis diminished, and as soon the glans penis could be uncovered the existence of a chancroid which had destroyed a portion of the frsenum was seen. The bubo was opened on the 29th day after the patient had entered the hospital. “ After having taken all 316 VEXEREAL DISEASES: SIMPLE VENEREAL ULCER OR CHANCROID. antiseptic precautions,” says M. Horteioup, “both as regards washing my hands in carbolated water and in sterilizing the skin covering the bubo with a carbolated solution of one part in fifty, I incised the bubo with a new bistoury which had previously been thoroughly washed in carbolated water. The bubo was immediately evacuated, the pus being sanious, tinged with red and of the color of chocolate. With the same bistoury I made an inoculation 3 cm. from the umbilicus, hav- ing first thoroughly sterilized the skin covering the abdomen. This point of inoculation was covered with a watch-glass. The inguinal wound was cleaned out with lint soaked in carbolated water, and a dressing was made with prepared cotton taken from a new package and exposed to a carbolated spray for several minutes. The whole dressing was kept in place by a bandage soaked in carbolated water. The pa- tient was then put back in his bed and he was strictly forbidden in any way to touch the watch-glass which covered the inoculation. On the 1st of December the dressing was removed, and the auto-inoculation of the day before was without result. The suppuration of the bubo had not been very abundant. The walls of the cavity were irregular in shape, but the borders had become ulcerated. About 1 cm. from the first inoculation a second one was made with a new bistoury, taking care to allow the blood to flow well before putting the pus upon the wound which had been made. A watch-glass, kept in place by dia- chylon, and the prepared carbolated cotton as before covered the bubo, and all of these dressings were kept in place by a carbolated band- age. The same precautions were taken in regard to interference or meddling with the inoculation. On the 4th of December the dressings were removed, and it was found that the inoculation of December 1 had been successful, a purulent vesicle surrounded with an inflamma- tory areola being seen. The pus from this first inoculation was taken and inoculated at a fresh point 5 cm. from the original point of in- oculation, after all antiseptic precautions had been taken, and also pus from the bubo was taken and a fresh inoculation made in the ab- dominal wall to the left of the umbilicus. The borders of the inguinal incision had become scalloped and ulcerated, presenting the clinical aspects of a chancroidal bubo. On the 6th of December the chancroid which resulted from the inoculation made on the 1st had become very pronounced. Reinoculation of the matter of this chancroid had given rise to a whitish vesicle which was surrounded by an inflammatory areola. The third inoculation from the pus of the bubo also gave posi- tive results. On the 8th of December, these various inoculations con- tinued to follow a regular course, and their clinical characteristics did not differ from those which are found in the simple chancroid.” M. Horteioup concluded that, while admitting that this complication of the chancroid was very much less frequent than certain statistics would lead one to suppose, it nevertheless unfortunately did exist, and in com- municating this observation he wished to accentuate the fact that vir- ulence of buboes is often too lightly thought about, and that conse- quently too favorable a prognosis is given in such cases, even after the open bubo has been dressed by absolute occlusion. Diday in the same journal also protests against the view of M. Straus, and considers that there are buboes by absorption independent of the question of auto-inoculation. VIRULENCE OF CHANCROIDAL BUBOES. 317 Mannino, in a communication made to tlie Royal Academy of Medical Sciences of Balano, in Italy, and reported in the Annates cle Dermatolo- gie et Syphillgraphie for 1885, boldly takes his stand with M. Straus in disbelieving in the spontaneous existence of the chancroidal bubo, and he gives as the result of his investigations the following points: In 24 patients who had an inguinal bubo and in whom the bubo showed all the characteristics of the chancroidal variety, as well as of the simple chancroid, inoculation was practised at the moment of open- ing the buboes, with the pus coming from both the superficial and deep parts of the ulceration. All antiseptic precautions were taken, both as regards the hands and the instruments used, and Mannino says that in all of these 24 cases he had not seen any ulcerations produced upon those portions of the body where he had inoculated the pus of the bubo. The results of his inoculations had always been negative. He then repeated the inoculation in all these 24 cases forty-eight hours or three days after the opening of the buboes, and only in two cases did he obtain a positive result. In the other 22 cases the results of these second inoculations were also negative. Mannino also examined the pus of the chancroids microscopically, as well as that coming from the buboes at the time of their opening, and he noticed in all 24 cases a large quantity of microbes in the pus cells as well as in the fluid surrounding them. These microbes he considered to be micrococci united in chains, some- times surrounding the cells themselves, and his conclusions in regard to this question are:— 1. That the pus of the bubo which accompanies the simple chancre is not inoculable at the time that the bubo is opened. 2. In certain cases this pus acquires virulent characteristics from forty-eight hours to three days after the opening of the bubo. 3. That in the pus of the chancroid bacilli are plentifully found in the shape of large numbers of micrococci united in chains, or sparsely scat- tered over the field. 4. That the pus of the bubo immediately after its opening has never been found to contain bacilli, nor micrococci, nor diplococci. 5. That the pus of the chancroid, when this latter has become a sim- ple wound, no longer contains bacilli. 6. On examining the pus of the bubo, after it has become chancroi- dal, the bacillus of the chancroid has disappeared; and 7. That the poison of the chancroid loses its virulence when it has been submitted to the action of heat, more or less prolonged, at a tem- perature of 35 to 40° C. (95 to 104° F.). Gemy in the Annates cle Dermatologie et Syphillgraphie, 1885, gives as a resume of 20 inoculations which he had made, 4 in which the re- sults were positive, 3 in which they were doubtful, and 13 in which they were absolutely negative, and his conclusions are as follows:— 1. The simple chancre (chancroid) in a certain number of cases has no comolications, as far as the groins are concerned. 2. When it is accompanied by an adenitis, this is purely inflammatory in about three-fourths of the cases, and the pus which it contains is not virulent. In the other quarter of the cases the bubo is the product of the transportation of a micro-organism, the contagious agent, through the lymphatic vessels, this being retained in the first set of inguinal ganglia and there producing chancroidal bubo. 318 VENEREAL DISEASES: SIMPLE VENEREAL ULCER OR CHANCROID. 3. In the last instance two phenomena may result. Either the bubo is chancroidal throughout its whole glandular tissue, but the periglan- dular cellular tissue is not as yet contaminated by the presence of the virus; pus from such a bubo is immediately inoculable. Or else the cellular tissue first becomes inflamed, and then, as it is this simple pus which escapes first after the opening of the bubo, the gland itself not becoming immediately chancroidal, a negative result is produced so far as inoculation is concerned; but it becomes positive if attempts at in- oculation are delayed until this simple pus has entirely escaped and nothing but the interglandular pus, or else that which comes imme- diately from the ganglion itself, is employed. Many cases might be cited in support or refutation of this theory, which, after all, sifts itself down to the following points:— 1. That in the large proportion of cases of chancroids of the genitals no glandular infection occurs. 2. That of those in which it does occur, the larger proportion are purely inflammatory at the beginning, and a very few of them may be- come virulent by carelessness in dressing the wound of the genital chancroids. 3. That a small proportion of them are virulent from the start, and this would seem to be borne out by the fact that occasionally, where the chancroids are virulent, there will be a virulent absorption, with breaking down of one or more of the lymphatics connecting the two points of ulceration. Such instances are not very frequent, but they have occurred. Treatment of the Chancroid. The treatment of this variety of venereal ulcer is as varied as that of gonorrhoea, every one having some pet drug which he deems facile princeps the thing to use, and which he thinks no chancroid, it matters not how inflammatory or angry it may be, can possibly withstand. One of the latest methods is the use of heat, which, by the way, is not a new thing. Aubert, surgeon-in-chief of the Antiquaille Hospital of Lyons, France, in the Lyon Medical for August, 1883, gives his opinion of the action of heat in depriving the chancroid of its inoculable virus, and says that heat, which he employed in the shape of hot baths beginning at from 42° to 43° C. (108° to 110° F.) completely destroys the inocula- bilityof the virus after twenty-four hours. After the first twenty-four hours the heat may be reduced from 42° to 38° C. (100° F.) with con- tinued happy results. Aubert prosecuted his experiments further in order to find the lowest point at which the virus was innocuous, and he discovered, or thought he discovered, that the chancroidal virus was rendered non-inoculable after the application of heat between 37° and 38° C. (98° to 100° F.) for several hours, that is to say, by a tempera- ture at or slightly above that of the interior of the human body. He subjected the pus of the chancroid to a microscopic examination, and while he found that before the application of the heat at high tempera- ture the secretion of the chancroid was purulent, after the application, even when carried only to 37° or 38° C. (98° to 100° F.), the pus corpus- cles were found to be absent, and in place of them there was a simple TREATMENT OF THE CHANCROID. 319 granular detritus, attended with a fetid odor and containing numer- ous bubbles of gas. While, undoubtedly, the action of hot water, applied in repeated baths, will often exercise a very happy effect in reducing inflam- mation and causing cicatrization of chancroids, this is not a method that commends itself either for the facility of its employment or for its speediness in curing, and Diday of Lyons, in the same journal, ridicules the deductions drawn by M. Aubert as to the action of heat in producing a cure and reducing the chances of inoculability of the chancroid. He does not deny its value as a therapeutic agent, but asks, if heat neutralizes the virulent properties of the chancroid while cold has the opposite effect, why it is that the face and head, which are parts of the body more exposed, and suffering probably from a lower temperature, than the rest of the body, should be the places of all others where the chancroid is very seldom found, whereas, if Aubert’s theory were true, the cephalic chancroid ought to be of frequent occurrence; and why also is it that a chancroid seated upon the glans penis and covered over by a tight foreskin, where, as far as the question of heat is con- cerned the conditions would be most favorable for cure, is so liable to accident and to be attacked by acute and virulent inflammation? Cavazzani, in the Giornale Italiana delle Malattie veneree delict Pelle, etc., 1892, recommends an admixture of hydrate of chloral, 5 parts, camphor, 3 parts, and glycerin, 25 parts, as a dressing for the chan- croid, and declares that it produces a most happy result. He rec- ommends that the camphor and chloral shall be rubbed up together in a mortar, the glycerin then added, and the whole put over a sand- bath for a quarter of an hour. He claims excellent results from this remedy. For the treatment of buboes, Otis, in the Journal of Cutaneous and Genito-Urinary Diseases, 1893, recommends evacuation of the ab- scess by puncturing with a narrow bistoury, and the subsequent intro- duction, after irrigation of the cavity with a solution of mercuric chloride one part in 1000, of a warm iodoform ointment, ten per cent., the subsequent dressings to be wet in the bichloride solution; and he claims that of 16 patients thus treated 9 were reported cured in six days, 3 in twelve, 1 in fourteen. 1 in twenty-three, and 2 unknown. He claims for this procedure the following advantages:— 1. That it is simple and safe. 2. That in suitable cases, cure, as a rule, seems to be more rapid than by any other method. 3. That the patient is not prevented from going about during treat- ment. 4. That the first gland being rendered thoroughly aseptic, renders it less likely that the other glands in the chain shall become infected. 5. That it leaves no telltale scar. (In the present style of dress this point could really be of comparatively no importance.) 6. That it in no way interferes with any subsequent surgical proced- ure, should such be deemed advisable. In the Medical and Surgical Reports of the Boston City Hospital for 1894, Dr. Watson reports 22 cases of bubo treated by excision and the use of sutures, securing union of the wound by adhesion. He re- ports that in a little less than fifty per cent, perfect primary union was 320 VENEREAL DISEASES: SIMPLE VENEREAL ULCER OR CHANCROID, obtained. The following rules were carefully followed out in these cases:— 1. To thoroughly remove all diseased tissue and to leave, as far as possible, a perfectly healthy surface, in every part of the wound. 2. To excise such portions of the skin as threatened to be necrotic, or had already become so. 3. To thoroughly cleanse the under surface of the skin flaps; and 4. To thoroughly swab the whole wound with dry sterilized iodoform gauze. The flaps were then brought together by sutures, and the re- sults, as claimed by Watson, were those stated above. This method might answer very well indeed in cases of non-virulent bubo, but in cases where buboes were virulent, of course very little, if any, result could probably be obtained. VENEREAL DISEASES: SYPHILIS. BY ARTHUR VAN HARLINGEN, M.D., PROFESSOR OF DISEASES OF THE SKIN IN THE PHILADELPHIA POLYCLINIC; PHYSICIAN TO THE DEPARTMENT FOR SKIN DISEASES, HOWARD HOSPITAL, PHILADELPHIA. Chancre. Herpetiform Chancre.—This almost always appears on the mucous membrane of the glans penis or on that of the prepuce, or on both at once. It is a very deceptive lesion, because it first shows itself very shortly after coition, and at first presents only the appearance of her- pes genitalis. Little by little its real character appears. The herpetic lesion becomes covered with a pseudo-membranous deposit, its base becomes gradually infiltrated, and if multiple the herpetic erosions coalesce, become elevated above the surrounding surface, and finally take on all the characters of a syphilitic initial lesion. Meantime the inguinal glands gradually become engorged in a typical manner. The multiplicity of the herpetic chancre is one of its most character- istic features. Mauriac has seen as many as twenty on the balanic mucous membrane. Mixed Chancre.—'When an individual has been inoculated with the virus of chancroid and syphilis simultaneously, or with only a few days* interval, the following symptoms are observed:— At the end of thirty-six or forty-eight hours a sore appears, having all the properties of a chancroid, that is to say, being auto-inoculable, having around it, perhaps, other small ulcerations, and, at a little dis- tance lymphangeitis, virulent adenitis, buboes, etc. After four or five weeks, however, the aspect of the sore changes. Induration about its base sets in, and without losing its chancroidal character the sore takes on the aspect of a syphilitic lesion with its generalized symptoms following. Of course if the patient has already had syphilis, inoculation with this mixed virus will only give rise to chancroid. The interval between the development of the two kinds of virus de- pends on the dates of their respective reception. If an individual is in- fected with syphilis on the first day of the month and with chancroid in the same place on the last day of the same month, the two poisons will break out almost simultaneously. Mauriac 1 gives numerous ex- amples of mixed infection at various dates. 1 Nouvelles Lemons sur les Maladies Veneriennes, p. 335. Paris, 1890 321 322 VENEREAL DISEASES: SYPHILIS. Relative Frequency of Chancre in Different Localities.—The following figures may be compared with those given in Vol. II., pages 354, 355, 358:— Seat oe Genital and Extra-Genital Chancres. In tile Male.1 Prepuce and glans 1343 Sulcus of the glans 217 Meatus 89 Urethra 17 Scrotum 20 Base of the penis 10 Anus 12 Abdomen 9 Thighs 1 Lower limbs 3 Fingers 2 Lips 36 Gums 1 Tongue 8 Cheek and nose 3 Eyelids 2 1773 In the Female.2 Labia majora. 140 Labia minora 39 Fourchette 15 Preputium clitoridis 17 Clitoris 16 Entrance of the vagina 15 Meatus of the urethra 4 Neck of the uterus 22 Superior commissure of the vulva 2 Anus 5 Thighs 1 Lips 9 Velum of the palate 1 Tonsils 1 Breasts 2 Vagina 3 292 Vaginal Chancre.—Gardillon 3 reports four cases. One of these occupied the posterior cul-de-sac; another, the right cul-de-sac; a third was situated behind the vulvo-vaginal ring on the posterior wall of the vagina; the fourth at the junction of the posterior and middle thirds. The vaginal chancre is painless and excites no functional disturbance. The accompanying adenopathy occupies the groins when the chancre is in the lower third of the vagina, and the smaller pelvic basin when it is in the other two-tliirds. The vaginal chancre heals spontaneously in one or two wreeks, according to Gardillon, but the period is probably computed from the moment that the lesion has reached its maximum development. The diagnosis of chancre of the vagina is not difficult, if the lesion is attentively studied. The chancroid of the vagina, which, like the chancre, runs a rapid course and heals spontaneously, is generally mul- tiple, non-indurated, and presents the appearance of a true ulcer, with sharply cut edges and uneven base, secreting an abundance of pus; it may be inoculated upon its bearer, and is usually accompanied by vul- var chancroids of a similar appearance. Vaginal chancres must be dis- tinguished from herpetic erosions, and from ulcerative or erosive syphi- lodermata, chiefly by the history of their development.4 Diagnosis of Chancre.—Leloir says that when an herpetic ulcer is pressed between the fingers, a drop of serous fluid is squeezed out. This manipulation can be repeated several times with the same effect. In the case of chancre, on the contrary, a little fluid is seen on the sur- face, but the quantity is not increased by pressure. When the base of 1 Combined statistics of Martineau and Fournier. 2 Combined statistics of Bassereau, Clerc Le Fort and Fournier. 3 Essai sur le Chancre du Vagin, Chancre non-infectant et Chancre infectant. These de Paris. 1881. 4 See also Bockhart (a very curious and instructive case, with references), Monatshefte f. prakt. Dermatol., Dec., 1885, S. 417; and Rasmussen, Vierteljahrssch. f. Derm, und Syph., 1880, S. 517, abstracted by me in Phil. Med. Times, March 26, 1881, p. 401. SYPHILIS OF THE CIRCULATORY SYSTEM. 323 the herpetic ulcer is indurated, the hardened tissues can be flattened between the fingers, while in chancre no amount of pressure can change the nodule. Treatment of Chancre.—Although indolence is characteristic of by far the greater number of cases of chancre, yet at times the ini- tial lesion of syphilis is so painful as to require special treatment with the view of allaying this symptom. Usually the pain is connected with some inflammatory condition, and in such cases local or general sedatives will relieve the symptoms. Occasionally, however, the trouble seems to be due to some lesion of the nerves in the immediate neighborhood of the chancre, and then exci- sion. when practicable, seems to be the only means of allaying the pain. Chancres of the clitoris, it is said, are peculiarly apt to be painful, a circumstance which seems not unlikely when we consider the very abundant nerve supply of this part. Possibly cocaine, externally or by injection, would give relief in painful chancres of this locality. Syphilis of the Circulatory System. Syphilis of the Heart.1—According to Jullien, syphilitic affections of the heart develop, on an average, about ten years after the com- mencement of the disease. In six cases, however, among those noted by this author, the affection occurred as early as the end of the first year, while in others it developed as late as the eighteenth year of the disease. Men are much more liable to the affection than women. Age does not seem to have any influence in determining this form of syphilis. The prognosis of syphilitic disease of the heart is grave. The affec- tion usually develops in a slow, continuous, and insidious manner. Occasionally, however, attacks of syncope occur, leading to a dangerous condition, and sometimes to a sudden fatal termination. This occur- rence is very frequent, having been observed in half the cases reported. At other times a slowly fatal process sets in, involving engorgement of the liver and lungs, with hydrothorax, ascites, etc. Death not unfre- quently occurs through involvement of the brain. In some cases a favor- able result may occur with or without partial dilatation of the heart. In the treatment of syphilitic heart disease, digitalis and similar remedies are useless. Mercurial inunction, with the internal use of iodide of potassium, are indispensable. These remedies should be begun early and pushed vigorously; life or death may depend on the prompti- tude of treatment. A strict milk diet is recommended in syphilitic heart disease, because it lessens the gastro-intestinal troubles and increases diuresis, while indirectly, by its diminution of ascites and meteorism, it removes some of the provoking causes of dyspnoea and angina. The soothing effects of precordial blisters, while marked in other forms of heart disease, are not obtained in syphilitic heart affections.2 1 Reference may be made to an excellent monograph by Lang : Die Syphilis des Herzens, Wien, 1889, and to the papers of Janeway (The Medical Recorder, 1872), and of Loomis (quoted by Bumstead and Taylor). Mauriac also gives a number of references. 2 Zakharine. (Editorial article, Med. News., Phila., Oct., 1890, from Rev. Gen. de Chir. et de Therap., 20 Aout, 1890.) 324 VENEREAL DISEASES: SYPHILIS. Syphilis of the Blood-Vessels.—The question whether syphilis may occasion aortic aneurism has been much discussed, but it is now generally conceded that this is possible. Jaccoud 1 says that though the ultimate prognosis of syphilitic arteritis is unfavorable, long remis- sions may be procured by appropriate treatment.2 Hutchinson 8 describes a case of coldness and lividity of the fingers of one hand, closely resembling Raynaud’s disease and occurring in a syphilitic patient, which was cured by specific treatment. In the earlier stages of syphilitic arterial disease prompt and vigor- ous treatment may cure the lesion by resolution. After a certain length of time the new growth breaks down and ulcerates, or more frequently becomes transformed into cicatricial tissue. All hope of cure is then at an end. Angina pectoris of syphilitic origin has been observed, sometimes complicated with other troubles of innervation involving the vasomotor system.4 I have noticed this symptom in a single case. Treatment of Syphilis. Of late years the hypodermic method has been extensively employed in the treatment of syphilis, almost every possible salt of mercury hav- ing been essayed. When first experimented with, mercurial hypodermic injections were often followed by untoward results: pain, inflammatory reaction, ab- scesses, phlegmon, gangrene, etc. More recently, however, such acci- dents have become rare and may in most cases be avoided. Fournier 5 gives the following suggestions to this effect:— 1. Caustic and extremely irritant compounds of mercury are to be avoided. 2. All solutions should be perfectly, chemically pure, filtered, steril- ized, and aseptic. Many accidents may be referred to the introduction of septic germs in the process of hypodermic medication. 3. The instruments employed must be very carefully purified. The syringe to be used should be so constructed that it may readily be ster- ilized. The needle should be somewhat more than an inch in length, so that it can be inserted deeply into the tissues, and should be made of some not readily oxidizable metal. The point should be kept perfectly smooth and sharp. 4. In performing the injection the strictest antiseptic precautions are to be employed as regards the instruments, the operator’s hands, and the surface of the skin. 5. The injection should be deeply made, superficial being much more likely to result in pain and inflammation than deep injections. Intra- muscular injections are best. 6. Certain localities are more tolerant of mercurial injection than others. The posterior surface of the trunk is the least sensitive, and 1 Lemons de Clinique Med., Gaz. des Hop., Fev. et Mai, 1886, Juin, 1887; and Aortite et anevrysme de l’aorte d’origine sypliilitique, La Semaine Med., 1887. 2 See also Knight, Syphilis and Aneurism, Archives of Medicine, New York, 1883. 3 Lornl. Med. Times, March 15, 1884. 4 Hallopeau, Annales de Dermatologie et de Syphiligraphie. Dec., 1887. 6 Traitement de la Syphilis. Paris, 1894. TREATMENT OF SYPHILIS. 325 the retro-trochanterian fossa is said to be also a convenient locality. The arms and legs are to be avoided. 7. After the needle has been plunged into the tissues, a moment’s pause may be made to ascertain if a blood-vessel has been wounded. If a drop of blood appears, the injection should not be proceeded with. If not, the syringe may be attached, and from fifteen to twenty drops of the fluid may then be very slowly thrown in. 8. If numerous injections are to be made, they should be spaced at intervals of at least an inch. Soluble salts of mercury are usually employed for hypodermic injec- tion, and of these the bichloride is that most commonly used. Lewin’s formula, which I prefer, is essentially as follows: 1} Hydrarg. chlor. corrosiv., gr. viij. Sodii chloridi., gr. xv. Aquae destillat., f 3 iij. M. Fifteen minims of this solution represents about one-twelfth of a grain of the bichloride of mercury. French syphilologists prefer the preparation known as the peptonate of mercury.1 1 For further details regarding the various salts of mercury, see Fournier, op. cit., and L. Wolff, Proceedings Phila. County Medical Society, April 25, 1894. SURGICAL DISEASES OF THE SKIN AND ITS APPENDAGES. BY J. ABBOTT CANTRELL, M.D., PROFESSOR OF DISEASES OF THE SKIN IN THE POLYCLINIC HOSPITAL AND COLLEGE FOR GRADUATES IN MEDICINE; PHYSICIAN FOR SKIN DISEASES TO THE SOUTHERN DISPENSARY, PHILADELPHIA. The following pages are intended as a supplement to the valuable article of Dr. J. C. White in Vol. III. The section on molluscum con- tagiosum has been entirely rewritten; there has been added a new sec- tion devoted to the description of psorospermosis; numerous minor additions have been made; and favorite forms of treatment, which have stood the test of years, have been described. Affections of the Sebaceous Glands. Milium.—Treatment.—The removal of these structures can usually be accomplished by making a slight incision in their most prominent part, and then expressing their contents by pressure applied to either side by means of the finger-nail or the edge of a knife. The bleed- ing is easily checked by direct pressure on the part. The application of the green soap (Sapo viridis), of German manufacture, exerts a curative effect by removing the upper layer of the epidermis and allow- ing the contents to escape. Electrolysis, applied as in removing super- fluous hair from the face, is followed by a rapid disappearance of the morbid condition. Molluscum Contagiosum. Synonyms: Molluscum sebaceum; Epi- thelioma molluscum (Virchow); Acne varioliformis (Bazin); Condyloma subcutaneum.—The contagiousness of this affection, which was main- tained by Bateman after having witnessed it in three persons in whom he had traced the source of contagion to a fourth, has been the oc- casion of decided controversy for some years. Numerous inoculations, which are said to have been successful, have been recorded. The dis- ease is marked by small or large, from pin-head to large pea-sized, semiglobular, raised or somewhat flattened, so-called tumors of the skin, which as a rule are shiny and transparent, and of a pinkish or lilac color, but often have the appearance of a common warty growth. The lesions in most instances are sessile, but often pedunculated; at 328 SURGICAL DISEASES OF THE SKIN AND ITS APPENDAGES. times they show an umbilicated appearance, resembling the condition found in varicella. For the most part they are found occupying the face, but may be seen in remote regions, such as the neck and genitalia, and in rare instances are scattered over the entire body in small or large numbers. They are of slow growth. Their course is chronic, although they may disappear spontaneously. They are usually unaccompanied by any sensation of the part, except when they are accidentally the seat of inflammation, by which they are often destroyed. Although usually observed in children, they may be found among those of adult life. Expressing the contents of one of these little tumors, we find a some- what thickened, white, opaque and cream-like material, the sac remain- ing hollow and flaccid. They have thus a resemblance to the ordinary sebaceous cyst, although the contents do not have the yellowish appear- ance of the material within the latter, nor do they have the characters of disordered sebum. Examined microscopically and chemically, we find neither fat, choles- terin, epithelial scales, nor earthy salts, but the creamy material is found to be composed of an oval transparent structure, having a pink- ish lustre and without a nucleus. In fact, in these little bodies we see the molluscum corpuscles which have so often been described. These bodies, first recognized by Wilson in 1842, were well described by him. They were subsequently rediscovered at the Hopital Saint Louis, being at this time described as cryptogamic spores, and believed to be the source of the contagion. This view, according to the ob- servations of Pye-Smith, is incorrect, because their size, appearance, and reaction to potassa, with their inability to undergo development, contradict such a supposition. Pye-Smith believes them to be epidermic cells which have undergone hyaline transformation. In most cases a certain amount of sebaceous substance is found in these tumors, but in other instances this is entirely wanting. Upon examination of a horizontal section the structure is found to be com- posed of several lobules, and in some cases we see a central cavity which somewhat resembles a sebaceous gland. Whether the cysts originate in the sebaceous glands, or whether their metamorphic cells arise from the lining of the acini, is a matter of doubt. Virchow believes that the tumor is a new growth which is en- tirely confined to the deeper cells of the epidermis, and that there is no connection with the sebaceous glands. The earlier view seems to be the more correct one, and Sangster in his observations has entirely con- firmed it. Within a short time Darier, followed by others, has claimed that the element of contagion lies not in a bacterium or fungus, but in a “ psorosperm,” but this fact is not evident in all the specimens examined, although in some instances it certainly looks as if the cells were attacked by parasites. But we should have more confirmatory evidence of their existence before accepting this theory altogether. Treatment.—One means of treating these tumors, when they are per- vious, is by forcibly pressing the opposite sides and thus expressing their contents; the bleeding that often follows this mode of treatment is very slight. When the cysts are entirely closed, and when they are small, sulphur ointment often gives good results; and when larger they may be scooped out with the dermal curette, or removed by means of curved INFLAMMATIONS OF THE SKIN—HYPERTROPHIES. 329 scissors or the knife. VThen very numerous and closely packed together, the use of the German or of the domestic soft soap may, by causing exfoliation of the epidermis and discharge of the contents, result in a rapid cure. The application of caustic potassa or silver nitrate to the interior of the cyst, after squeezing out its contents, is at times ad- missible. The use of electricity, by means of the galvanic current applied as in the operation for removal of superfluous hair, may be tried in all cases with advantage. Inflammations of the Skin. Dermatitis Venenata.—The action of chlorine, used in the form of the solution of chlorinated soda (Labarraque’s solution), will commonly effect a cure in four or five days. It may be applied in full strength, except in a decidedly acute case, when a weaker solution will be pref- erable. Hypertrophies. Callosities.—Tyloma may be congenital. Five cases of this form of disease have been described by Unna under the name of keratoma palmare et plantare hereditarium. Crocker 1 has also recorded similar cases to which he has given the name of ichthyosispalmaris etplan- taris. The internal use of arsenic, when long continued, may give rise to this affection, and it may likewise probably be caused by liy- peridrosis. Treatment.—After soaking the feet in warm water and paring down the callosity with a knife, a plaster of salicylic acid, twenty per cent., or salicylic acid dissolved in collodion or ether, will cause maceration of the hardened tissue which can then readily be removed. Clavus.—Treatment.—Should the patient object to the pain of cut- ting, salicylic acid plaster may be applied until the thickened layer becomes softened and can be removed. The following is a favorite remedy much in vogue: $ Acidi salicylici, 3iss;Extr. cannabis ind., gr. x; Collodii, q. s. ad f 5 i. This should be painted on with a brush, three times daily, for one week; the feet should then be soaked in hot water, when the corn can be picked out. Warts.—Although not absolutely proven, it would appear probable that warts were contagious. A very striking example of contagion occurred in Payne’s case; after having removed a wart with his nail, he noticed that subsequently one developed under the nail, and some on the dorsal surface of the thumb. Treatment.—Among other remedies may be mentioned the internal use of Fowler’s solution of arsenic, in the dose of Tqij t. d. for adults and ttl 4 for children. Eecently sulphate of magnesium has been given, 2 or 3 grains for children, and 3 ss for adults. Crocker thinks that nitromuriatic acid in full doses acts well at times. Condylomata of larger size may be removed with Paquelin’s cautery. Salicylic acid in 1 British Journal of Dermatology, vol. iii., 1891, p. 169. 330 SURGICAL DISEASES OF THE SKIN ANI) ITS APPENDAGES. the form of a rubber plaster, may be advantageously employed, or the following prescription may be used: Acid, salicyl., 3ss; Ext. canna- bis ind., gr. x; Collodii, f 3 i. M. This is to be applied for three or four days, and the wart is then to be scraped. The removal of the larger, vascular warts is best accomplished by the ligature, galvano-caustic wire, or ecraseur; to stop the bleeding which follows, perchloride or persulphate of iron, and pressure, will be sufficient. Liquor sodse chlor- inatse, diluted, may be employed in the treatment of venereal warts occurring about the labia, to be followed by the application of calomel in powder, resorcin, or burnt alum and savin, equal parts. Van Har- lingen recommends the following prescription for patches of warts: 1$ Pulv. acidi arsenios., gr. vi; Ung. hydrarg., Empl. hydrarg. aa q. s. ad 3ij. It is best to apply this salve on thin kid skin; it must not be used over too large an area at a time, as absorption may take place. Diseases of the Nails. Onychia Syphilitica.—During the secondary and tertiary stages of syphilis the disease frequently manifests itself by various lesions of the nails and their immediate surroundings, and these lesions may be mild or severe, and transient or permanent in their effects, according to the intensity of the localization of the specific virus in this portion of the body. At the best the affection is chronic, and the management of these cases may become exceedingly tedious and unsatisfactory. Etiology.—This form of onychia is due, as has been said, to inocula- tion of the specific virus of syphilis, and develops as one of the later manifestations of that systemic condition. Symptoms.—Clinically, the affection most commonly appears in the dry or friable form, called by the French onyxis craquelee, in which the implicated nail presents a lustreless and dry appearance, becomes yellowish-gray in color, exceedingly friable, and irregularly thickened, with furrows and ridges alternating upon its distorted surface. These depressions in the nail are due to a form of disintegration and dry rot- ting of the nail substance, and their formation is accompanied by a cor- responding rolling upward of the edges of the nail, the condition being just the reverse of that seen in onychauxis. It must be borne in mind, however, that the coexistence of onychia and onychauxis is frequently noted, and this distinction therefore cannot be regarded as of diagnostic importance. Very often the tissues surrounding the nail present a con- gested, purplish appearance, with some desquamation of the surface, and pressure made upon this purplish rim may cause a few drops of un- healthy-looking pus to exude. It is claimed by some sypliilograpliers that this condition is most frequently encountered among women. At times, without any manifestations of inflammatory action in the sur- rounding parts, the nails may become loosened and may finally be shed, the whole process being unattended with subjective signs, as in the case of syphilitic alopecia. When onychauxis is associated with this condi- tion, the nail assume a size three or four times that of the normal, and to this form has been given the name of hypertrophic onychia. As has been indicated above, syphilitic onychia is frequently associated with a form of paronychia or inflammatory disease of the tissues in. DISEASES OF THE HAIR. 331 which the nail is embedded, and to this associated condition may be due most of the symptoms complained of by the patient. The inflam- mation in these softer tissues may go on to superficial ulceration, with purulent or sanguinolent discharge and crust formation, and slight burrowing of the secretion under the nail. Owing to the involvement of the matrix the nail shows evidence of impaired nutrition. The fin- ger in such a condition presents a characteristic appearance due to the swollen and bulb-like form of the distal phalanx. Frequently in this form of syphilitic onychia the nail may become dislocated or entirely separated from its attachments. Diagnosis.—The syphilitic history of the case will generally simplify the diagnosis of this condition. In the bulbous form, with associated paronychia, the disease must not be confounded with digital chancre, the nail in the latter affection not being the seat of the main trouble, nor with parasitic disease due to the presence of the trichophyton fun- gus (trichophytosis unguium). The prognosis depends upon the early administration of the proper treatment. The disease may be arrested if promptly recognized and vigorously combated. Treatment.—The treatment should be mainly internal, supplemented with antisyphilitic applications. The iodides and mercurials should be pressed to the utmost limit. Locally, Hyde recommends the white pre- cipitate salve (one scruple to the ounce) applied on linen cloths. Appli- cations of silver nitrate will have a beneficial effect upon the indolent ulcer, and these should be followed by iodoform, iodol, or europhen in powdered form. The local applications should be persisted in as long as there is any sign of inflammatory action, and even after this has disappeared internal medication must be urged. Treatment of Ingrowing Nail.—The surface, after the nail has been removed, may be dressed with iodoform, iodol, or a mercurial, such as the ung. hydrarg. oxid. rubr., and moist boric lint should then be ap- plied and covered with oiled silk. Internally, quinine in full doses and a nourishing diet are indicated. Diseases of the Hair. Hirsuties. Synonyms: Hypertrichiasis; Polytrichia; Trichauxis ; Hypertrophy of the hair. In the condition known as trichiasis, which may be either congeni- tal or acquired, the eyelashes grow in a backward direction and are a source of great irritation to the eyeball. Treatment of Hirsuties. —When galvanism is employed the positive pole should never be used, as permanent scars would follow. When the parts are very sensitive, cocaine hydrochlorate (20 per cent.) and lanolin, in ointment form, maybe rubbed in before operating, or cocaine may be used hypodermically, though its employment sometimes gives rise to alarming symptoms. Generally speaking, the coarser hairs only should be operated on; the lanugo hairs should not be touched. Hardaway employs a needle made of iridium and platinum; he says that it is easier to find the papilla with this needle than with one made 332 SURGICAL DISEASES OF THE SKIN AND ITS APPENDAGES. of steel. Other operators use a fine jeweller's broach, selected with care, and No. 5 or No. 7 in size. The use of depilatories is not advis- able, as already mentioned. The following formula is recommended by Duhring: 1} Barii sulphidi, 3 ij; Pulv. zinci oxidi, Pulv. amyli, aa 3iij. This is to be made into a thin paste with water, and applied to' the hairy part; after ten or fifteen minutes or as soon as the skin com- mences to feel warm, the paste is washed off and a soothing ointment applied. Anderson uses the following: IJ Barii sulphatis, 3iss; Zinci oxidi, 3 vi; carmine, gr. i. Water is applied to some of this powder and made into a paste; after remaining in contact with the parts for three minutes it should be washed off. Elephantiasis Arabum. Acromegaly may be regarded as a rare form of elephantiasis; in this variety the bones of the hands, feet, and face become hypertrophied; some of the fibro-cartilages also, as those of the ear and larynx, and all the tissues undergo enlargement and thickening. Treatment of Elephantiasis.—The internal administration of quinine, particularly in marshy localities, should not be omitted. Cases in which the swelling is not extensive, or in which the solid deposits in the tissues have existed for only a short time, will be benefited by massage, which procedure tends to cause absorption. Potassium iodide also has its ad- vocates in the treatment of this affection. The administration of calcium sulphide in from 3 to 6 grain doses daily, has been followed by good results in lymph scrotum. It is thought that this drug destroys the parasite (filaria) in the blood and lymph channels. Change from a hot to a moderate climate often has a bene- ficial effect in cases in which the hypertrophy has not become very marked, and renders the prognosis more favorable. While in advanced cases of this disease the prospect is unfavorable as to perfect recovery, a fatal termination is decidedly rare, although in severe cases death may sometimes ensue. Acne Hypertrophica. As effective causes of this disorder may be mentioned dyspepsia, de- bility, nervous prostration, and compression of the vessels at the base of the neck by means of the clothing, tumors, etc., thus interfering with the circulation of the blood and giving rise to dilatation of the veins. Treatment.— The following is the formula for what is known as Ivummerfeld’s lotion, which is of great benefit in the treatment of this affection: IJ Sulph. praecip., 3 i; Pulv. camphoric, gr. v; Pulv. traga- canth, gr. x; Aq. calcis, Aq. rosarum, aa f 3 i. This mixture has de- cided astringent properties, and exercises a very beneficial action on the rosaceous condition. Keloid and Hypertrophy of Cicatrices. Electrolysis has been recommended by Hardaway. Multiple punc- tures are made with a needle into and some distance around the growth; FIBROMATA—XANTHOMA—ANGEIOMA—LYMPHANGEIOMA. 333 a mild current should be used, and the needle must not remain in con- tact with the parts too long, for fear of aggravating the conditions. Brocq also speaks well of this method in cases of hypertrophied cica- trix. Fibromata. These are sometimes congenital. When fibromata exhibit a tendency to hang in soft, loose folds, due to hypertrophy and excessive develop- ment of the cutaneous and subcutaneous structures, they are designated fibromata pendula, which is a more appropriate term than dermatolysis. Xanthoma. This disease is not a common one. The term xanthoma multiplex has been given to that form of the malady in which multiple xantho- matous lesions are generally distributed.1 When the lesions occur in strise, they are designated by the name of xanthoma lineare vel stria- tum. Usually the affection does not cause much inconvenience, though itching and burning sensations are at times complained of by the patient. Hallopeau2 regards the xanthomatous growths as benign neoplasms of embryonic origin, and shares the view of Touton, that they owe their origin to the generative embryonic fat-cells which persist in the tissues and proliferate. Hallopeau is of opinion that the jaundice which frequently is present in this disease may be due to the presence of these cells in the biliary passages, and thinks it not improbable that the glycosuria which exists in those exceedingly rare cases known as xanthoma diabeticorum, may be due to these cells being located in the pancreas. Treatment.—Recently electrolysis has been employed in the removal of the lesions; this method is preferable to the use of the knife. Angeioma. Sodium ethylate, applied by means of a glass rod, is regarded by some as a very good remedy in cases of angeioma. Lymphangeioma. Synonyms: Lymphangiectasis; Lupus lymphcdicus; Lymphan- geioma cavernosum; Pachydermia lymphorrhagica. Prognosis.—It would appear from the scant literature on the subject that this affection does not tend to disappear spontaneously, and that the growth has reappeared even after it had been removed with the knife. 1 See reports of two cases of extensive xanthoma multiplex; the one by George Thomas Jackson, Journal of Cutaneous and Genito-Urinary Diseases, 1890, vol. viii., p. 241; the other by E. J. Stout, ibid., June, 1894. 2 Annales de Derm, et de Syph., 1893, tome iv., p. 935. 334 SURGICAL DISEASES OF THE SKIN AND ITS APPENDAGES. Rhinoscleroma. Bacilli have been found in the lesions of rliinoscleroma; these organ- isms are rod-shaped, their length exceeds their breadth by one and one- half times, they have rounded ends and are enclosed in a capsule, and they occur in free groups, or in cells. In appearance they are very sim- ilar to the pneumococci of Friedlander; some authors regard these or- ganisms as the etiological factor of the disease, and think that their presence causes the lymphatics to become blocked. Others consider the infiltrated condition as being closely allied to the granulation tumors which occur in such diseases as leprosy, syphilis, etc. Treatment.—Salicylic acid has given encouraging results in Lang’s hands; this remedy was employed both internally, in the dose of 10 grains three times daily, during a long period, and externally in the form of hypodermic injections, of one-per-cent, strength, repeated daily. Douches of sodium salicylate were used in the naso-pharynx, and solu- tions of the drug in alcohol were applied to the diseased mucous mem- branes. Lupus Erythematosus. Synonyms: Seborrhoea congestiva; Lupus superficialis; Lupus erythematodes; Lupus sebaceus; Lupus non-exedens. French, Scrofu- lide erythemateuse; Erytheme centrifuge. Four varieties of this affection have been described: the circumscribed or discoid, the telangiectasic, the nodular, and the diffuse or dissemi- nated. Some authors regard lupus erythematosus as a species of cutaneous tuberculosis; it has a tendency to occur in scrofulous in- dividuals. Treatment.—Iodine, arsenic, and potassium iodide may be given in- ternally. McCall Anderson recommends the administration of iodide of starch in heaped teaspoonful doses, in water or gruel, given three times daily. Bulkley advocates to grain doses of phosphorus thrice daily. Strict attention should be paid to hygienic conditions and to the general health. Locally the use of Paquelin’s cautery, applied lightly to the diseased areas, is regarded very favorably by some writ- ers. Scarification with the multiple scarifier, making longitudinal and transverse incisions, about yg in. apart, may be emplo}7ed. Before operating, local anaesthesia may be produced with the rhigolene or ether spray; the application of absorbent cotton and pressure will readily check the hemorrhage. The operation may be repeated after the wounds have healed. This method is followed by very slight scarring and is highly recommended. Electrolysis has also proved useful. Lupus Vulgaris. Some investigators consider this a local manifestation of tuberculosis. In America the coexistence* of phthisis and lupus has been but rarely observed. The disease is undoubtedly at times due to direct inocula- tion. Experimental inoculations with lupoid material, introduced into LEPROSY—CONNECTIVE-TISSUE CANCER—MADURA FOOT. 335 the abdominal cavities of guinea-pigs, have given rise to general tuber- culosis in these animals. Morbid Anatomy.—Koch has succeeded in finding bacilli in lupoid tissue, which cannot be differentiated from the bacilli of tuberculosis. The reaction following the injection of tuberculin in lupus patients also points to lupus as being a cutaneous tuberculosis. Treatment.—Applications of salicylic acid, in the strength of 10 to 20 per cent., on plaster, are a good remedy; creasote is advantageously combined with the acid, equal parts of each, for the purpose of decreas- ing the pain. Bichloride of mercury in solution, gr. 1 to 2 to the ounce, or in ointment form, of the same strength, is reported to act very beneficially. Injections of tuberculin have proved too dangerous, and the results obtained too temporary, to justify their use. Dr. George Fox removes small nodules with dental burrs and the excavator. Scarification with the multiple scarifier is a very good method of treatment. A multiple scarifier devised by Van Harlingen 1 will be found very useful in this operation. The incisions are to be made longitudinally and transversely and should extend through the diseased area to the sound tissues. Besnier advocates the use of electro- cautery knives of different sizes. Electrolysis in multiple punctures, or by means of a metallic button, may also be employed. Leprosy. In the treatment of leprosy segregation and isolation of the affected individuals must be rigidly enforced in order to prevent the spread of the disease. Connective-Tissue Cancer. This constitutes the so-called cancer en cuirasse of Velpeau; when this condition exists, the chest movements are interfered with and res- piration becomes difficult. Madura Foot. Synonyms: Ulcus grave; Tubercular disease of the foot; Podelcoma; Mycetoma. Usually only one foot is attacked, and at times only parts of a hand or foot are affected. In very rare cases the shoulders and scro- tum are the seat of the disease. The palmar surface of the finger or thumb, and the plantar surface of the toe or the spaces between the toes, are the locations in which the disease often makes its first appearance. The affection has been attributed to the presence of a splinter or thorn in the foot, or to a slight traumatism; in a number of cases dracunculosis has been observed to have been followed by podelcoma. The possibility of the fungus penetrating through the skin in individuals who are ac- customed to go barefoot in wet, low ground, has been mentioned by 1 Handbook of Skin Diseases, p. 298. 336 SURGICAL DISEASES OF THE SKIN AND ITS APPENDAGES. writers who have had occasion to observe the disease in India. Very often we are completely at a loss to account for the origin of the affec- tion. Two observers, Carter and Crookshank, have arrived at the conclusion that the clinical as well as pathological conditions existing in mycetoma are analogous to those observed in actinomycosis, and are of the opinion that the disease should be considered as actinomy- cosis occurring in the human race. Two varieties of the disease have been observed, known respectively as the pale or yellow, and the black; the latter variety occurs most frequently. Treatment.—When the disease is still confined to the superficial lay- ers, and has not. been of long duration, the affected area should be thoroughly curetted and an appropriate dressing applied. Parasitic Diseases. Favus. — Synonyms: Honeycomb Ringworm; Porrigo lupinosa; Porrigo favosa • Tinea lupinosa ; Crusted Ringworm. German, Erb- grind. French, Teigne faveuse.—This disease is due to the presence of a fungus known as the achorion Schoenleinii. Remak, in 1836, first called attention to the fungoid character of the crusts; three years later Schoenlein established their fungoid nature beyond a doubt. In Eng- land the disease is decidedly rare, but it is often met with in Scotland; it is of frequent occurrence in France, and is very common in Poland and Italy. In the United States favus is rare, but is not infrequently seen among the lower classes of recently arrived immigrants, and a case occurring in the head of a child eight years of age, of American par- ents, and supposed to have been contracted in a barber-sliop, has re- cently come under my notice. Although usually located on the scalp, favus may attack any part of the surface, and even the mucous mem- branes. Epidermic favus is regarded as rare, although quite exten- sive cases of that character have been recorded by Kaposi, Roddick, E. J. Stout, myself, and others.1 Authors have described several varieties of favus fungus. Three forms have been spoken of by Unna, to which he has given the name of favus griseus, favus sulphureus tardus, and favus sulphureus celerior. Quincke has also differentiated three varieties of the fungus, which he has named respectively «, /?, and y fungus. The majority of authors, however, are of the opinion that there exists but one achorion fungus. It appears that favus, in common with other vegetable parasitic affec- tions, shows a disposition to attack certain individuals in preference to others; thus it would seem that certain soils are peculiarly favorable to its propagation. Treatment.—The employment of poultices or hot applications is to be deprecated in the treatment of this affection, as it is a well-known fact that moist heat is favorable to the growth of the fungus. The treatment formerly in vogue, known as the “calotte,” or pitch cap, has been abandoned, being very severe and even dangerous to life. Bulkley advocates the use of epilating sticks, which consist of: R Cerae flavse, 3 iij; Laccae in tabulis, 3 iv; Resinae, 3 vi; Picis burgundicae, 3 xi; Gummi dammar, § iss. These sticks are from two to three inches 'Journal of Cutaneous and Genito-Urinary Diseases, September, 1894. PARASITIC diseases. 337 in length, and from one-fourth to three-fourths of an inch in diameter. After the hair has been clipped quite short, the stick is heated and ap- plied to the scalp, and after remaining in contact with the scalp until quite cold, it is removed with a rotary motion. Numerous hair-stumps and adhering fungous growth will be found clinging to the stick. Onychomycosis—Favus of the nail {Tinea favosa unguium) is a de- cidedly rare affection; in almost every case the fungus is introduced under the nails by scratching the scalp affected with favus. The treat- ment is tedious. The nail should be rendered quite thin by filing, and a parasiticide should then be used. Removal of the nail and applica- tion of a parasiticide to the affected area is the quickest method of effecting a cure, although this process is decidedly heroic. Tinea Tonsurans.—A good method of treating this affection, based on the fact of the fungus being aerobic, consists in combining a suita- ble parasiticide with collodion. This excludes the air and does not allow the fungus to develop. Thus corrosive sublimate, in the strength of from i grain to 4 grains to the ounce of collodion, or salicylic acid ten grains to the ounce, should he applied daily with a camel’s-hair brush to and around the patches. At the expiration of one week the crust formed by the collodion should be removed with forceps, when large numbers of hair-stumps will be found adhering to it. This pro- cess is repeated in the same manner at the end of a week. In cases of short duration, occurring among older children, Coster’s paste may be used with advantage. The formula is as follows: 1$ Iodi, 3 ij ; Olei picis, §i (the ingredients should be slowly and carefully mixed). This solution is applied to the patches with a brush. It is advisable to re- move the crusts which form with forceps, as more fungi and diseased hairs stick to the crust when pulled off in this manner than when allowed to drop off themselves. The parts are then rubbed well with sapo viridis and flannel, and the remedy is reapplied. Dr. James Foulis recommends the following treatment: A towel is tied around the child’s head so as to protect the eyes; the hair is cut quite short in the vicin- ity of the lesions, or when a number of lesions exist the entire hair should be clipped. Oil of turpentine is then freely applied to the affected area and rubbed in well with the finger. This removes the scales and dirt, and after a few minutes penetrates quite deeply. The head is then thoroughly washed with 10 per cent, carbolic acid soap and warm water, which relieves the smarting caused by the turpentine. After drying the head well with a towel, several applications of tincture of iodine are made to the affected areas, and after the parts have become dry, the entire scalp is rubbed with carbolized oil (1 to 20), which de- stroys any spores that may exist. Foulis states that this treatment, used every morning, or morning and night in obstinate cases, is fol- lowed by cure in a week. Tinea Versicolor.—Synonyms: Chromophytosis; Dermatomycosis furfuracea; Mycosis microsporina. German, Kleienflechte. —In Biart’s case1 patches of the disease were found on the left cheek; the forehead was also affected and the scalp slightly; a spot was also dis- 1 Amer. Jour. Cutan. and Yener. Diseases, vol. iii., 1885, p. 43. 338 SURGICAL DISEASES OF THE SKIN AND ITS APPENDAGES. covered behind the ear. Payne has observed the presence of the para- site on the scalp and beard. I have quite frequently observed the dis- ease in married couples, in whom it was confined to one individual alone. Experimental inoculations have been successfully practised by Kobner, who has managed to inoculate men and also rabbits wTith the disease. Treatment.—Hyposulphite of sodium, 3i to the ounce of water, ap- plied night and morning, is a very good remedy. The applications should be preceded by a warm bath and the free use of soap, which will enable the remedy to penetrate more readily. The use of tincture of iodine in cases which are not extensive is also followed by good and quick results. Scabies.—The strength of the remedies employed in the treatment of scabies must be graded according to the age of the patient, and the sensitiveness and general condition of the skin. The following ointment is a very useful one: $ /? Naphthol, Sulph. sublim., aa 3 i; Adipis, 3 i. This salve is to be thoroughly rubbed into the affected parts with the hands night and morning, and its use is to be continued for three or four days. At the expiration of that time a bath is taken, and the underclothing and bed-linen are changed. Should signs of the disease still exist after three or four days the same treatment is repeated. Owing to its non-irritating and non-toxic properties oxynaphthoic acid, a remedy recommended by Schwimmer, can be used advantageously upon children. The formula is as follows: Ijfc Acidi oxynaphtlioici, Pulv. cretse, Saponis viridis, aa 3iv; Adipis, q. s. ad 5 i- M. Pediculosis Capitis.1—The color of the liead-louse is usually gray- ish or ashy, but is said to vary according to the color of the individual on whom it is found; thus it is black on the negro, white on the Es- kimo, and yellowish-brown on the Chinese. The ova or “nits” are attached to the hair by means of a glutinous material, called chitin. The pediculus capitis gains its nutriment by inserting its haustellum, or proboscis, into a cutaneous follicle to reach a small vessel. Lice do not bite. The condition known as plica polonica, or Weicliselzopf, presents a frightful picture of aggravated lousiness. In appearance the pediculus capitis is very similar though smaller than the pediculus corporis. Male lice are not as large and are less numerous than the female. Treatment.—The following application will be found very useful. Extract staphisagrise fid., f 3 i; Acidi acetic, dil., f 3 iij. Sig. Apply thoroughly to the scalp. The stavesacre destroys the lice and the dilute acetic acid the ova. Naphthol used in the form of oil, or soap, is also a good remedy. Pediculosis Corporis.—The pediculus corporis procures its nutri- ment by means of a haustellum or sucking apparatus, consisting of a membranous tube, which it inserts into the follicles of the skin. Treatment.—The application of Extr. stapliisagrice fid., f3i-ij; Adipis, 3 i, to the affected area, will be followed by the destruction of the parasites that may be found on the skin. 1 Lice belong to the order rynchotta. PARASITIC DISEASES. 339 Pediculosis Pubis.—Sometimes the parasite is met with on the whiskers and beard, and on the hairy part of the chest. The female louse is nearly twice as large as the male. Treatment.—A very cleanly method consists in applying lint satu- rated with chloroform and covering it with oiled silk. This kills the parasite quickly; to remove the remaining ova, vinegar answers well. Bichloride of mercury, in the strength of 1 grain to the ounce of vine- gar, destroys both the pediculi and ova. It should never be forgotten that the mercurials, especially when numerous excoriations or abrasions are present, may be absorbed and produce salivation. Mercurial oint- ment, quite a popular remedy, is uncleanly and should be dispensed with. Psorospermosis.—Synonyms: Keratosis follicular is (White); Ich- thyosis sebacea cornea (E. Wilson); Acne sebacea cornea; Prolifer- ative follicular psorospermosis; General hypertrophy of the sebaceous system (Lutz); Darter's disease; Psorospermose folliculaire vegetante (Darier); Ichthyosis follicularis.—This is a disease of the skin, of un- known etiology, commencing on the face or trunk, but ultimately spreading to other portions of the body, and characterized by the de- velopment of papules of small size and of a dirty-red color, with firmly adherent and grayish, brown, or black, horny crusts which may be squeezed out of the papules by the thumb-nails. Etiology.—Darier, who was the first to accurately describe the affec- tion in 1889, and other dermatologists who followed him, supposed that the disease was due to certain unicellular, oviform parasites, the psorosperms or coccidiae. More recent investigators, however, have proved that these supposed psorosperms were in reality nothing more than altered epithelial cells. It is possible that there maybe an hered- itary factor present in the disease; the true etiology is still, however, merely a matter of conjecture. Symptoms.—1. The papular stage. The disease nearly always starts upon the face, but in time involves the adjacent parts, and then spreads to the trunk; it especially affects the axillary and inguinal regions. The cutaneous lesions are at first papillary, each papule being pin-head in size and dull-red in color; it is capped by a dark gray, brown, or black crust, which, if removed, leaves a funnel-shaped depression. At the outset there are but a few of these discrete lesions, but with the progress of the disease they increase rapidly in number, and may even become confluent in places; such patches are covered with a large brownish and oily-looking crust, with a rough and irregular surface. 2. The papillomatous or vegetating stage. Each papule, late in the disease, takes on a renewed growth and becomes excessively developed; marked elevations of the skin are thus produced, and these may be surmounted by horny crusts one-quarter to three-quarters of an inch in length. These papillomatous masses are most frequently found in the hypogastric and inguinal regions and around the arms. They are very apt to show spots of superficial ulceration, especially in the neigh- borhood of the orifices of the hair follicles; when this occurs the dis- charge is very fetid and sero-purulent in nature. The ulcerated spots are sensitive, and by preventing sleep and locomotion tend greatly to reduce the patient’s strength and vitality. When the disease attacks 340 SURGICAL DISEASES OE THE SKIN AND ITS APPENDAGES. the scalp it gives an appearance closely resembling that produced by seborrhcea sicca, with the exception that the hairs do not show a ten- dency to fall as in that disease. The parts of the face most liable to attack are the creases around the nostrils and lips, the temples, and the inner surface of the concha of the ear. The course of the disease is slow as a rule, with, however, occasional acute exacerbations, during which considerable areas may rapidly become involved. The eruption is developed symmetrically in its usual sites. Pathology.—According to Bowen, Robinson, and other dermatolo- gists, the change in the skin consists in a “ keratinization of the epi- thelial lining of the ducts of the pilo-sebaceous conduit. ” This harden- ing of the tissues, as it progresses, gives rise to the formation of the horny masses. Between the stratum granulosum and the rete are de- veloped numerous small roundish bodies containing what are supposed to be nuclei and nucleoli; these are the so-called psorosperms. The pathology is by no means accurately determined as yet, a sufficient number of cases not having been reported. Diagnosis.—From molluscum contagiosum it may be distinguished by its greater generalization, and by the absence of the characteristic enu- cleable mass of the latter disease, containing the molluscous bodies. Then, too, the base of the papule is pearly white in molluscum conta- giosum, while it is dirty-red in color in the disease in question. In the later stage the two diseases are quite distinct. From pityriasis rubra pilaris it may be distinguished by the presence in that disease of the typical, isolated, scale-capped papule pierced by the hairy filament. Prognosis.—This is bad as regards a cure. The disease progresses steadily, and seems to be but little influenced by medication. As a rule, the general health is not seriously affected. Treatment.—This should consist of cleanliness, with shampooings and soft-soap inunctions, followed by the application of drying and absorbing dusting powders, such as boric or salicylic acid. If the parasitic theory of the causation of the disease be accepted, parasiticides should be em- ployed. These would include salves of iodoform or dermatol, baths of sulphide of potassium and other sulphur-containing waters, and in ad- vanced cases cauterization with chloride of zinc. DISEASES OF THE CELLULAR TISSUE. BY SAMUEL ASHHURST, M.D., SURGEON TO THE CHILDREN’S HOSPITAL, PHILADELPHIA. The paper of the late Professor Howe 1 needs hut little amendment, since the annals of surgical science do not contain much to add to the es- say as it came from his pen. The task of the present writer will be chiefly to indicate the modifications of treatment which have received the general approbation of practical surgeons since the original paper appeared, and which consist mainly of alterations brought about by the universal adoption and more thorough application of the principles of aseptic surgery. Modern investigation has, however, made some advances which have an important bearing upon the theory which seeks an explanation or elucidation of the causes of disease in the cellular tissue. By these investigations, made by means of improved microscopical methods, we have learned to look upon the all-including areolar tissue of the body as something more than a framework to support and unite other or- gans. There is good reason to think that the all-pervading cellular tis- sue, by its connection with the lymphatic system, is itself an organ of the highest value, having functions of a most important and vital kind— a circumstance which throws much light upon its pathology. The same investigations point to the fact as very highly probable, if not yet conclusively demonstrated, that in the areolar interspaces begin the mouths of the lymphatics, if these interspaces are not those mouths themselves. If this histological inference should prove to be correct, and it is supported by many observations, it will go far to account for the vari- ous inflammations which have their seat in the cellular tissue. Foreign and injurious matter, whether from without or from the detritus of the various organs, seeking admission to the circulation, is arrested primarily in the areolar interspaces and afterward extends through the primary lymphatic trunks to the nearest collection of lymphatic vessels or glands. According to its character it excites more or less irritation in the vessels through which it passes, at the first gland it reaches, or in the cellular interspace—that is, lymphatic mouth—by which it finds admission to the general S}Tstem. Modern observation tends to confirm the doctrine that upon the character of the materies morbi thus ad- mitted depend the various kinds and grades of areolar inflammation, rather than upon any local peculiarities of the areolar tissue itself. 1 See Yol. III., page 117. 341 342 DISEASES OF THE C ELLUL A K TISSUE. Thus continued study of bacteriology may enable us to speak positively as to the modifying influence exerted by this or that microscopic germ upon different kinds of pus, and to account for the varieties observed. There would seem to be little doubt that these varieties are accompanied by different kinds of spores, and when repeated observations have proved the connection between them to be more than accidental, we shall have gained a point from which we may begin to differentiate the varieties of areolar disease dependent thereupon. But at present we are not able to do more than frame hypothetical structures in accordance with the dim teachings of observations thus far made. Everything points to the important sphere which the bacteriologist is to occupy, and it is upon what is to be learned from his cultures that the development of our exact knowledge concerning varieties of areolar disease in large measure depends. It would also seem as if much information might be obtained from a larger and more accurate knowledge of the parasites infesting all ani- mal structures. With his advancing years the late Dr. Joseph Leidy devoted more and more attention to parasites, but without reference to the diseased conditions brought about by their presence. No member of the animal kingdom was brought to him that he did not detect many, and often new, varieties of parasites. The writer recalls the fact that in an ordinary ocean sun-fish Professor Leidy showed him no less than five parasites which he had detected in those few tissues that he had examined, and no less than two of them had been previously unde- scribed. Dr. Howe describes three of the forms which are known to cause disturbance in the connective tissue of man, but even a moderate acquaintance with parasites might lead us to a better understanding of those which in their process of entry, growth, or death, cause diseases which we term inflammatory, but of the true etiology of which we are entirely ignorant at the present time. Adhering to the divisions made by Dr. Howe, it will be the aim of the present writer merely to make such additional observations upon each as seem to him to be called for or made necessary by the rapid progress of surgical science. Simple Cellulitis.—This is of frequent occurrence, and the impor- tance of searching for and removing the cause should not be lost sight of, as upon it the treatment must largely depend. This will generally lie along the lines laid down by Dr. Howe. As a general thing local pressure will be found advantageous in the treatment of cellulitis, and the use of such dressings only as are found by experience to he unirritat- ing. Yet moderately strong solutions of sugar of lead will generally be found beneficial, either alone or combined with laudanum, lead from its well-known sedative qualities being less irritating than the other as- tringents. When suppuration occurs, the free incisions advised by Dr. Howe should he immediately resorted to, and here compression, together with proper drainage and the use of aseptic lotions, will help to secure sound healing of the parts. Both pressure and drainage act as preventives of that entrance of the “exudates” into the circulation which modern surgeons have learned to dread, while the comfort to be obtained from a properly applied band- age either of cotton or flannel is a matter of daily experience. As a CELLULITIS. 343 general thing that which is really comfortable to the patient, and not merely pronounced so from the fear of interference, is good for him. Experience has taught the writer the advantage of blowing both hot and cold in such cases as do not require the use of the knife. He has very often seen marked advantage from the use of a counter-irri- tant, such as the tincture of iodine, followed immediately by a poultice or warm-water dressing, while he must also bear his testimony to the good effects secured by either the simple or the compound iodine oint- ment as an aid to resolution. The same is true of belladonna and mer- curial ointments, either alone or in combination in chronic cases. Where repeated attacks of cellulitis occur without any traumatic cause, some vice of constitution underlies it, and alkalies, colcliicum, or mercury, may be needed according as rheumatism, gout, or syphilis is at the bottom of the trouble. Peri-Venous Cellulitis.—Of peri-venous cellulitis there is noth- ing to be added to what has already been so well said by Professor Howe. While the inflammation is primarily and chiefly outside the neigh- boring veins, it is somewhat difficult to say positively that there is not a true phlebitis also present, as shown by the presence of more or less adherent thrombi and by the softened condition of the walls of the veins. Yet the distinction as drawn by Dr. Howe should be borne in mind, and the treatment which he recommends in these cases should be carefully followed. In free stimulation lies the only hope of the patient, and should systemic poisoning ensue, either from breaking down of the clots contained in the veins, or from without by means of septic matter entering through their open channels, the issue will hardly differ from that to be expected in true septicaemia. Peri-Arthritic Cellulitis.—The interesting and important ques- tion in peri-arthritic cellulitis is to discriminate between disease within and without the joints. In the vigorous it is attended with little dan- ger to life, but in those possessing vitiated constitutions, either young or old, the drain upon the vital powers may easily exceed their ability to endure. Ordinarily, however, the fact that the suppuration lies out- side the joint will bring relief to the mind of the surgeon, who may therefore quite safely commit himself to a favorable prognosis, with the assurance that no permanent injury to limb or danger to life need be anticipated. To satisfy himself on this point, therefore, the surgeon will do well to spare no pains in seeking to arrive at a correct diag- nosis by carefully following out the rules clearly if succinctly laid down by Dr. Howe. Prompt opening of the abscess or abscesses, with good drainage, absolute rest for a time by the use of splints, and the use of a supporting diet, are the indications for treatment. Ischio-Rectal Cellulitis.—This is very common, and its impor- tance as a cause of fistula in ano is generally recognized. This comes not from peculiarities in the inflammation itself, nor from those of the areolar tissue in which it is situated. The trouble lies in the anat- omy of the region, in which the mouth of a tube, through which so often very irritating matters pass, is surrounded by a sphincter and other 344 DISEASES OF THE CELLULAR TISSUE. muscles, the constant contraction of which interferes with union be- tween the walls of any abscess. Sometimes, yet often enough to make the attempt worth while, the very early and free incision of an abscess, causing its entire emptying, and the accurate apposition of its walls, with perfect quiet, may prevent the formation of a sinus, and secure union without destroying the integrity of the sphincter; but generally no such desirable result is obtained, and a fistula is formed. Indeed, so rare is such a union that when it is necessary to open an ischio-rectal abscess it becomes a question whether the muscle should not be divided at once, and further trouble and pain thereby be avoided. The immediate division of the muscle is a trivial addition to the incision and packing of the abscess required, and the certainty of securing prompt and sound union is thereby so great that the writer has many times adopted it as the regular treatment of the abscess, and has never had occasion to re- gret it. The advice of Dr. Howe concerning the opening of fistulous tracks is good, but as a general thing the abscess is a very simple affair at first, and when freely opened and then put at rest by a divi- sion of the sphincter, there is little danger of burrowing of pus and the consequent formation of a series of such tracks. Even should there be no communication of the abscess with the bowel, it is better at once to divide the sphincter, as thereby an open wound is secured, to the heal- ing of which there is no impediment, while there is no likelihood of incontinence of foeces following. It is not generally necessary to extend the incision up the wall of the bowel to the highest point of the abscess, as healing will generally follow, especially in recent cases, when the incision merely includes the sphincter and the wall of the rectum covering it. Peri-Phalangeal Cellulitis.—In the few graphic words with which he depicts peri-phalangeal cellulitis Dr. Howe does not in the least exaggerate the suffering experienced in connection with it, rarely, indeed, exceeded by that induced by any other surgical affection. Nor will any practical surgeon question the correctness of the advice given by him. Yet experience teaches that the prompt use of the knife, and it should be used without reference to the presence of pus, is not in every case attended by the relief looked for. Occasionally the pain persists and the periosteal irritation extends despite the free use of the bis- toury. When this state of things exists, we can only make free and repeated incisions to favor the escape of matter, and prevent burrowing by the use of fine drainage-tubes, horsehairs, or catgut. Peri-Caecal Cellulitis.—This is an affection which has attracted more and more attention of late years, and the remarks made by Dr. Howe are in some degree prophetic, indicating the treatment which has become the established one, and foreshadowing that exploration of the abdominal cavity in cases of acute peritonitis which, however desper- ate a measure in the eyes of our predecessors, has been resorted to of late years as one which can hardly increase the perilous condition of the patient, while giving him one more chance of life. Dr. Howe was familiar with the inflammation produced by the appendix vermiformis, but he did not know that its removal as a useless and often dangerous organ would become the fashion. hypertrophy of the areolar tissue. 345 When cellulitis depends upon impaction of faeces in the caecum the use of purgatives is very clearly indicated, but in the experience of the writer they should be used cautiously and frequently, rather than actively, nothing in his experience being equal to repeated and small doses of calomel, with or without opium according to circumstances, continued for some time. This treatment combined with hot fomenta- tions will often obviate a resort to the use of the knife, but if pus has once . formed, its prompt evacuation by operation is imperative. The operation is often attended by most satisfactory results, and may be undertaken without the dread of wounding the peritoneum once so prevalent among surgeons, as nature has generally glued the parts together as a prelim- inary to the exit of pus. The condition of the appendix vermiformis is a question which intrudes itself into every case of perityphlitis, and in cutting down to evacuate matter in this region no surgeon would nowadays rest until he had informed himself as to the state of that organ, the question of the removal of which is considered elsewhere. Painful Hypertrophy of the Areolar Tissue.—In the Ameri- can Journal of the Medical Sciences for November, 1892 (page 521), Dr. F. X. Dercum narrates a case of what he terms “adiposis dolorosa,” and similar cases are recorded by the same gentleman and by Dr. F. P. Henry in the University Medical Magazine for December, 1888, and in the Journal of Nervous and Mental Disease for March, 1891, all of the cases having points of resemblance to myxcedema. There was a great increase of the connective and adipose tissues over greater or less areas, together with painful symptoms indicative of fugitive and irregular irri- tation of nerve trunks, possibly a neuritis. The cases were unaffected by treatment and eventually ended unfavorably, the patients dying from long-continued suffering and exhaustion. INJURIES OF BLOOD-VESSELS AND ANEURISM BY LOUIS McLANE TIFFANY, M.D., PROFESSOR OF SURGERY IN THE UNIVERSITY OF MARYLAND, BALTIMORE, MD. Injuries of Blood-Vessels. In the ten years that have elapsed since the article on “Injuries of Blood-Vessels” 1 was written, little has been recognized which can in any wise improve upon or modify the masterly exposition of the sub- ject presented by Dr. Lidell. His philosophic reasoning and discus- sion remain now, as formerly, in the first rank of surgical writing. In the matter of treatment, however, a revolution has taken place, which has been brought about through the agency of those principles first enunciated by Lister, and now recognized and practised throughout the civilized world. What I shall say, therefore, refers to the effect which the presence or absence of suppuration has to do with wounded vessels. The occurrence of secondary hemorrhage, the methods for its arrest, the methods of arresting primary hemorrhage, in order that such ar- rest shall be definitive, is really nothing more or less than a considera- tion of whether the operator is able to close the wounded vessel in an aseptic way, whence there is to be expected recovery without com- plication. On the other hand, torsion, acupressure, the use of ligatures of one kind or another—metal, animal, or vegetable—constriction by crushing, aerteriversion, cauterization, and the employment of chemi- cal haemostatics, are simply gropings after a method for the arrest of hemorrhage without having suppuration as a necessary sequence—a method which we now are very largely able to understand and prac- tise. The application of an aseptic ligature in an aseptic wound secures defi- nitive closure of the vessel and recovery without complication. The lig- ature to be used for the closure of a vessel is subject somewhat to the fancy of the surgeon, silk and catgut being the preference of most operators. Perhaps as time goes on, silk is more often the choice than catgut; and, if clean, it gives no trouble. It can always be obtained pure, and is not absorbed before the ligated vessel is definitively closed. The same will be said of catgut by those who prefer it. The method, however, of obtaining clean silk is so simple as to be at the disposition of every one. Heat, that absolute destroyer of all life, will render silk sterile, and at the same time not materially impair its strength, so that 1 See vol. II., page 495. 347 348 INJURIES OF BLOOD-VESSELS AXI) ANEURISM. it is always at hand, and in that respect leaves little to be desired. Steam heat kept up for forty or fifty minutes prepares silk for any emergency. Catgut, properly prepared, is doubtless quite as efficacious. My own preference is for silk. I use it always and have no complaint to make. Perhaps the first and most important advantage which is brought about by aseptic operation is the absence of suppuration; the ligatures applied to vessels remain and are not cast out. One end of the liga- ture is not allowed to hang out of the wound for the purpose of with- drawal, but the wound is closed and nothing ever is seen of the liga- tures, which, being cut short, remain permanently. The method by which the definitive closure of an artery is brought about when ligated is described differently by different observers. It appears certain, however, that, while in applying the ligature the in- ternal and middle coats are easily bruised and perhaps divided, such bruising and division are not necessary. What is necessary is that the internal surfaces of the artery should be pressed together and the lumen thus closed. Great stress was formerly laid on the necessity for dividing by ligature the two internal coats—a necessity now known not to exist. Again, it is a point about which there is difference of opinion as to whether a proximal thrombus is necessarily present in an artery after ligation. As a matter of fact, it usually is, and while it may not be necessary as an essential factor of the obliteration of the vessel, yet it does by its presence diminish the shock of the blood against the point ligated, and furnishes a medium in which the blood-vessels may prolif- erate and assist definitive and permanent closure of the vessel, and a framework for granulation tissue. It is probable that the extent of the traumatism enters as an immediate factor in to .the size of the throm- bus, and it is probable, also, that the presence of sepsis influences unfavorably the organization of the thrombus, as it unquestionably does the exudation surrounding the ligated point. In this connection it is worth noting that Warren calls attention to the presence of clots in the hypogastric arteries of newly born infants; and in certainly one instance found a clot of large size in the obliterated ductus arteriosus of a young child—a place from which both trauma and sepsis could be excluded. In veins there appears to be no doubt that the presence of a clot is not necessary to insure definitive closure after a wound; the lateral ligature of the vein wall shows this, the lumen of the vessel be- ing restored by immediate union of the opposed surfaces; and in the same way a fine lateral suture of the wounded vein wall is followed by permanent closure. Hence the presence of a proximal thrombus is to be considered in relation to arteries only. It is proper to consider the method by which a ligated artery is closed definitively, in much the same way that one is accustomed to consider the formation of callus in rela- tion to a broken bone. A vessel tied without much disturbance of, or interference with, surrounding parts heals with a minimum of callus (clot), whereas if there is much injury to soft parts and much denudation of the vessel wall the amount of callus is increased. Investigators are not in accord as to how this callus is formed: whether it be by imme- diate union of proliferating cells from the intima, by the exit of wander- ing cells from the vessels, by proliferation of connective-tissue cells, or ANEURISM. 349 by proliferation of muscle cells from the media, does not seem yet to be settled, and it is not worth while to discuss the matter here; hut in the absence of sepsis, a clean ligature applied to the vessel aseptically, results in definitive closure of that vessel at the point tied, without suppuration, the ligature remaining encysted and never being heard from. The dis- turbance of surrounding parts when an artery is ligated, and the neces- sity at one time thought to exist for very limited denudation, need not be considered, provided that there is absence of sepsis. The evil influ- ence of suppuration on the process of cicatrization of blood-vessels can- not be too earnestly insisted on. Failure to obtain definitive closure of a vessel is not seen in clean wounds; and the many deaths recorded as resulting from secondary hemorrhage are mainly evidences of failure to preserve wounds aseptic. Of course it is a fact that, in a cer- tain number of cases, a vessel after having been once injured may give way without the supervention of suppuration, but such cases are rare. Again, when it is recognized that a surgeon has usually in his hands the power of preventing secondary hemorrhage and the evil effects of suppuration on vessels by prompt and cleanly action, it is all the more necessary for him to exercise such power. Aneurism. During the time that has elapsed since the article on aneurism was published,1 the changes which have come to pass are those mainly due to the recognition of the advantages directly resulting from aseptic methods in operating, and the unhappy state of affairs which would follow if such a method of operating were not recognized and followed out; and the treatment of aneurism has accordingly been much modified. The methods of flexion and compression in aneurisms of the extrem- ities, are much less made use of at present than in times past, owing to the comparative safety of the ligature and the good results which may be expected confidently to result therefrom. Indeed, it is proper to say that when an aneurism is recognized, the question will present it- self at once to the surgeon's mind, “Is there any reason why ligation should not be done?” and if not proper, then other methods may be had recourse to. Atheroma of an artery, or a diseased arterial wall from other cause, scarcely seems to be a sufficient reason why ligation should not be practised, provided that it is done in such a way as to avoid the occurrence of inflammation. The application of a ligature, then, to an artery on the proximal side of an aneurism, and the almost certain closure of the same without trouble, has done away with the necessity for employing other methods of treatment so well explained and described in the original article of Mr. Barwell. The material to be used for ligatures can be appreciated by referring to the preceding section on Injuries of the Blood-Vessels. Secondary hemorrhage after ligation for aneurism is now not to be expected, at least from the point where the ligature is applied; but other complications resulting from the persistence of the sac of the aneurism, containing more or less blood and coagulum, still remain to endanger the otherwise excellent outcome resulting from the ligation— 1 See Yol. II., page 825. 350 INJURIES OF BLOOD-VESSELS AND ANEURISM. suppuration of the sac and gangrene of the extremity, both of which oc- currences have been noted not infrequently; and while aseptic ligation of the vessel relieves the operating surgeon from one anxiety, the danger resulting from the other still remains; consequently much attention has been given, of late years, to the removal of the sac. The good results which follow aseptic ligation of a vessel have em- boldened surgeons to try, and the result of experience seems to justify, the extirpation of the aneurismal sac, ligatures being placed on the main vessel at points proximal and distal to the dilatation, the aneurism itself being considered and treated as a tumor to be removed in its en- tirety, leaving a simple connective-tissue wound, which will heal as the wound remaining after the removal of a tumor of any other kind. It is only necessary to look into the records of cases to see how often other- wise successful treatment of an aneurism has been rendered nugatory by the behavior of the sac; the contained blood failing to organize, and so becoming a suppurating focus and entailing the loss of what would otherwise have been a useful limb. I cannot avoid thinking that it is a very great advantage in the surgical treatment of aneurism to ex- tirpate the sac. The fear that the vessel close to the aneurism, both above and below, will not hear ligature, is obviated by aseptic operating; and it is without doubt a fact, that the removal of the tumor, by re- lieving tension in the limb and pressure on the veins, renders the occur- rence of gangrene less likely. An atheromatous artery will unques- tionably resist sepsis and suppuration less well than a healthy artery, but sepsis and suppuration should not occur; hence it is to be expected that a ligature applied very close to the sac, if done in a clean way, will be followed by definitive closure of the vessel. Wherefore it becomes proper in extirpating an aneurism to tie the main vessel close to the sac above and below. If the ligature is applied at a distance, as in the Hunterian method, there occurs, when the pa- tient recovers, an obliteration of the vessel at the point ligated, and also where the aneurism exists, two places some distance apart. By tying the vessel above and below the aneurism, close to the sac, there is de- finitive closure at hut one place and not two, and the danger of gan- grene would seem thus to be diminished. Just what vessels may or may not be properly subjected to this ope- ration, we are as yet not in a condition to know, since the operation is of too recent a date for one to speak of it dogmatically, but so perfect has the result been in my own hands that I am inclined to think it should he made use of wherever possible. There are many difficulties inherent to this treatment—the irreg- ularity of the sac, close adhesion of adjacent and important structures, irregular protrusion of the sac in one direction or another, making its removal not easy—which at first sight may seem to militate against it; hut these difficulties are physical ones, and the skill of the surgeon will overcome them. No other insuperable objections at this time present themselves to my mind. Should a portion of the sac be indissolubly united and incorporated with important structures, and so incapable of removal, it might have to be left, but I imagine that such a condition of affairs would be very exceptional. Should a dilatation of the artery exist in that part of the vessel where large branches are given off, it would be proper, in removing the sac, that those branches should be tied just as would the main vessel. The best method of removing a sac is more or less uncertain, and will have to be decided by the special case. Of course the most simple and easy way is to remove it without opening it, as any other tumor is removed, the first ligature being applied on the proximal side of the sac, which is then shelled out toward the distal end, and the vessel then again tied. Another method would be the application of ligatures above and below the sac, which should then be split and dissected out; or it might be expedient to begin at the distal extremity of the sac and dissect upward; but no rule can be given which would apply to every case. In the case of a burst aneurism, the extravasated blood should be removed by curette or otherwise, according as might seem proper, but at all events the ope- rator should take away the foreign body from the limb and so give rest to adjacent and important structures, as well as relieve pressure, which would unquestionably interfere with the restoration of the circulation in the limb, the main artery of which had been tied. In traumatic aneurism there is no possible doubt about the fact that the indications are to freely expose and tie the vessel above and below the seat of injury, removing the coagulum entirely if possible, and thus placing the limb in the best possible condition to recover. This is now and always has been accepted as the best treatment, and needs no dis- cussion. In order to extirpate an aneurism it is necessary to thoroughly un- cover it by external incisions, to freely open and incise overlying parts, whether soft tissue or bone—the clavicle, for instance, in axillary or subclavian aneurism. The sac is not to be pulled and roughly treated, but is to be removed by dissection, and the surgeon in this operation, as in removing deep tumors elsewhere in the body, is to work with the edge of his knife well in sight, retractors being employed to draw aside adjacent structures. AXEUR1SM. 351 SURGICAL DISEASES OF THE VASCULAR SYSTEM. BY JOHN A. WYETH, M.D., OF NEW YORK. ASSISTED BY W. W. VANARSDALE, M.D. Phlebitis. Two things have united to extend our knowledge of the pathology of the venous system since the appearance of the first volumes of the pres- ent work: the recent great advances in bacteriology; and the part played by the blood-plates in effecting thrombosis, the study of which is inti- mately connected with that of phlebitis. We may, for the better elucidation of the subject, divide phlebitis into infections phlebitis, an inflammatory condition due to the presence of micro-organisms in the tissues involved; and simple hyperplastic phle- bitis, characterized by an infiltration of the tissues with new cells and a proliferation of their structural elements—a type of inflammation of low grade and mainly reparative in character. Either form of phlebitis may be associated with the occurrence of thrombosis within the vein (thrombo-phlebitis)—or it may be due to the advancement of inflammatory conditions from the immediate vicinity of the vein (periphlebitis)—an advancement which is the more readily accomplished, as the adventitia of man}r veins is practically continuous with the surrounding connective tissue. I shall first consider simple proliferating thrombo-phlebitis. The question whether thrombosis is the primary condition and phle- bitis the consecutive one (as represented by Rindfleisch, Ziegler, and others), or whether this order should be reversed (Dupuytren, Cornil and Ranvier), is still one in regard to which unanimity has not been reached. But it now appears probable that some injury to the endothe- lium is the primary exciting cause of phlebitis, which on the one hand, under certain conditions, leads to the formation of a thrombus within the vein, and simultaneously gives rise to hyperplastic changes in the vein-walls (Weigert). Thrombosis is, therefore, now believed to take place only when injuries to the endothelial lining of the vessels are associated with a stagnation 353 354 SURGICAL DISEASES OF THE VASCULAR SYSTEM. or a slackening of the velocity of the blood-current. With stagnation a red thrombus is formed; with a slackened arrest a white or a mixed one. This latter process, the formation of a mixed thrombus, is now known to be brought about by means of the blood-plates, or plaques (Kemp), Fig. 1606. Normal Rapid Blood-Currents, Axial in Character. (Eberth and Schimmelbusch.) the third corpuscles of the blood, first described by Donne (Osier), and identical with the hsematoblasts of Hayem. If a small vein in the mesentery of an animal be watched under the microscope (Bizzozero, Eberth and Scliimmelbush, Loewit), and the blood-current retain its normal velocity, a red homogeneous streak will be observed occupying the centre of the lumen of the vessel, being the appearance produced by the blood-corpuscles in rapid motion. On Fig. 1607. Marginal Position of White Blood-Corpuscles: the Current Slower. (Eberth and Schimmelbusch.) either side of this streak, between it and the wall of the vessel, as seen through the microscope, may be observed a transparent zone of plasma, in which but one or two white blood-corpuscles appear, as they slowly roll along the walls (Fig. 1606). If the blood-current be now caused to move somewhat more slowly, the red blood-discs may be discerned more plainly, and the white corpuscles are observed attaching themselves to tlie vessel-walls in greater numbers (Fig. 1607). And if the current Fig. 1608. Currant Still Slower: Fewer White Corpuscles. «, Blood-plates in plasmatic zone. (Eberth and Schim- melbusch.) be still more retarded, so that the shape of the red blood-corpuscles maybe distinctly viewed, the leucocytes again become fewer, and among them, in the plasmatic zone and close to the vessel-wall, appear the lit- tle blood-plates (Fig. 1608, a) in great numbers; and if there be any in- jury done to the wall of the vessel, these platelets immediately collect PHLEBITIS. 355 at the injured point, adhering tightly to the vessel-wall and to each other. Sooner or later the leucocytes also take part in this accumula- tion, provided that the force of the current is not sufficient to carry them away; and red corpuscles may also be imprisoned in the mass, in case the conditions of the current are favorable. The accumulated blood-plates are said to undergo a change of consis- tency at the time that they attach themselves to the seat of injury (Fig. 1609); they become very adhesive (the viscous metamorphosis and conglutination of Eberth), and undergo a fine granular change, after Fig. 1609. Stagnation of Blood-Current. A, Red hyaline thrombus; /?, communication with vessel in which current continues; a, blood-plates. (Eberth and Schimmelhusch.) which they appear split up into fine threads; and, possibly, are after- ward transformed into hyaline substance (Aschoff). Simultaneously with the appearance of leucocytes, fibrin is seen in the clot; but whether this fibrin-formation is due to the blood-plates alone, or to the presence of the leucocytes, has not yet been satisfac- torily established. The theory of A. Schmidt, referred to in Vol. III., p. 327, has of late years become somewhat modified in consequence of the general acceptance of the above views. The fibrin-ferment, the liberation of which is believed to precipitate the coagu- lation of the blood, is said to emanate from the blood-plates at the time when they become massed together; although some authors (Hauser) hold that any living cell may set free fibrin-ferment on its disintegration. Again, Giirber has shown that it is not necessary that leucocytes should perish in order that fibrin be formed; and Mosen has demonstrated that masses of pure plates collected from the blood by centrifugation, when coagulated, present unmistakable fibrin-forma- tion. Salvioli, indeed, maintains, that by extraction of all blood-plates from a living animal (which he achieves by repeated blood-letting and re-infusion) coagulation of the blood is rendered impossible. Ou the other hand Pekelharing and Lilienfeld, who have studied the chemical aspect of coagulation of blood, still hold the leucocytes principally responsible for the formation of fibrin-ferment. The former found that fibrin-ferment was an organic calcium-compound (calcium-nucleol albumin) which was formed, most generally, when leucocytes were destroyed. The latter considers the nuclei of the leucocytes to be composed of leuco-nuclein and histon (a kind of peptone). Nuclein (a protein containing phosphorus) causes coagulation; histon prevents it. But calcium chloride combines with histon, setting nuclein free, and thus causes coagulation. Lilienfeld, moreover, regards the blood-plates as identical with the nuclei of the leucocytes, set free by karyoschisis. If corroborated, these theories will explain many incongruous tenets in vogue at the present time. Conformably with this description of the formation of a white throm- bus, the microscopical examination of a clot reveals a ramified frame- structure resembling a (red) coral-growth, composed of accumulated 356 SURGICAL DISEASES OF THE VASCULAR SYSTEM. blood-plates (Aschoff), which appears as an irregular network in any given section of a clot, and is the cause of its “streaked” appearance. In the interstices fibrin threads are seen radiating from the framework, and, in addition, red and white blood-corpuscles (Weigert), the latter of which probably to some extent actively penetrate into the thrombus after its formation (Welch). The further fate of such a thrombus, provided that it remains in situ, and is not invaded by pyogenic micro-organisms, is this: it con- tracts, and finally undergoes the same changes as do the vessel-walls; by which, on the one hand, so-called organization of the clot (by which is meant substitution by connective tissue) takes place, and on the other hand phlebitis is established. This latter consists in the infiltration of all the layers of the vessel- wall with leucocytes and so-called fibroblasts (spindle-shaped, often ramified, nucleated cells, somewhat larger than the leucocytes), derived, most probably, from the endothelia and the external coats. At the same time new vessels are formed, which advance toward the throm- bus itself, originating from the small vasa vasorum supplying the ves- sel-walls. The establishment of this form of phlebitis, through the medium of lesions to the endothelium combined with a diminished rapidity of the blood-current, with thrombus formation, may be traced to any of the following primary causes; irregularities of the inner surface of the vein, such as contractures or unevennesses due to localized dilatations, causing eddies and irregularities in the blood-current; local lesions of Fig. 1610. Blood-Plate Thrombus. (Eberth and Schimmelbusch.) the vessel-walls, chemical, mechanical, or thermal; intoxications by- chemical agents; and, lastly, general impairment of health (Aschoff), Very similar to the infiltration and hyperplasia of the vein-walls as- sociated with thrombosis, is that form of inflammation of the veins con- sequent upon periphlebitis, with only this difference, that in the latter case the thickening of the adventitia is more marked, at least in the earlier stages of the process (Ebeling). The final result of all these simpler forms of phlebitis, in extreme cases, is the substitution of cicatricial tissue for the entire venous tunics (the same fate that befalls the blood clot), so that in those cases where the process is entirely completed nothing remains after the lapse of several months but a fibrous cord. In case the thrombus becomes partly detached and deprived of its nutrition to a great extent, it is apt to undergo calcareous degeneration and petrify, and in this manner the so-called vein-stones or phleboliths are formed. In case organization of the thrombus does not take place, the clot PHLEBITIS. 357 may undergo simple (red) softening, and be carried away as molecular detritus by the blood-stream. An entirely different process, however, from those above described, may be observed the moment pyogenic germs gain access to the vein- walls. If the invasion occurs from without (as in infected wounds), the first condition encountered is a purulent periphlebitis. This condi- tion may extend along the course of the vein and external to it, giving rise to the reddened and indurated cords clinically characteristic of this disorder. As soon, however, as the invasion of pyogenic micro-organ- isms extends through the vessel-walls to the intima, conditions of far greater severity are at once established: necrosis with suppurative in- flammation is produced, and thrombosis takes place in the lumen. But the thrombus thus formed does not undergo organization and absorp- tion as in the uninfected forms of thrombo-phlebitis: it likewise be- comes invaded by the pyogenic micro-organisms, and in due course of time becomes disintegrated by bacterial action. It melts to a yellow, puriform mass, and is subsequently swept away by the blood current, and bearing, as it does, numberless active and virulent germs among its particles, gives rise to numerous infectious emboli in the capillaries of remote organs and causes irreparable mischief. These inundations of the system by infectious material are clinically characterized by severe rigors, and go to make up the clinical picture of pyaemia. During the progress of this disease such emboli may also, in their turn, be the exciting cause of thrombo-phlebitis. Finally, mention may here be made of a morbid condition of the veins, which may be properly classified under the heading phlebitis, although all writers do not consider it an inflammatory process. I refer to phlebosclerosis, a disease recently described more minutely by Sack, and bearing analogy to arteriosclerosis, but one which hardly ever attains the same development or the same importance as the arterial lesion. Phlebosclerosis consists in a fibrous thickening of the inner coat of the vein (endoplilebitis). The thickening may be either diffuse or cir- cumscribed, and is accordingly designated as phlebosclerosis nodosa or cliffnsa. The newly formed tissue lies in the intima, and consists of con- nective tissue, which, however, soon undergoes degeneration, generally hyaline in character, and then may again become disintegrated into fatty and granular detritus, or may calcify (atheroma). The tunica media and tunica adventitia, however, are not unaffected in the later stages of phlebosclerosis, both foci of infiltration with small round cells and recent or cicatrized areas of connective tissue, in which degeneration, hyaline or fatty in character, has taken place, being observed here. The primary cause of these conditions is a weakening of the muscu- lar tone and contractile power of the media, by which secondary com- pensating changes, consisting in the proliferation of the tissues (chronic phlebitis), are induced at first in the intima. Of the varieties of phlebitis other than those described, some forms are ascribed to constitutional disturbances—gouty phlebitis, rheumatic phlebitis (Schmitt). But the greater part are recognized as due to specific infectious agents (tuberculosis, glanders, actinomycosis, and, probably, syphilis and acute articular rheumatism). Tubercular phlebitis, described by Weigert and Muegge, induces in- filtration of the vein-walls with round cells and proliferation of the tis- 358 SURGICAL DISEASES OF THE VASCULAR SYSTEM. sues, with consequent cicatrization or coagulation-necrosis and cheesy degeneration. If this process progresses so far as to affect the intima, ulceration may take place into the lumen of the vessel, in which case cheesy material, accompanied by the tubercle bacilli, is introduced into the blood-current, inundating the entire system and establishing gen- eral acute miliary tuberculosis. Very similar in its pathology is the phlebitis of glanders, which fre- quently causes a generalization of the disease by means of infected thrombi (Israel). In traumatic phlebitis exactly the same conditions obtain as were de- scribed under the head of simple proliferating tlirombo-phlebitis, pro- vided the injury done to the veins is of an aseptic character. After aseptic ligature of the veins, no thrombus is formed, unless an injury of the endothelium is associated with a reduced velocity of the blood- current. Obliteration of the vein is completed b}T newly formed tissue in a comparatively short time, in about five days, on the average. If septic conditions are permitted to complicate the wounds, the vein- walls and the thrombus behave in the manner described on page 0257 in speaking of periphlebitis and purulent tlirombo-phlebitis. Arteritis. The subject of traumatic arteritis has been one of unabated interest and continued research since the first volumes of the present work ap- peared in print, and deligation of arteries in animals has been practised to the present time by various observers as a simple and efficient method of inquiry into the difficult problems associated with this theme. Not, however, until comparatively recently has much attention been given to the influence of antisepsis and asepsis upon the facts under discussion. This now appears as a point of great importance, although some writers deem it of only secondary interest or advisedly dismiss it from view as immaterial. We now know that the pathological changes in an artery after trau- matism vary considerably with the immediate effect of such traumatism upon the blood-current. If the blood-current in an artery be not intercepted for any length of time, as in the cases where ligatures have been tightly applied to the arteries and then immediately removed (Zalin), or where sutures have been laterally applied to the arterial walls after incisions, etc., repair to the injured portions progresses toward restitution without the forma- tion of any appreciable clot whatever. Only in those cases in which a slowing of the current occurs, or is artificially maintained for a time (Jassinowski), do clots appear, and these consist solely of aggregated masses of blood-plates (white thrombus). If, on the other hand, deligation of the artery is carried out with suffi- cient force to interrupt the blood-current, the formation of a blood-clot is dependent upon the fate of the endothelial lining of the artery. If this retains its vitality no clot is formed; if it loses its vitality a red thrombus is formed of the stagnant blood in the immediate vicinity of the ligature, aud reaching, on its proximal side, to the next lateral branch, however small or microscopic in size this may be. ARTEKITIS. 359 Now, generally speaking, deligation of an artery is practised in such a manner that the inner coat of the artery is injured or ruptured; and in these cases we have the formation of a (red) thrombus and definite occlusion of the vessel by substitution of this thrombus by newly formed tissue. But it is possible to tie the ligature about an artery in such a man- ner that no laceration of the inner coat is produced; and it is now sufficiently well established experimentally, that aseptically conducted deligation of arteries does not necessarily cause the death of the endo- thelium (Weigert). In such cases we have occlusion of the vessel by proliferating endarteritis alone, as well as by the immigration of leuco- cytes from the nearest vasa vasorum, without the formation of a clot (Landerer). We may, therefore, sum up our present knowledge in the proposition, that clotting takes place only when damage to the endothelium is asso- ciated with a too rapid current, and that, generally speaking, the size of the blood-clot is in inverse proportion to the asepticity of the proce- dure. It must not be imagined, however, that unanimity in these questions has been arrived at by all experimenters. Many results differing from the above have been recorded in the literature of this subject (Ballance and Edmunds, Delepine and Dent, Arnaud, etc.), which for the present must be ascribed to variations of technique. The effects of atrophic changes in the endothelia due to ligature-pressure, upon the formation of a clot, likewise require more elucidation. Repair or definitive occlusion after an injury to an artery, without the formation of a clot, then, begins by the proliferation of the single layer of cells of the endothelium, which embryologically belongs to the con- nective-tissue group (His), with karyokinesis. This occurred, in the cases observed by Pick, on the fifth day. In this manner buds and spurs were formed projecting into the lumen of the artery (eighth day); flat and spindle cells appeared in great numbers, all showing mitoses, which now occurred also in the media and in the adventitia as well. Infiltration with round cells, however, was mostly limited to the outer coat. By the eighth day the blood, hitherto unchanged in the lumen of the vessel, began to undergo granular disintegration. Karyokinesis continued with unabated vigor till after the twentieth day, when the lumen was almost entirely filled with proliferated elements of the intima. In those cases, on the other hand, in which a clot is formed after liga- tion of an artery, from the causes mentioned above, the definitive obliteration of the vessel progresses simultaneously with the substitution of the clot by newly formed tissue. On this point all writers are agreed. But until recently there has been much discussion on the more minute histological processes involved in this transformation. While one school of pathologists believed that the leucocytes enclosed in the thrombus led to its organization (Virchow, Weber), others at- tributed the tissue-change to the white blood-corpuscles emigrated from the vasa vasorum (Cohnheim, Ziegler), and still others held that the tissue substituting the thrombus originated by proliferation from the cells of the intima (Waldeyer, Thiersch). 360 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Of late, however, Apollonio appears to have adjusted these discrep- ancies more satisfactorily. Examining a large number of arterial liga- tions in animals by means of series of sections, and staining the mitoses, he found that in various portions or sections of the ligated arteries en- tirely different tissue-elements took part in the organization of the thrombus, as well as in the repair of the arterial walls. In the neigh- borhood of the ligature, atrophy of the vessel-walls took place, and re- generation and organization of the clot was effected by leucocytes. In sections more removed from the ligature, however, but occurring in the same artery, where the intima adjoining the portion undergoing atro- phy was stimulated to proliferation, the organization of this part of the clot was due to the proliferation of the intima. The conclusion drawn from these observations is that any histological element capable of pro- liferation may take an active part in the organization of a blood-clot, a conclusion which not only at once unites all the dissenting views of numerous accurate observers, but one which is substantiated in some particulars by observations less generally accepted. Thus Warren declared that muscle-elements could take part in the organization of the thrombus, a point which had once been maintained but was afterward again abandoned by Zahn. The remarks made thus far pertain to traumatic arteritis in healthy tissues only, and it is apparent that the process encountered, of infiltra- tion and proliferation with new vessel-formation and cicatrization, is more characteristic of the course of repair, than of inflammation proper. With the neglect, however, of precautions to preserve the field of experimentation free from infections or chemical irritations, more serious inflammatory reaction may be observed; and suppuration and necrosis may be induced through the introduction of a contagium vivum into the wound. In such forms of traumatic arteritis of a septic nature, greater num- bers of emigrated leucocytes are found, with copious fluid extravasa- tion, gelatinous in character and not spontaneously coagulable. Here, too, reproduction of tissue elements takes place. The wall of the artery presents a cloudy appearance, assumes a brownish-yellow color, loses its consistency, and finally, being permeated by immense numbers of round cells, melts, and is dissolved into pus, or succumbs to necrosis in irregular shreds and particles. The thrombus shares the same fate; it is turned to a yellow or brownish pulpy mass through the action of micro-organisms, and may become more or less putrid. Embolism of virulent septic matter may occur through the melting of the thrombus, or secondary hemorrhage may be caused by the sudden yielding of an occluding clot in the lumen of an artery. Septic emboli may reproduce this picture of septic arteritis in remote vessels. Perfectly analogous to the forms of traumatic arteritis just described, are the other forms of arteritis of non-traumatic origin, and this anal- ogy has become more marked with the tendency to assume some damage to the tissue as the immediate cause of inflammatory conditions in the economy. In this way not only the simpler idiopathic forms of acute arteritis are viewed at the present time, but also those chronic changes which affect principally the internal coats, and are classed in many handbooks ARTERITIS. 361 on pathology, not as inflammatory but as degenerative processes: I re- fer to arterio-sclerosis and atheroma. Simple hyperplastic arteritis is observed in connection with throm- bosis (when some damage to the endothelium has been associated with a slowing of the blood-current), and consists in an infiltration of all the coats of the vessel-walls, both with round cells extravasated from the vasa vasorum and from neighboring vessels, and with spindle-shaped or digitated nucleated cells, so-called fibroblasts, emanating from the endothelial and peripheral connective tissue. New vessels are also formed, and push inward into the thrombus. In time new connective tissue is produced by which the thrombus is replaced. After a long interval of time the intima alone appears thickened and hyperplastic. Arterio-sclerosis, in its first stage, is now considered as a reactive in- flammatory proliferation of the tissues of the intima, due to damage done to the walls of the vessel. Such damage may be caused by simple senile weakening of the tissues, as well as by chronic pathological con- ditions, such as chronic nephritis; the results of infections, as acute articular rheumatism, endocarditis, typhoid fever; or chronic poisoning with alcohol, lead or mercury, and syphilis. Thoma lias pointed out that the muscle-elements of the media were the first to suffer damage, and that this impaired the elasticity and led to a functional deficiency of the me- dia, which was compensated by hyperplastic changes in the inti- ma. Tissue-proliferation and in- flammatory areas are, neverthe- less, frequently found outside of the intima, in the media and ad- ventitia, as well as at the primary seat of damage. At a comparatively early period, however, the newly formed con- nective tissue undergoes hyaline degeneration, with granular and fatty metamorphosis, mucin-for- mation, or calcification, and in areas of complete necrosis masses of fatty detritus result, which may open by ulceration into the lumen of the artery. Atheroma is said by Thoma to originate from the necrosed, newly formed connective tissue, having first undergone hyaline degeneration. If these simpler forms of arteritis just described may be considered analogous to simple traumatic arteritis, we might look for a further analogy to the septic suppurative form of traumatic arteritis in the re- maining undescribed forms of infectious arteritis, such as the syphilitic and the tuberculous (Fig. 1611). The analogy, however, is only one of etiology, and, for a description of arterial syphilis the reader is referred to Vol. III. of the present work; while the remarks made on tuberculosis of the veins on page 0257 apply as well to that of arteries. Fig. 1611. Tuberculous Arteritis. (Ziegler.) 362 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Varix. In spite of the large number of new studies that are added each year to the extensive literature of varicose veins, our knowledge as to the morbid condition which is the primary cause of varix-formation ad- vances but slowly. The proliferation of tissue which causes the veins to become longer than is normal, and therefore to appear tortuous and serpentine, still remains an obscure factor in the pathology of the dis- order. Another factor, on the contrary, that of dilatation of the lumen and changes of thickness in the walls of the veins, has received consider- able elucidation by the work of Epstein, which has more recently been corroborated by Sack. It now appears that two conditions must be in force simultaneously in order that varices be formed; first, increased local blood-pressure and embarrassment of the return circulation, and, second, some spe- cific pathological condition as yet not satisfactorily defined. Von Lesser could not induce varicosities in animals by increasing the blood-pressure alone with the help of injections of plaster-of-Paris, and was therefore led to assume that the process active in the formation of varices was analogous to the growth of a tumor; and he believed this theory confirmed by the discovery, made by means of injections, that varicose veins were most generally situated superficially to the lym- phatics, and were therefore, in most cases, simply enlarged veins of the skin. Epstein made a special study of ectatic veins, and found that the cirsoid and varicose phlebectasiae of the lower extremities sliowred ana- tomical changes in all the coats of the vessel-walls. The tunica media generally shows an eccentric hypertrophy, which in great degrees of dilatation becomes an eccentric atrophy of the muscularis; oftentimes, however, atrophy of the muscular coat may be observed with only moderate dilatation of the lumen of the vein. The media and adventitia present increased vascularization and a vary- ing infiltration with small round cells, while in the intima fibrous endo- plilebitis occurs, evidently compensatory in character, and analogous to plilebo-sclerosis. Epstein, therefore, believes that the primary cause of varix is the decreased resistance in the middle or muscular tunic, and considers the mechanical factors merely secondaiy in importance. In accordance with these views he sketches the course of the develop- ment of varicose veins as follows: (1) loss of resistance in the tunica media; (2) dilatation of the lumen; (3) compensatory endoplilebitis; (4) eccentric hypertrophy; (5) (incases of greater dilatation) eccentric atrophy. The infiltration in the outer tunics is of the character of reparative inflammation. The predisposing causes of varix formation are general disorders of nutrition, and similar to those of phlebo-sclerosis (see page 0257). Ben- nett, who in addition to the element of pressure is fain to accept some factor at present unknown to us, ascribes the formation of varicosities in some cases to congenital defects in the venous apparatus, and even attributes these to hereditary influences. This element of heredity is brought forward by other writers as well (Fischer); and Soboroff lias VARIX 363 shown that the histological structure of the veins differs as to thickness and strength in various individuals from their birth. If we accept the foregoing views, we are led to consider the treatment of varicose veins from two main standpoints. If the formation of varix is due to the combination of continued augmented pressure with a morbid condition of the vein-walls, we will not expect a radical cure from the elimination of only one of the factors which go to make up the disorder, but will endeavor to combine a systemic treatment with some proceeding, palliative or oj)erative, to eliminate the local discrepancy in equal distribution of pressure. And, in point of fact, we know by long experience that most methods aiming at a radical cure, which have only attacked the one factor of undue pressure, have proved futile, in that a recurrence after a longer or shorter interval has been observed, about two years on the average. Notwithstanding these theoretical conclusions, we find a great in- crease in the number of operative measures employed for the radical cure of varicose veins, keeping pace with the advances in antiseptic and aseptic methods. The procedures most generally favored at the present time are mul- tiple ligations, subcutaneous (Scliede, C. Phelps) or open (Bennett), of the varicose veins; excisions of more or less extensive portions of the dis- eased veins (Madelung); and the ligation of the trunk of the saphena (Trendelenburg). The latter method is advised onl}r for cases where the saphenous trunk is enlarged as well as its branches. A new palliative method has been devised by Landerer, who occludes the enlarged veins by means of pressure exercised by parabolic springs with pads filled with water, worn around the leg after the manner of a truss. INJURIES AND SURGICAL DISEASES OF THE LYMPHATICS. BY CHARLES B. NANCREDE, A.M., M.D., PROFESSOR OF SURGERY AND OF CLINICAL SURGERY IN THE UNIVERSITY OF MICHIGAN; EMERITUS PROFESSOR OF GENERAL AND ORTHOPAEDIC SURGERY IN THE PHILADELPHIA POLYCLINIC, ETC. General Considerations. The superficial lymph-plexuses are so numerous, and are so situated, that poisonous antiseptic solutions must be employed with caution when applied for long periods to extended skin surfaces; for a similar reason the external application of germicidal substances beneficially influences the course of some varieties of lymphangeitis. Again, very slight fric- tion—even none that can be appreciated—may cause the penetration of organisms into the superficial lymphatics, giving rise to so-called dissec- tion and post-mortem wounds, where in reality no solution of continuity exists. There can be no doubt of this fact, since the cutaneous form of erysipelas, that is, a reticular lymphangeitis, has been produced by rub- bing pure cultures of the streptococcus into the unabraded skin, while, clinically, such cases as that of Sir James Paget’s occur from time to time. Exception must be taken to the statement of Mr. Bellamy, that the “outpoured lymph” from a wound “becomes ultimately developed into the bond of union whereby reparation of the injured tissue chiefly comes about,”1 since modern investigation certainly has long since shown that the coagulable lymph of wounds is not the same as the lymph in the lymph-vessels, but that the proliferated cells of the two sides of the wound, fusing, become vascularized and develop into scar tissue. Traumatic Affections of Lymphatcs. Traumatic Lymph-Cysts.—This is the condition described by Morel- Lavallee as a “traumatic serous effusion,” and is believed by Gussen- bauer and Kohler to result from subcutaneous rupture of lymphatic vessels. These soft, rounded, ill-defined tumors contain a fluid identical with lymph. 1 Vol. III., p. 27. 365 366 INJURIES AND SURGICAL DISEASES OF THE LYMPHATICS. Traumatic Lymph Fistula.—These occur chiefly7 in the neighbor- hood of joints, as at the fold of the elbow, on the inner side of the thigh, near the ankle in front of the malleoli, and in the neck. Wounds are more apt to be followed by fistula) when pre-existing lyTmpliatic dila- tation is present. S. Georgjovic, analyzing 28 cases of wounds of lym- phatic trunks, found that 5 involved the thoracic duct, G followed bleeding, 2 resulted from opening buboes, 9 followed incisions or punctures, while the remaining 6 were caused by the opening of ab- scesses or the removal of tumors. Treatment.—Antiseptic tamponnade, or digital pressure, suffices for recent cases. Leudesdorf obtained a success by maintaining digital compression for eight hours. When failure follows compression applied chiefly below the fistula—as is commonly7 recommended—direct pressure over the fistulous opening should be tried, remembering, however, that in some cases this method produces retention of lymph, oedema, and repeated abscesses. In old cases the use of iodine, caustics, or the hot iron, to destroy the indurated margins of the fistula, may have to pre- cede and supplement pressure. Rupture of the Thoracic Duct.—Divesting the report of all de- tails not pertinent to our present purposes, the following is a typical case of the fatal result which too often follows from this accident, while it proves the correctness of Mr. Bellamy’s statement that death is often postponed for a long time:— A man, aged 28, had his thorax violently compressed. On the seventeenth day a fluctuating swelling was detected in the inguinal region, which gave vent, upon incision, to offensive gas and a faecal-like fluid; but in a few days all odor ceased, and the discharge became milky in appearance. Such rapid emaciation ensued (four pounds daily), that twenty-two days subsequently—that is, on the 38th day from the accident—the man died of inanition. After death it was found [the point of interest for my present purposes] that a cavity, formed by dissecting up the right pleura posteriorly, extended from the apex of the thorax to the dia- phragm, and contained a similar milky fluid to that which had escaped from the fistula during life; an opening was detected in the thoracic duct where it passed through the aortic opening in the diaphragm, thus explaining the two routes pursued by the chylous extravasation.1 Of the seventeen cases in Kirchner’s list, the cause of injury was twice contusion of the chest; once each, puncture, incision, and shot- wound ; thrice ulceration following suppuration, while in the remaining nine the cause was not made clear. Chylothorax resulted in nine cases, chylous ascites in six, one was a doubtful instance of mediastinal extra- vasation, and the remaining one was due to an operation wound inflicted near the terminal portion of the duct. Symptoms.—These depend upon the location and extent of the extra- vasation ; thus a patient of Krabbel's died on the 5th day from compres- sion of the lung by an extensive chylothorax; one of Kirchner’s patients developed an increasing dyspnoea from a pleural effusion, which upon aspiration proved to be chyle, improvement, followed by recovery, taking place. Rapid emaciation and death from inanition must sooner or later supervene unless the opening becomes occluded, or unless a double duct, or a variation in the method of formation of the duct, admits of a 1 Alvin Eyer, Med. Record, Aug. 1, 1891. LYMPHANGEITIS. 367 collateral lymph circulation becoming established. Small experimen- tal wounds in animals have been found to heal, the same result being of course possible in the human being. Treatment.—I have seen in consultation two cases of chylous ascites caused by the pressure of enlarged lymphatic glands which probably led to rupture of the receptaculum chyli or a large lymph trunk, though in neither, at the post-mortem examination, could any opening into a lymphatic vessel be demonstrated. One patient died after repeated tappings from exhaustion, and the other from the same cause after an apparently successful abdominal section with drainage, all chylous fluid having soon ceased to flow*, doubtless owing to occlusion of the leaking vessel by plastic peritonitis. The operation was done with this end in view, and, as far as one case goes, suggests the propriety of abdominal section with antiseptic packing and drainage under similar circum- stances. Treatment of Wounds of Large Lymphatic Trunks.—With our present knowledge of the germicidal power of carbolic acid, but still more on account of its irritant effects, the advice to apply pressure “ by a suitable compress, . . . soaked in a lotion of carbolic acid (1 to 40)” should be substituted by the recommendation to employ a thoroughly aseptic pad after dusting with aseptic iodoform or the interposition between the wound and compress of some protective whenever carbolic acid, corrosive sublimate, or other poisonous germicide is used. Four cases of accidental wound of the thoracic duct, inflicted while removing cervical tumors, have been collected by Keen.1 These show* what should be done in the way of treatment: one patient recovered after imme- diate antiseptic tamponnade of the wound, and another after the appli- cation of pressure-forceps for three days to the tissues forming the exter- nal orifice of the fistula (a secondary operation). Keen detected a wound one-fourth of an inch long in a tube one-eighth of an inch in diameter, and sewTed it up with fine silk, employing drainage for a few hours and then closing the wound. The patient returned home in eight days. Lymphangeitis. The division into simple and septic lymphangeitis may be an excel- lent one clinically, but the idea implied that one occurs without the presence of germs, and that the other results from the action of micro- organisms, is incorrect. All forms of lymphangeitis, even the most typical reticular variety,1 result from the presence in the lymph vessels of some one of the pyogenic organisms. The “wandering” form of Curnow, or what Rosenbach has described as “erysipeloid,” has been shown by the latter to be due to the invasion of the superficial lym- phatic plexuses by a specific thread-forming, spore-producing micro- organism which is derived from decomposing animal matter. The pres- ence of micro-organisms in the lymphatics induces the formation of clots, which usually incompletely block the lumina of these vessels. 1 New York Med. Jour., vol. lix., pp. 569-572. 2 F. Fischer and E. Levy, Verhandl. Deutscli. Gesellseh. f. Chirurg., XX. Congress, 1892 (Annals of Surgery, vol. xv., p. 488). 368 INJURIES AND SURGICAL DISEASES OF THE LYMPHATICS. The entire absence of any such thrombus has beeen suggested as a cause of the rapid spread in certain hyper-acute cases, a clot acting for a time as an obstacle to the further progress of the disease. The possibility of infected lymphatic emboli becoming a cause of sec- ondary pysemic deposits must not be overlooked. The same'germs which initiated the primary suppurative focus are found enclosed in the lymph- thrombus. The endothelial lining of the vessels has been described as completely preserved,1 or as at first thickened, then desquamating in patches, and finally disappearing throughout the extent of the diseased portion of vessel.2 The vessel-walls are thickened from infiltration with round-cells, and a similar slighter infiltration is detectable around the capillaries. When suppuration occurs, the usual changes take place both in the thrombus, in the altered wall, and in the perivascular infil- trate. In all “ lymphatic abscesses” micro-organisms are invariably found, the suppuration resulting from either a simple or a “mixed in- fection,” when more than one form of germ is present; the bacillus coli communis even has been detected as the sole pyogenic organism. Superficial wounds involving the complex plexuses of the deeper epi- dermic layers, those of the true derm or the subcutaneous tissues, are most apt to give rise to lymphangeitis. Although nearly always fol- lowing a wound, lympliangeitis may occur without any visible lesion of the skin, but ATerneuil contends that this results from the “interstitial auto-infection” produced b}T germs present in the uninjured skin (Staphy- lococcus epidermidis albus of Welch?). Still further, Jouet8 points out that sometimes many days or weeks after cicatrization of the wound which gave entrance to the infective organisms, a lympliangeitis may commence, going on to enlargement of the neighboring glands or even to suppuration (lymph angites tardives). Simple lympliangeitis may also occur around neoplasms, the avenues for the entrance of the ordi- nary micro-organisms being afforded by lesions of the tumor, the in- flammation resulting from these and not from infection by the tumor elements. Skin diseases frequently give rise to attacks of lympliangeitis, but this affection rarely originates in any but one of the suppurative forms. The environment and the habits of the patient exercise a marked in- fluence upon the initiation of the disease, and upon the supervention of the graver accidents, such as suppuration or gangrene. Diabetes is supposed to exercise much influence in this direction, but it is very doubtful whether this disease especially predisposes to inflam- mation of the lymphatics. Chronic alcoholism and overwork certainly appear to favor the occurrence of the graver forms. Unfavorable hygienic surroundings such as overcrowding, dampness, insufficient food, overwork, and lack of cleanliness unquestionably ex- plain how overlooked or trivial abrasions may be sufficient to give en- trance to micro-organisms in such numbers of cases, commencing at or about the same time, as to give rise to the idea that lympliangeitis may be epidemic.4 What has already been said will serve as introduction to the following paragraphs. The differing results from the same poison are to be explained by the 1 Ibid. 3 Ibid., p. 649. 4 Ibid., p. 650. 2 Duplay et Reclus, Traite de Chirurgie, tome i., p. 651. 369 LYMPH AXGEITIS. condition of the tissues': thus, if of normal vitality, they can certainly resist a considerable number of germs; if their vitality be lowered, but few of the same germs are requisite to produce serious consequences; of course, given an enormous dose of germs, no condition of tissues howsoever healthy can inhibit their development. The time at which a dead body can convey an infective and therefore dangerous form of lym- phangeitis, is before putrefaction is well established—that is, the more recent the death the greater the danger—because the infective germs thrive and multiply only in living tissues, while the septic germs can develop only in dead or dying tissues; hence the introduction of the latter into an ordinary dissecting or post-mortem wound can only pro- duce a local irritation from the accompanying ptomaines; the germs themselves cannot multiply in the living tissues. The slow development of septic lymphangeitis results not from “the slow nature of the lymphatic circulation,” but because the germs re- quire a certain time for their diffusion along the lymph-vessels, for their multiplication to the point at which their numbers are adequate to overcome the vitality of the parts, and for a sufficient amount of ptomaines or toxalbumoses to have been elaborated to produce the con- stitutional reaction. Certain rare cases exist, such as one mentioned by Berthod, where the point of infection is at the elbow, and yet the lymphangeitis de- scends, and suppuration occurs in the forearm; Berthod explains this on the anatomical ground of the presence of recurrent lvmph-vessels.2 The rapidity with which a septic lymphangeitis may develop is shown by a case of Hunter's, mentioned by Crooksliank, where, after a puncture, redness extending to the axilla, swollen and painful glands, with a chill, all occurred inside of a few minutes. Weber3 relates a similar case, and I have myself seen one where the axillary lymphatic engorgement was so great within about three hours as to cause marked tingling and numbness in the median and ulnar nerve distri- bution. The role played by lymphangeitis in plegmonous processes, whether circumscribed, diffused, or visceral, can hardly be exaggerated, since cellulitis of an extremity is always consecutive to lymphangeitis, the connective tissue being infected by two routes—(1) indirectly, by the lymphatic vessels, and (2) by the direct inoculation of the connective tissue (that is, lymph-spaces) by germs deposited in these by the vulner- ating body. According to Cornil and Babes, at the first spot in which the bacteria multiply there occurs softening of the surrounding tissue, an irritation marked by a neuro-paralytic dilatation of the capillaries and by diapedecis of lympli-cells, constituting already a small abscess (this is where direct inoculation of the connective tissue has occurred). In- flammatory reaction then ensues with diffusion of the micro-organisms in the interfascicular lymph-spaces, whence they enter the lymphatic and blood capillaries. A more or less distant point is thus invaded, and then in succession new collections occur, which unite to form diffuse infiltration in a larger or smaller abscess. 1 It is not due to a “mortification” which “takes place in the vital endowments of the septic organism, whereby it acquires a parasitic habit which enables it to breed in tissues of degraded vitality, or even in the healthy tissues, ” as stated by Mr. Bellamy, who quotes from Roberts. See Vol. II., p. 30. 2 Abstract from Gaz. Med. de Paris, 1884, in Annals of Surgery, vol. i., p. 369. 3 Duplay et Reclus, tome i., p. 656. 370 INJURIES AND SURGICAL DISEASES OF THE LYMPHATICS. Suppurative Lymphangeitis.—This occurs in many forms. Toward the termination of a reticular lymphangeitis, little rounded purulent elevations of the epidermis occur, such as form the popularly termed “run-arounds” at the root of a finger-nail. Again, deeper in the derm small purulent collections may form. In ordinary tubular lymphan- geitis a series of painful, indurated spots form in the course of the lymph-vessels, which appear successively, do not point as an acute abscess does, but form rounded, fluctuating spots which if opened give vent to a greater quantity of creamy pus than the appearances would indicate. Occasionally the pus resembles more that of a cold abscess, and small sloughs may be detected. Sometimes the number of these purulent collections is great, one case having been reported by Clias- saignac with 21; a second, by J. Roux, which required 33 incisions, in a patient on whom two years before, for the same trouble, 22 incisions had been made.1 Cicatrization usually readily occurs. While often multiple, there may be only one or two abscesses, and they may even, in rare instances, disappear by absorption.2 Unless followed by a lymph-fistula they usually heal rapidly after evacuation. In a certain number of cases, much larger circumscribed abscesses may form as the result of a circumscribed perilymphangeitis. Again the relation between diffuse cellulitis and suppurative lym- phangeitis must not be overlooked, for at times, instead of circumscribed collections of pus, this is diffused first along the whole extent of the peri- lymphatic tissues, whence step by step it infiltrates the cellular tissue until a widespread purulent collection has formed, distending the skin. This, stripped off and deprived of its vascular supply, sloughs; it is a mere step from this to the further involvement of the intermuscular cellular planes, and diffuse cellulitis of the whole limb. The fistulse occurring after multiple suppuration along the course of lymphatic trunks, usually open at the position of the lowest abscess. A button of granulations, covered by white or yellowish clots of lymph, usually marks the site. The flow is continuous, drop by drop, but is increased by standing—especially if in the lower extremity—walk- ing, or straining, and may even jet out if pressure be exercised upon the vessel. The amount poured out is said to be less than when the fistula results from damage to a lymph-gland. Fistulse resulting from suppuration opening into a lymph-trunk usually close in the course of a week or ten days, but they may persist, especially on the penis. Complications.—Phlebitis, bursitis, and arthritis are far less uncom- mon than is usually believed, while peritonitis and pleuritis may occur, if the view is correct that ly mphangeitis and erysipelas are closely allied if not identical diseases, manifesting their morbid action in somewhat different tissues. Albuminuria is occasionally observed, probably re- sulting from renal congestion produced by the effort to eliminate mi- crobes or ptomaines. Richet was compelled in one case to cut subcuta- neously the contracted lymphatics at the bend of the elbow, as they interfered with its movements. Uterine Lymphangeitis.—I cannot agree with Mr. Bellamy that septic uterine lymphangeitis “is invariably fatal,” because this disease must result from germs and the ptomaines, toxalbumoses, etc., elabor- 1 Ibid. 2 Ibid. LYMPHANGEITIS. 371 ated by them, which can only prove fatal if a vital depravation of the tissues, either primary or secondary, render them efficient; wherefore I believe that a prompt disinfection of the uterine cavity upon the first onset of suspicious symptoms will in some cases reduce the number of germs to a point compatible with successful resistance by tissues, even of lowered vitality. Deep Lymphangeitis.—This may follow a similar affection of the superficial trunks. Symptoms.—When attacking the deep vessels from the start, pain is first felt in the course of the lymphatics, along which a deep knotted induration can be detected, tender on pressure. The glands are swollen, and sometimes there is a little oedema. The skin, at first normal, shows here and there reddened spots overlying the indurated masses. At times the superficial vessels now become in- volved. Suppuration may either give rise to deep-seated, diffused sup- puration, with all its profound septic complications, or may result in deep, circumscribed abscesses, which may even be situated at some dis- tance from the primary inflammatory focus. Treatment.—Beyond what has been mentioned by Mr. Bellamy, and a caution as to much more rigid asepsis and antisepsis than he has in- culcated, I would merely suggest the propriety of the constant applica- tion of weak antiseptic lotions, and possibly the adoption of Hueter’s advice to inject small quantities of a 2 or 3 per cent, solution of carbolic acid along the course of the affected vessels.1 The constant application of an ointment of ichthyol, 25 per cent., seemed to me of value in one case. Gangrenous Lymphangeitis.—This chiefly attacks the lower ex- tremities and commences as an ordinary lymphangeitis, but the general condition is from the outset grave, as shown by the occurrence of chills, high temperature, prostration, and early delirium. On the second or third day small bullse form, which afterward fuse into larger ones, or a large one may exist surrounded by a circle of smaller ones, all filled with fluid, transparent or variously tinged with blood. The early rupture of the vesicles reveals the previously dead derm, pultaceous, whitish or red- dish-brown, then greenish or black. The gangrene often extends pe- ripherally, and may destroy considerable skin, the depth of the eschar varying from the superficial layers to the whole thickness of the skin. Oftentimes a diffused phlegmonous inflammation supervenes, frequently terminating fatally. A. M. Jalaguier, who has most carefully studied this disease, distinguishes three forms: (1) A grave form, dangerous from the spreading tendency of the gangrene and from the systemic condition; (2) limited gangrene, but a form where the systemic in- volvement is most grave; (3) a benign, circumscribed gangrene, with relatively mild constitutional symptoms, where recovery most often ensues. Treatment.—This must be actively antiseptic, and Jalaguier advises puncturing of sloughs and evacuation of pus, etc., by means of the hot iron rather than the knife, as less likely to lead to renewed infection. 1 As to the advantages of absorption of antiseptics kept applied to the skin, see Annals of ;Surgery, vol. iv,., p. 429. 372 INJURIES AND SURGICAL DISEASES OF THE LYMPHATICS. Tubercular Lymphangeitis.—That this disease primarily attacks the lymphatics of the limbs has only comparatively recently been dem- onstrated, it having been confounded with chronic lymphangeitis. In the reported cases, inoculation-tuberculosis of the skin has nearly always given rise to tubercular lymphangeitis. Thus, it has followed a case of anatomical tubercle; a tuberculous verrucous patch on the dorsum of the hand; nodules on the digits, etc.; but occasionally a more deeply seated focus has given rise to it, as in the forearm, from fungous synovitis of the carpal sheaths. Pathological Anatomy.—Thickened, nodular, of a yellowish-white, the vessels form small knotted cords, the nodules subsequently caseating and forming tubercular abscesses. The walls are at first infiltrated with embryonal cells, and the vessel is surrounded with a wide zone of similar elements; afterward, when the nodules are completely formed, although chiefly due to the perilymphatic exudate, they project into and narrow the lumen, causing stagnation of the lymph which partially coagulates, is yellow, and of a caseous appearance. Microscopically, a caseated centre surrounded by giant-cells and bacilli is always found.1 Symptoms. —These are slow and progressive in their development. There may be violaceous red streaks extending in the course of the lymphatics from the original lesion to a varying distance up the limb, but as a rule the skin is not reddened, only an elongated, indu- rated cord being sensible to the touch, although sometimes also visible to the eye, with nodular masses located at different points. The nod- ules, at first small, are clearly subcutaneous, rounded, firm and sharply defined, but as they enlarge the skin becomes adherent, they stand out in relief, becoming even as large as an egg or small orange, and soon soften. Connecting these are the hardened, cord-like lympli-ves- sels which at a later period may present fluctuating points. The knotted cords may extend the whole length of the limb, but often, as in the hand, the disease ceases at the wrist. The glands are attacked, but rarely become much enlarged, nor do they usually soften. The skin over the softened lymphatic nodules thins, finally yielding to give vent to agru- mous pus, leaving irregular, crater-like ulcers, with violaceous, thinned, undermined edges. If not cured by treatment, involvement of the glands will follow, and, finally, a generalized tuberculosis. Diagnosis.—In its typical form this can hardly be confounded with anything but syphilitic gummatous lymphangeitis, but the location and the coexistence of other syphilitic lesions, the more diffused and flattened form of the nodules, and the response to treatment, should re- solve all doubt. Treatment.—Prompt, early, thorough removal, by the knife and cu- 1 Duplay et Reclus, op. cit., p. 275 et seq. The following may be consulted :— LannelongUe, Societe de Chirurgie, Fev., 1880; Weigert, Die Verbreituug des Tuberkel- giftes nacli dem Eintritt in den Organismus, Jahrbucli f. Ivinderheilkunde, 1886, Bd. xxi. ; Weichselbaum, Wiener medicinische Wochensclirift, 1884, Nos. 12undl3; Merklen, Societe medicale des hopitaux, 12 juin. 1885, and Annales de Dermatologie, 1888 ; Martin du Magny, TliSse de doct., Lyon, 1887 ; Birch-Hirschfeld, Die Geschwlllste der Lympligefasse, Lehrbucli der p'athologischen Anatomic, 1887 ; Hanot, art. Phthisic, Dictionnaire de medecine et dc chi- rurgie pratique ; Sanchez, de doct., Toledo, 1887; Tuffier, Un fait d’inoculation tu- berculeuse chez l’homme, Etudes experimentales et chirurgicales sur la tuberculose (Verneuil), 1888; Morel-Lavallee, Scrofulo-tuberculose de la peau, Ibid. ; Lef£vre, Sur la tuberculose par inoculation cutanee chez l’homme, These de doct., 1888. I must express my indebtedness to the work of Mm. Duplay et Reclus for all that is given in this section. LYMPHANGEITIS. 373 rette, of the fistulous openings together with the related glands, is the best practice, although injections with iodoform have proved successful, violaceous cicatrices being left at the site of the nodules; but relapses not uncommonly occur, or new foci develop at other points along the lymph-vessels. Probably the injection of proper doses of Vaughn’s “nuclein”1 and the internal use of iodine would prove useful suc- cedanea. Venereal Lymphangeitis.—This may be simple or specific. Simple venereal lymphangeitis may result from any source ad- mitting of infection by pyogenic germs of either a chancre or chancroid, although very rare in the former. There is also apparently a gonor- rhoeal form, from the gonococcus, although this has not yet been dem- onstrated by bacteriological examination; but whether caused by the gonococcus or, more probably, by the ordinary pyogenic germs, at times a varicose condition remains, leaving the skin rugous, mammil- lated and roughened like that of an orange, presenting scattered vesi- cles. If the lymphatic trunks have been involved they are tortuous and beaded, the enlargements being translucent; lymphatic fistulte may even result. Specific venereal lymphangeitis is a very rare complication, and sel- dom ends in suppuration. It starts ordinarily about the eighth day, showing itself probably by red, ribbon-like streaks upon the dorsum of the penis, with a twisted, knotty, and hard linear median induration; oedema of the prepuce and phimosis follow. Should suppuration occur, several small rounded masses form, which once opened leave fistulous tracks and persistent ulceration, the discharge being inoculable pus identical with that from a chancroid. Treatment: This at first is similar to that of the simple variety; afterward that proper for chancroid. Tertiary Syphilitic Lymphangeitis.—This occurs in two forms, of which the first occurs late, from three to thirty years after infection, and is often located on the genitals near the original seat of the primary lesion; or, again, these cords may connect many gummatous lymph- glands. The cords are hard, rounded, or flattened and slightly irregu- lar, but almost cylindrical. They may sometimes be united into bun- dles by surrounding induration, rendering their isolation impossible. Interference with the genital function may ensue from their contraction, producing lateral curvature of the penis. The second variety is a gummatous lymphangeitis of the skin, as in a case of M. Lailler’s, presenting a series of projecting, elastic, flat- tened projections, with their longer diameter corresponding to the long axis of the member and connected together by an indurated cord or band. 2 The treatment resolves itself into that of the tertiary period of syphilis. Treatment of Adexitis.—If this affection be the result either of the direct transmission from the infected area of microbes, or theoreti- cally—as in simple contusions—from the absorption of the retrograde products of tissue metamorphosis which so lower the vitality of the gland-tissues that localization of microbes elsewhere gaining access to 1 The Germicidal Action of Nuclein, by F. C. Vaughn, M.D., F. G. Novy, M.D., and C. T. McClintock. M.D., Medical News, May 20, 1893. 2 Duplay et Reclus, Traite de Chirurgie, tome i., p. 675. 374 INJURIES AND SURGICAL DISEASES OF THE LYMPHATICS. the blood is effected, the first therapeutic indication is to prevent fur- ther absorption of the cause, that is, to treat the infection atrium.1 The advice given by Mr. Bellamy, in other respects excellent, should be altered to read “aseptic evacuation of pus, followed by rigid antiseptic methods in dressing.” Thorough curetting of abscesses resulting from lym- phangeitis and, after disinfection, packing with iodoform gauze, will often develop such healthy granulating surfaces that, in a short time after the packing has been removed, fusion of the surfaces will readily occur if they are maintained in contact by compresses. Lymphangeioma, etc.—In many instances these conditions are con- genital in origin, possibly the result of mechanical obstruction or block- ing of the lymph-current by inflammations arising during intra-uterine life. Those really of post-natal origin are mechanical obstructions due to thrombosis or cicatricial contraction following inflammation, to the pres- sure of tumors, or to the blocking of lymph-vessels by neoplastic growths (carcinoma, tubercle), or by the filaria sanguinis liominis. Treatment.—When circumscribed, removal by the knife; when col- lateral circulation can occur, in the diffused forms, much relief from the oedema may be secured by elevation, by the elastic bandage, and by mas- sage ; if stasis cannot be relieved, ligation of the main artery has often enough succeeded to render the operation justifiable, and even the ex- treme measure of amputation of a member may be warranted. Chyle Cysts. Chyle Cyst of the Neck.—An abstract of the history of the fol- lowing singular case is worthy of the consideration of surgeons, since it presents points of interest regarding diagnosis and treatment:— J. S., aged 57, healthy, never having been injured, noticed, one year before presenting himself for examination, a rounded, tense, painless swelling just above the right clavicle, which steadily grew until, when I showed him to my class in Ann Arbor, the whole right inferior carotid triangle was filled by a tense, globu- lar, pulsating mass, extending from the clavicle upward to a level with the angle of the jaw, from the middle of the sternal notch outward to the margin of the trapezius, being bounded on its median aspect by the trachea below, and above by the anterior edge of the sterno-cleido-mastoid muscle, which passed over the swelling; the tumor projected far beyond the level of the clavicle. Neither the skin nor the superficial veins presented anything abnormal, and the only com- plaint made was of uneasiness from pressure upon the trachea. Suspecting a so-called hydrocele of the neck, a puncture was made with an exploring needle, which gave vent to such a peculiar fluid that I proceeded to aspirate before incising and draining. A chyle-like fluid to the amount of eighteen ounces was withdrawn, and, during all stages of the evacuation, presented a uni- form, very slightly rosy tint, which was more marked upon the surface; the tint apparently deepened upon exposure to the air, while a relatively large.clot promptly formed. No trace of thickening remained after emptying this uni- locular cyst. The cavity rapidly refilled despite pressure, and twelve days later 1 The admirable results effected by attention to this advice upon both lymphangeitis and adenitis is well illustrated by the abstract of the history of two cases where corrosive subli- mate dressings were substituted for less efficient methods in septic wounds, followed by lym- phangeitis and adenitis. See Annals of Surgery, vol. iv., p. 429, from Le Progr£s Med., AoQt, 1886. CHYLE CYSTS—ELEPHANTIASIS ARABUM. 375 eight ounces of the same fluid were removed. The patient declining radical treatment, a third aspiration was attempted, but only two ounces could be with- drawn owing to the canula becoming blocked. From the microscopic examination made by Prof. Heneage Gibbes, there can be no doubt that the fluid was chyle. For the anatomical reasons which render such a condition possible upon the right side of the neck, I must refer the reader to Quain’s Anatomy, 9th edition, p. 529, and to my original paper.1 Treatment.—This can only be palliative, by tapping, unless the sur- geon and patient are willing to run the risk of a lymph-fistula if the opening into the duct cannot be occluded. If a radical operation were to be attempted, antiseptic packing should be tried, because dissecting out the sac with ligation of the supplying lymph-vessels would proba- bly be a physical impossibility, owing to the tenuity of the walls and the anatomical relations of the parts. Iodine injections would be hazardous, owing to the necessarily free communication with the large lymph-trunk which empties in this region so promptly into the large veins. Chylous Cyst of the Mesentery.—An instance of this condition, mistaken for an ovarian or parovarian cyst, reported by Dr. A. Rasch, presents certain points of interest:— A Jewess, aged 21, liad a rounded elastic tumor occupying mainly the left side of the abdomen, its upper limit reaching two inches above the umbilicus. When the abdomen was opened the tumor was found of a pale pink color, and “ very glossy,” unlike any ordinary abdominal cyst. “ A perfectly milk-like fluid squirted out with great force” when the cyst was tapped,2 the walls being seen upon further examination to be merely the two layers of the mesentery separated from one an- other by the collection of fluid. The small intestine was normally related to the mesentery, which in turn originated from the usual point. The interior of the cyst was intensely congested, of a dark-red color, and oozed freely. The edges of the incised mesentery (cyst) were stitched to the skin wound, and recovery ensued.3 Treatment.—This is well illustrated by the case quoted; no attempt should ever be made to dissect out the cyst itself. Elephantiasis Arabum. The common cause of this disease, chyluria and chylocele, or chyl- ous hydrocele, with numerous other lymphatic affections, is so clear, 1 Transactions of Am. Surg. Association, vol. x., p. 201. 2 F. Bramann reports from von Bergmann’s clinic an interesting case where no discharge of chyle occurred after evacuation of the cyst. He thinks that stenosis of the thoracic duct is present in most cases, although this sometimes produces only dilatation of the lymph-trunks; but here Bramann thinks that the thoracic duct was double, or pursued an anomalous course. No evidence existed at the time of operation of any pressure on the main duct, since the lympha- tics of the intestines were not dilated. The absence of epithelial or endothelial lining excludes a secretion from the cyst-wall itself, and Grawitz’s theory as to small peritoneal cysts will not avail. Rokitansky’s view as to the genesis from a lymph-gland is untenable. Bramann con- cludes that the cyst may have originated from a dilatation of the receptaculum chyli, or from a subperitoneal cavernous lymphoma or angeioma, such as has been described by Yirchow (Annals of Surgery, vol. vii., p. 395, from Arch. f. klin. Chir., Bd. xxxv., lift. 1). 3 Transactions Obst. Society, London, vol. xxxi., p. 311; J. Bland Sutton, Surgical Dis- eases of the Ovaries and Fallopian Tubes, etc., 1891, p. 195. According to Sutton, cysts sim- ilar to the above have been reported by Bergmann, Arch. f. klin. Chir. (Langenbeck), 1887, S. 201; Mendes de Leon, Am. Journ. of Obstet., vol. xxiv., p. 168; and Fetherston, Aus- tralian Med. Journal, 1890, p. 475. 376 IXJULIES AXD SURGICAL DISEASES OF TIIE LYMPHATICS. that an account of the principal facts pertaining to the discovery, life history, and pathological effects of the filaria sanguinis liominis and its parent the filaria Bancroft!, will be subjoined. Otto Wucherer, of Bahia,1 first described in 1866 embryonic filarise detected in chylous urine, hut Klencke in 1843 possibly discovered similar organisms in the blood, though his descriptions are too vague to decide this question. T. R. Lewis,2 of Calcutta, in 1872 detected filarise in the blood of a native, and afterward in that of several individuals who were or had been chy- luric. Bancroft, of Brisbane,3 on December 21, 1876, obtained a dead female filaria from a lymphatic abscess of the arm, possibly having been slightly antedated in this discovery by Carter, of Bombay.4 Carter next reported the withdrawal of four living female filarise from a hydrocele of the spermatic cord, while Lewis secured both the male and female worm alive from the scrotal tissues in a case of nsevoid elephantiasis of the scrotum.6 Manson 6 reported in 1880 the finding of a living worm in a dilated lymphatic of the scrotum, thus determining the habitat of the filaria Bancrofti (the adult organism), in a patient who had had craw-craw and chyluria. He contends that the female, occupying a lymph duct, emits the embryos, which are small enough to pass through the lymph glands and thence reach the blood. Both Manson and Lewis have found the embryo en- tozoons in the stomach of the culex mosquito, this insect having ab- stracted them with the blood from an infected human being; many are digested, some are cast off, others bore through the stomach and undergo developmental changes in the thoracic and abdominal tissues. After escape from the living or dead insect they probably, as free nema- todes, contaminate potable water, by means of which vehicle they reach the human organism. “ Filarial periodicity” must not be overlooked when searching for these haematozoa in any suspected case, since they only begin to appear at sunset, increase in numbers until midnight, then diminish until about 10 o’clock in the forenoon, after which it is rarely possible to detect them. By changing the habits of eating and sleeping, it has been alleged that an “ inversion” of this process can be effected. Manson’s theory of elepliantoid diseases seems to give the best explanation, and is as follows: “1st, parent filaria in a distal lym- phatic; 2d, premature expulsion of ova; 3d, embolism of lymphatic glands by ova;7 4th, stasis of lymph; 5th, regurgitation of lymph and partial compensation by anastomoses; 6tli, renewed or continued ex- pulsion of ova; 7tli, further embolism of glands.”8 1 Gazeta Medica da Bahia, Dec., 1868, p. 99. 2 On a Haematozoon Inhabiting Human Blood, its Relations to Chyluria and other Diseases ; by T. R. Lewis, Eighth Ann. Report Sanitary Com. with Government of India, 1871, Ap- pendix E, Calcutta, 1872; See also Quain’s Med. Diet., art. Chyluria. I would here express my indebtedness to W. M. Mastin’s article on Filaria Sanguinis Ilominis in the Annals of Sur- gery, vol. viii., p. 321, for the information contained in this abstract. 3 Cobbold, Parasites, A Treatise on the Entozoa of Man and Animals, including Some Account of Ectozoa, p. 186. London, 1879. 4 Sir J. Fayrer, On the Relation of Filaria Sanguinis Ilominis to the Endemic Diseases of India. Lancet, Feb. 8, 1879, p. 188. 5 Indian Medical Gazette. Sept. 1, 1877. 6 Chinese Imperial Customs Med. Reports, No. XIV., 1878. 7 The semi-spherical ovum when coiled up in its sheath cannot pass through the glands, while the outstretched embryos, having a diameter about that of a lymph-cell, can readily pass and do not block the lymph current. * This may be complete, preventing any filarim from reaching the blood, explaining their ab- sence in that fluid in certain cases where they abound in the lymphatics. ELEPHANTIASIS ARABUM. 377 I shall briefly enumerate the following surgical affections which have been found to be commonly of filarial origin: Chylocele; varico- cele;1 helminthiasis elastica (varicose or cavernous lymphangeioma) of the groin and axilla; lymph-vesicles on the abdomen and scrotum; craw-craw; acute orchitis; abscess of the scrotum and cervical lym- phatic glands; abscess of the lymphatics of the arm and thigh; intra- pelvic abscess; peculiar steatoma of the face; venous varix; and of course all the varieties of undoubted elephantiasis Arabum. Since the worm is a native of such widely separated countries as are contained in the subjoined list, it behooves all to remember the possible presence of this hsematozoon, or lymphazoon, when investigating any case of the diseases above mentioned. It has been found and is believed to be a native of Brazil, India, Australia, Egypt, the East and South African coasts, China, the West Indies, and the Southern part of the United States of America, viz., Charleston, S. C., and Mobile, Ala. Craw-Craw.—This disease, proved to result from the presence of filarke, attacks the negroes of the South African coast. According to O’Neill it closely resembles• scabies in all its stages, appearing in the clefts between the fingers, on the front of the wrist, the back of the elbows, but seldom on the face. It is contagious, with an incubation period of about three days. Craw-craw is popularly believed to become latent upon removal to a cooler climate, as that of the Cape, only to burst out with all its old violence upon return to a tropical region. Symptoms.—Small, firm papules develop on the parts mentioned, which slowly increase to the size of pin heads. They are usually dis- crete, but sometimes accidentally assume a crescentic or annular form. In about two days vesicles replace the papules, and in forty- eight hours more are converted into pustules; these latter rapidly in- crease in size, oftentimes merging with other contiguous pustules. As intense itching attends all stages of the affection, from scratching pus is effused, and, drying, forms large, irregular, unsightly scabs.2 Treatment.—This seems unsettled, as sulphur is of doubtful value, while O’Neill says that the natives seem to know of nothing which exerts any influence on the disease, and suggests no remedies himself. As change to a colder climate is alleged to render the disease latent, this should be tried, with sedative remedies; possibly some anthelmintic rem- edy locally employed might be useful. Chylocele of the Tunica Vaginalis Testis.—While this may be due to any obstructive adenitis of one or more of the glands through which the lymph is returned from the testicle, causing dilatation fol- lowed by rupture of a lymphatic trunk into the tunica vaginalis testis, yet in most cases it is of filarial origin. Symptoms.—I need spend but little time on these, as they are identi- cal with those of ordinary hydrocele, with perhaps in addition some enlargement of the lymphatic glands in the groin. Tapping first re- veals the condition by giving vent to a milk-like or chylo-serous, coag- ulable fluid; in rare instances the fluid may not be even opalescent, but may appear identical with ordinary hydrocele fluid, yet on a closer ex- 1 Fayrer, Lancet, Feb. 15, 1879, p. 222. 2 O’Neill, Lancet, Feb., 1875. 378 INJURIES AND SURGICAL DISEASES OF THE LYMPHATICS, animation it will be found to be lymphoid, and to be produced by and to contain the filaria. Treatment.—While iodine injections may in rare instances cure, ex- perience has shown that the better procedure is incision of the tunica vaginalis, and the application of a ligature to the leaking lymph-vessel. INJURIES AND DISEASES OF NERVES. BY JOHN B. BEAVER, M.D., ASSISTANT PROFESSOR OF APPLIED ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE PHILADELPHIA HOSPITAL, TO THE GERMAN HOSPITAL, TO ST. AGNES’S HOSPITAL, ETC., PHILADELPHIA. Traumatic Lesions of Nerves. Dislocation of Nerves.—This is a form of injury that is occasionally encountered. The ulnar nerve has been found displaced from its nor- mal position at the elbow after certain violent movements, as in fenc- ing ; loose connections of the nerve, small size of the internal condyle of the humerus, and marked prominence of the internal lateral liga- ment predispose to the occurrence of this accident, according to Zuck- erkandl. It may also follow fractures of the internal condyle. Dislo- cation of the peroneal nerve in fractures of the head of the fibula has been seen. The subjective symptoms consist in pain, and motor and sensory disturbances. The treatment would be to replace the nerve, place the limb at rest in the proper position, and, if need be, apply anodynes. For habitual luxation of the ulnar nerve, Kolliker advises deepening of the groove wherein it lies, and suturing the parts; cicatri- cial contraction would tend to retain the nerve in its place. • Phenomena Consecutive to Injuries of Nerves. Regeneration of Nerves.—Benecke, Gluck, Backowetzki, and others believe that the nuclei of the primitive sheath of the nerve forms the new axis cylinder, basing their views upon experiments on lower animals. Bowlby 1 coincides with this view, and has observed this mode of reproduction of the axis-cylinders in pieces taken from the peripheral portions of divided human nerves; he also says that “the peripheral end may become regenerated without forming any union with the proximal extremity, but that it again tends to degen- erate if union fails.” Tli. Kolliker2 absolutely denies that any other elements besides the axis-cylinder itself (that is, its proximal portion) have anything to do with the regeneration of this tissue, which is an outgrowth from the epiblastic ganglion cells. 1 Injuries and Diseases of Nerves. 2 Die Yerletzungen u. Erkrank. der periph. Nerven. 379 380 injuries and diseases of nerves. Inflammatory Lesions of Nerves. Neuritis.—Occasionally there are observed thickenings of peri- pheral nerves of the paralyzed side in cases of cerebral hemorrhage; this condition has been called “neuritis hypertrojihica,” and Charcot believes it to be due to trophic influences. In the neuritis of anass- thetic leprosy, the bacillus leprae has been found in the connective tissue of the nerves. Mobius has described a form of neuritis occurring in the puerperal state, to which he has applied the name of “neuritis puerperalis;” the disease affects particularly the nerves of the upper extremity. The cause is not known. Tubercular and syphilitic in- flammation are, according to Ziegler, most often seen in the cranial por- tions of the cranial nerves and in the roots of the spinal nerves. Multiple Neuritis.—It has been suggested that this disease, in which there is a parenchymatous inflammation of many of the periph- eral nerves, is of an infectious nature. It has been quite frequently seen in connection with pulmonary phthisis (Striimpell), and has been observed after influenza. The peculiar affection known as “beri-beri,” or “kak-ke,” which is met with in the East Indies, Islands of the South Pacific, etc., has been shown by Balz, Sclieube, and others to be a form of multiple neuritis; it seems to be due to micro-organisms which exist as rods and as cocci, and are found in the air and soil, and in the blood of persons affected. The symptoms of beri-beri are those of neuritis, affecting particularly the nerves of the lower extremities, and the branches of the pneumogastric which are distributed to the heart. Disturbances of sensation and motion, paralysis and wasting of muscles, oedema, and cardiac murmurs are developed. The disease is usually chronic, and death, when it occurs, is most often due to cardiac failure. Treatment: Removal from the infected locality is, of course, the first requisite; an attempt at disinfecting the surroundings should be made; rest is very important, especially as the heart is affected; strychnine, quinine, and digitalis are appropriate remedies. Neuralgia in General. Neuralgia.—Dana'and Putnam ’ state that in many cases of tri- facial neuralgia, obliterating endarteritis of the vessels supplying the affected nerve maybe found. Putnam, Horsley, Rose, and others have described sclerotic changes in the nerve fibres and in the Gasserian ganglion. Putnam also lays stress on the fact that the trifacial nerve has a very extensive, deep origin, and many connections with other nerves which render it particularly liable to disturbing influences; it has also been asserted that a neuritis ma}7' be caused by repeated and severe “nerve storms” traversing the nerve track. The size of the foramen ovale has been investigated by Carless, who finds considerable variations in its diameter, and this may possibly be a causative factor 1 Journ. of Nerv. and Ment. Dis., No. 1, 1891. 2 Bost. Med. and Surg. Journ., Aug. 20, 1891. TUMORS OF NERVES—TETANUS. 381 in the production of neuralgia. Gussenbauer has reported cases of re- flex neuralgia due to constipation. Metatarsalgia.—Morton’s “painful affection of the foot,” or meta- tarsalgia, was first described by Dr. T. G. Morton, of Philadelphia, in 1S76.1 It consists of severe neuralgic pain radiating from the head of the fourth metatarsal bone. There are no marked signs of inflammation, but there is tenderness on pressure over the articulation. Morton be- lieves it to be due to pressure upon the plantar digital nerves, particu- larly the fourth, for on account of the anatomical conformation of the parts, the head of the fifth metatarsal is so placed that when lateral pressure is applied it will impinge upon the head and neck of the fourth metatarsal, and nerve filaments may thus be pinched or squeezed. The disease may be caused by some traumatism, as a twist of the foot, or some unusual exertion may precipitate an attack, especially if ill-fitting shoes are worn. Sometimes no cause is apparent. Women are oftener affected than men. From frequent repetitions of the pain, or perhaps from an ascending neuritis, various neurotic disturbances may arise. In the acute form of the affection the pain may be almost intolerable, and patients are unable to bear the loosest shoe. The treatment advised by Morton in mild cases consists in rest, the application of a flannel roller over the ball of the foot, and the subse- quent wearing of broad, properly fitting shoes so as to avoid all pres- sure. Others have secured relief by alternate hot and cold douches and local anodynes, together with rest. In severe cases, Morton excises the metatarso-phalangeal articulation of the fourth toe, or sometimes am- putates this toe with the head of the fourth metatarsal, securing in this way a complete cure. Tumors of Nerves. Neuroma.—Bruns2 regards the plexiform neuroma as a form of congenital elephantiasis. Tetanus. Traumatic Tetanus.—Of late the microbic origin of this disease has become firmly established. Carle and Rattone, in 1884, first showed it to be an infectious disease by inoculating rabbits with the pus de- rived from the wound of a patient suffering with tetanus, and producing thereby fatal tetanic convulsions. Nicolaier showed that a specific form of bacillus was present in various kinds of soil, which was capable of producing tetanus in the lower animals when inoculated. Subsequently, Rosenbach demonstrated that the bacillus found by Nicolaier could also be found in the wound secretions, and in the neighborhood of the point of entrance in the human being; and many other investigators have confirmed these statements. In inoculation experiments it was found that bacilli existed only in the immediate vicinity of the wound and in its secretions, but not in 1 Amer. Journ. Med. Sciences, Jan., 1876. 2 Beit, zur klin. Chir., Bd. viii., Heft 1. 382 INJURIES AND DISEASES OF NERVES. the blood or internal organs, or, at least, only to a very slight extent. It, therefore, seemed plausible that the symptoms of the disease were caused by chemical poisons generated by the vital activity of these micro-organisms. Brieger has isolated four of these toxines from cul- tures of the bacilli, and has applied to them the names: tetanine, tetano- toxine, spasmotoxine, and muriate of toxine. Brieger has also found te- tanine in the recently amputated arm of a patient affected with tetanus. Wely and Kitasato have isolated from pure cultures a very poisonous substance, allied to the albuminoids, by the inoculation of which typi- cal tetanus can be produced. Brieger and Frankel have also isolated this substance, and it is probably to be regarded as the true tetanus poison. The bacillus tetani is an “obligatory anaerobic” existing in the shape of a delicate rod, and, as usually seen, having the appearance of a drumstick, owing to the presence of a spore at one extremity; its mo- bility is slight. The bacilli can be readily stained with an alkaline alco- holic solution of methyl-blue; also with fuchsin, and by Gram’s method. They grow slowly, best in an atmosphere of pure hydrogen at a tem- perature of 98.G° F. When stab cultures are made in gelatin, con- taining 2 per cent, of grape-sugar, there develops in the deeper part, at a distance from the atmosphere, a rod-like growth from the sides of which pass out streaks into the surrounding medium; at a later stage, the gelatin becomes cloudy, liquefies, and a gas of peculiar odor is set free. Pure cultures are found very difficult to obtain, but Kitasato and others have succeeded in securing them. The spores are very resistant to heat and to the ordinary antiseptics. Rosenbach found that it required fifteen hours’ exposure to a 5-per-cent, carbolic acid solution to render them innocuous. Kitasato found that moist heat of 212° F. destroyed the spores, as did also exposure for thirty minutes to 1-1000 bichloride of mercury solution. The bacilli are found in street dust and dirt, manure, and in various soils, particularly in hot countries, for which reason, probably, the disease is more com- mon in those regions. In patients affected with the disease, the micro- organisms are found in the vicinity of the wound and in its secretions, but only in very small numbers, and often not at all in the blood and central nervous system, owing to the fact that the oxygen carried by the red corpuscles is inimical to their development, while the wound se- cretions prevent access of oxygen to the site of infection (Woodhead). The bacillus tetani is non-pyogenic, hence infection may occur without the presence of pus. It effects an entrance into the body through some lesion of continuity, not being able to pass through sound mucous mem- brane or skin. It has been suggested that the cases of so-called idio- pathic tetanus, in which there is no apparent place of ingress of bacilli, can be explained by supposing that they had entered through some for- mer lesion of continuity and had become encapsulated; that then, through failure in health or some traumatism, they have been liber- ated, and that, thereupon, the symptoms of tetanus have arisen; or the original wound may have been so insignificant as not to attract atten- tion. In infants, trismus nascentium is caused by the bacillus enter- ing at the site of the umbilicus. The period of incubation varies greatly in length, sometimes being only twenty-four hours or less, at other times weeks, depending upon TETANUS. 383 the number of bacilli which have entered, the location of the point of infection, the histological characteristics of the surrounding tissues, the degree of virulence of the micro-organisms, and the susceptibility of the tissues to the action of the ptomaines (Senn). According to Kitasato, to whom we owe so much of our knowledge of this bacillus, infection in man usually occurs by spores which are in- troduced on some foreign body. The reason that wounds of the ex- tremities are comparatively often followed by tetanus, is to be sought in the fact that the agents producing these injuries have upon them the spores from contact with the soil, and that the parts themselves are often begrimed with dirt. Wounds of considerable extent are not so often followed by the disease, because, as has been suggested, they are more apt to be efficiently cleansed and dressed than are small wounds. In punctured wounds, the conditions for the growth of the bacilli are more favorable owing to the exclusion of air and light. There has not been found much to add to the result of former inves- tigations as to the morbid anatomy of tetanus. Obliteration of the central canal of the spinal cord, and disintegrative changes in the pos- terior horns, have been found by Tyson. Monastyrski has found semi- lunar extravasations of blood in the interstitial connective tissue of the cord and peripheral nerves, and granular infiltration of the nerve cells. The bacilli, or rather their poisonous products, probably produce changes in the nervous matters, the exact nature of which future investigations must determine. Recently, tetanus toxine has been found in the kid- neys and urine of human beings and of animals suffering from tetanus, showing that nature makes an effort to eliminate the poison by the kidneys. Prophylaxis and Treatment.—Of course strict antiseptic and aseptic procedures are necessary for the prevention and cure of tetanus. All wounds, even the most insignificant, are to be thoroughly disinfected and kept so, especially if, from the nature of the injury and circum stances surrounding it, infection with the germ seems probable. Tiz zoni and Cattani, basing their advice upon experiments on lower ani mals, advise the disinfection of a suspicious wound with a TV to 1 per cent, solution of nitrate of silver, and for the further treatment of the case, if tetanus develop, a mixture of 1-1000 solution of bichloride of mercury, 5-per-cent, solution of carbolic acid and solution of hydrochloric acid. Punctured wounds are to be enlarged so that the germicides may be brought into contact with the deeper tissues. Pack- ing the wound with iodoform has been advised by Sormaiini. The usual antispasmodics, etc., are to be given to lessen the intensity of the convulsions, and a supporting treatment is to be adopted. Ampu- tation for already existing tetanus is to be regarded as an irrational procedure. Baccelli and others have reported cures by the injection of solutions of carbolic acid. Baccelli used 0.01 gramme every hour. De Renzi has cured three out of four cases by absolute rest; the patient is placed in a dark, quiet room, cotton is put into the external auditory meatus, liquid food is poured directly into the mouth of the patient, and ergot and belladonna are administered. By the injection of small amounts of blood serum derived from ani- mals affected with tetanus, Behring and Kitasato have produced im- munity to the disease in animals; they have also cured animals by the 384 INJURIES AND DISEASES OF NERVES. injection of blood serum from other animals affected with tetanus. Tizzoni and Cattani, moreover, have prepared from the blood serum of animals thus rendered immune, a substance called tetanus anti-toxine. This substance, injected hypodermically, is said to have cured a number of cases of tetanus in human beings. Schwarz, Taruffi, Casali, Moritz, and others have reported such cases. • Tetanus Hydrophobicus.—According to Rose and others, there occurs a peculiar form of tetanus after certain injuries to the regions sup- plied by the cranial nerves. In this form of the disease, which is some- times known as cephalic tetanus, there occur trismus, paralysis of the facial nerve, and spasms of the pharyngeal muscles; from the last-named symptoms, owing to their resemblance to hydrophobia, the disease has been called tetanus hydrophobicus. Klemm recognizes two forms of tetanus following injuries in the regions supplied by the cranial nerves: in the first, the muscles in the neighborhood of the injury first become affected, and the process spreads thence; in the second, there is paraly- sis of the facial nerve as well as tetanic contractions of the muscles of the face. There are an acute and a chronic form of tetanus hydrophobi- cus, the former being far more fatal. Brunner has produced the disease in animals by inoculations of pure cultures of tetanus bacilli; he denies that there is palsy of the facial nerve, and says that the contractions of the muscles produce an of the face which makes it appear as though there was paralysis, and that the facial paralysis is an error of observation. It may he considered settled, however, that there is a form of tetanus in which facial paralysis exists, usually.upon the in- jured side, as numerous careful observers have noted it. Ptosis also lias been noted in several cases. The cause of the paralysis is not definitely known. Rose attributes it to swelling and inflammation of the nerve in the Fallopian canal, but autopsies fail to confirm this view. Gowers says that it is reflex. Nearly all the autopsies have given negative results; in one case there were found vacuoles in the cells at the origin of the facial and trifacial nerves. In America this form of the disease seems to be less common than in Europe: during the Civil War there were 21 cases of tetanus follow- ing head injuries, yet paralysis of the facial nerve was not observed. Tetany.—This disease is usually regarded as a neurosis, which mani- fests itself by tonic spasms, more especially of the muscles of the limbs, accompanied by increased excitability of the peripheral nerves, and, in many cases, by pain, elevation of temperature, various parsesthesise, and vasomotor disturbances. Of peculiar interest to the surgeon is the fact that it very often follows complete removal of the thyroid gland, as was first shown by N. Weiss and as has since been confirmed by nu- merous investigators. Of this srt-called “post-operative tetany,” von Eiselsberg reports 12 cases, all in females, occurring ill 53 cases of com- plete removal of the thyroid gland by Billroth; of these 12, 8 ended in death, 2 became chronic, and but 2 terminated in recovery. In 109 partial extirpations of the thyroid gland, tetany did not occur. Von Eiselsberg also made experiments upon more than 100 cats, and draws the conclusion that total removal of the thyroid gland gives rise to TETAXUS. 385 tetany, whereas partial removal does not. In certain other animals, as sheep and rabbits, these results do not occur. Why complete thy- roidectomy should cause tetany, and also myxoedema and cachexia strumipriva, which frequently accompany the former affection, is not known; nor will it be until the, at present, mysterious function of the thyroid gland becomes known. Symptoms.—General malaise and painful sensations coming on soon after the operation, or after an interval of several days, generally precede the muscular spasms, though not always. The spasms nearly always begin in the muscles of the forearm, and then attack the lower ex- tremities. Sometimes the facial muscles are first attacked. Both sides of the body are as a rule affected, and the flexor muscles are chiefly in- volved, leading to contractures. “Trousseau’s phenomenon,” which is highly characteristic of this disease, consists of spasms cf the limb muscles brought on by pressure upon the main arterial and nerve trunks of the extremity. “ Chvostek’s sign” consists of contractures of the facial muscles, caused by pressing or tapping upon the seventh cranial nerve at its point of emergence from the parotid gland. This symptom is regarded by von Jaksch as even more characteristic of tetany than “Trousseau’s phenomenon.” The duration of the individual spasms is from a few seconds to several minutes; of the entire disease from two or three days to several weeks; some cases may become chronic. Consciousness is preserved. Dyspnoea often exists owing to spasmodic contraction of the diaphragm and thoracic muscles. In the intervals between the attacks the electrical and mechanical excitability of the nerves is exaggerated. The bodily temperature is often elevated, and the frequency of the pulse is moderately increased. Pain, tremors, cedematous swelling, and excessive secretion of sweat have been met with. Another form of the disease is the epidemic tetany, occurring most often in the spring; then there is a variety of the disease due to lower- ing of the general standard of health from long-continued diarrhoea, over-lactation (contracture des nourrices, Trousseau), rickets, certain fevers, etc. There is also a form which is met with in some cases of gastrectasis, as first mentioned by Gerhardt. The symptoms of these varieties of tetany are in general the same as those detailed above for the post-operative form. Von Jaksch, who has studied a large num- ber of cases of epidemic tetany, noted 36 males and 5 females. The affection was most common among the followers of certain trades, notably among shoemakers. It was met with most often at about the age of 17 or 18. No hereditary taint could be traced in his cases. Post- mortem examinations have, thus far, given no definite results. Diagnosis.—The diagnosis from tetanus is to be made by considering the etiology of the disease, by the fact that in tetanus the spasms begin in the masticatory muscles and are more general, and that there are no periods of relaxation. Trousseau’s and Chvostek’s signs will also be of avail in differentiating tetany from tetanus. The carpo-pedal spasms, which are often seen in rickety children, along with laryngismus stridulus, are not to be mistaken for true tetany. The prognosis is favorable, except in cases of post-operative tetany, and in that form which is associated with gastrectasis. Treatment.—The general hygienic management is, of course, to be 386 INJURIES AND DISEASES OF NERVES, attended to. Of drugs, chloral, morphia, and the bromides may be given. Berger has seen good results follow the use of curare admin- istered subcutaneously. Electricity is often of use. An ice-bag may be applied to the spine, and tepid baths may be made use of. Bibliography.—Yon Eiselsberg, Ueber Tetanie im Anschluss an Kropf-Extir- pationen, Wien, 1890; Smith (.7. L.), Tetany, Archives of Paediatrics, Phila- delphia, 1889, vol. iv., pp. 372, 4G8, 532; von Franckl-Hochw'art, Ueber Psychosen bei Tetanie, Jahresbericlit fur Psychiatrie, 1889-90, Bd. ix.; von Jaksch, Zeitschrift f. klinische Medicin, 1890, Supplement-Heft, S. 144; Gang- hofner, Ueber Tetanie im Kindesalter, Zeitschrift f. Heilkunde, Bd. xii., S. 447; Schlesinger, Ueber einige Symptome der Tetanie, Zeitschrift f. klinische Medi- cin, Bd. xix., Heft 5 u. 6; Park (Roswell), Tetany, Annals of Surgery, 1890, p. 125; von Jaksch, Ueber Tetanie, Internationale klinische Rundschau, 1889, Bd. iii., S. 2093. Operations which are Practised upon Nerves. Nerve Stretching.—Bowlby has collected thirteen cases in which death occurred after nerve stretching, from injury to the spinal cord. Nerve Extraction (Thiersch, Witzel).—This operation consists in exposure of the affected nerve, seizing it with an appropriate pair of forceps, and twisting and tearing it away along with many of its periph- eral branches. Thiersch has reported twenty-four cases where the operation was done on branches of the trigeminus, with good and perma- nent results in all but two. He states that there is not much danger of atrophy following the operation. Division of the posterior roots of the spinal nerves has been performed by Abbe, W. H. Bennett, and others in cases of severe neuralgia and of spasms accompanied by pain. The operation is done b}7 removing the laminae of one or more vertebrae and dividing the posterior roots as they lie in the spinal canal. The value of this procedure has not yet been determined. Nerve Suture.—When the ends of a divided nerve are sutured im- mediately after the injury, the procedure is known as “ primary suture when it is done later, as “secondary suture.” Bowlby advises that the ends be sutured under all circumstances, whether they come into ap- position without it or not. He advises also to pass the thread through the entire nerve; but Kolliker1 says that it is preferable to employ the paraneurotic suture unless there is great tension, or when the ends can- not readily be brought together, as the sutures offer more or less of a hindrance to union. Bowlby, Gluck, and others believe primary union to be possible, and numerous cases are reported where this is said to have occurred. Even after secondary suture apparent primary union has been obtained, in cases reported by Nicaise, Langenbeck, and others. Howell and Huber, Calm and others, however, draw the conclusion from experimental investigation that primary union does not occur. Eighty-one cases of primary nerve suture have been collected by Bowlby; of these 32 were completely successful, 22 were partial suc- cesses, in 12 the result was doubtful, 14 were failures, and in one the 1 Die Verletzungen u. cliir. Erkrank. der periph. Nerven, Deutsche Chirurgie, Lief. 24, b. OPERATIONS PRACTISED UPON NERVES. 387 result was not known. Of secondary suture he has collected 73 cases, with 32 successes, 26 partial successes, and 15 failures. Nerve Grafting.—Successful results have been obtained by Landerer, and others. Assaky has suggested the use of loops of cat- gut between the divided nerve ends to aid in the healing process; it is not possible at the present time to state definitely the value of this procedure. It has also been suggested to introduce a decalcified bone tube between the ends of the nerve, on the supposition that nerve tissue would be prolonged into the calibre of the tube. Operations for Trifacial Neuralgia.— First Division.— The supra-orbital nerve may be readily exposed by making an incision along the upper margin of the orbit, parallel with the fibres of the orbicularis palpebrarum, the centre of the incision corresponding to the supra- orbital notch or foramen. After division of the orbicularis and the fibrous membrane of the lids, the nerve may be seized and a portion excised. The supra-trochlear nerve, the other terminal branch of the frontal, which makes its exit from the orbit between the supra-orbital foramen and the pulley for the superior oblique, may also be reached by an incision along the upper margin of the orbit, nearer the internal canthus. Second Division.—Subcutaneous division of the infra-orbital nerve at its foramen of exit was formerly practised, but at the present time is not considered desirable. To resect a portion of this nerve it is simply necessary to make a semilunar incision over the infra-orbital margin, parallel with the fibres of the orbicularis palpebrarum; the nerve makes its exit under the levator palpebrae superioris; upon finding it here, a portion is excised, or the method of Thiersch may be followed: this consists in seizing the nerve with a pair of forceps and, by rotating the instrument, coiling up the nerve on the forceps and finally tearing it away; thus not only the proximal but also the distal portion is torn away, and in this manner quite a long piece may be removed. Wagner, after exposing the nerve, raised the orbital contents from the floor of the orbit, separated the artery from the nerve, chiselled open the canal, and then severed the nerve behind the posterior dental branches. Fow- ler compared this method with the removal of Meckel’s ganglion, and found that the latter method gave slightly better results. Horsley has described a similar operation: in this, the lids are first sutured together, the orbital periosteum is raised up, the canal opened with a pair of for- ceps, and the nerve traced to the foramen rotundum, where it is divided. In Carnochan’s method, which was suggested and carried out for the first time in 1858, Meckel’s ganglion is removed along with the nerve. A “V” or “T” shaped incision is made upon the cheek, and the infra- orbital foramen exposed ; the anterior wall of the antrum of Highmore is trephined, and then the posterior, using a smaller trephine for the posterior wall; the floor of the infra-orbital canal is broken through, and the nerve is traced back to the foramen rotundum, where it is divided with a long curved pair of scissors and removed along with Meckel’s ganglion. Bleeding from branches of the internal maxillary artery will be rather profuse, and electric light or a reflecting mirror will be found very useful. 388 INJURIES AND DISEASES OF NERVES. The second division of the trifacial nerve has also been attacked through the pterygo-maxillary region. In the method of Professors Braun and Lossen, an incision is made from a point 1 cm. above the outer canthus and 2 or 3 mm. from the outer margin of the orbit, downward'and forward, to the lower border of the zygoma; another incision is made from the upper end of this, along the upper border of the zygomatic arch, to about the position of the tragus; the skin and subcutaneous tissue are then turned down, the temporal fascia is di- vided, and the zygoma is severed at both ends so that it, with the masseter muscle arising from it, can also be reflected downward ; then the anterior border of the tendon of the temporal muscle, the fat and the internal maxillary artery, and a venous plexus, are drawn backward; the nerve is sought for as it passes through the splieno-maxillary fissure, drawn outward with a strabismus hook, and divided at the foramen rotundum. If it is desired, an incision may then be made over the in- fra-orbital foramen, and the nerve excised. The is then re- placed and fastened by periosteal sutures or by wiring. Tillmans, in five cases operated upon by this method, secured firm bony union, and no deformity remained. Third Division.-—The inferior dental nerve may be divided or re- sected at the mental foramen, either by incising the mucous membrane of the lower lip or by making the incision through the integument. Neither of these procedures, however, gives satisfactory results. Exposure in the Inferior Dental Canal.—The inferior dental nerve, the largest of the three sensory branches of the third division of the fifth cranial nerve, may be exposed by turning up a flap from the inferior maxilla, and then trephining the bone; when the disc, consist- ing of the external layer of the maxilla, is removed, the nerve will be seen lying with its accompanying artery in the inferior dental canal, and a portion of the nerve is then resected. If the anterior wall of the canal is chiselled away for some distance, a much longer portion of the nerve can be removed, thus tending to prevent reunion of the ends. The nerve may also be reached before its entrance into the inferior dental canal, by attacking it from within, that is, through the mucous membrane of the mouth; secondly, behind the ramus of the jaw (Liicke, Sonnenburg), and thirdly, through the ramus of the maxilla, The intra-buccal method consists in making an incision through the mucous membrane and periosteum, one inch in length, along the inner aspect of the anterior border of the ramus of the inferior maxilla, the mouth being held open with a gag and the tongue drawn to the opposite side; the internal pterygoid is raised from the bone and the internal lateral ligament divided, the point where it is inserted, viz., the spine of Spix, or the lingula, having been previously recognized. The nerve is then freed from its accompanying vessels and a portion of it excised. To this operation various objections may be urged: there is but little room for the manipulations, only a small portion of the nerve can be removed, and hemorrhage from the inferior dental artery is difficult to check, even requiring in some cases ligation of the external carotid. The lingual branch of the fifth nerve may also be resected by the in- trabuccal method. An incision is made through the mucous membrane over the course of the nerve, which lies at a point corresponding to the junction of the upper and middle thirds of a line drawn from the angle OPERATIOXS PRACTISED UPON XERVES. 389 of the jaw to the last molar tooth (Rose). Pulling the tongue forcibly to the opposite side will make the nerve tense; it is then picked up with a strabismus hook and a portion excised. To excise the inferior maxillary nerve by the Liicke-Sonnenburg method, the incision begins about one inch above the angle of the jaw, and is carried along the posterior edge of the maxilla to the angle, and along the lower border of the ramus to its middle; the fascia covering the parotid is then incised, the lower part of the gland raised up, and the internal pterygoid muscle raised from the maxilla. After locating the spine, into which is inserted the internal lateral ligament of the lower jaw, the nerve can readily be reached, for it lies below that ligament and the bone. When it is desired to divide the nerve at the foramen ovale, through the ramus of the jaw, various methods may be employed. Pancoast first performed this operation; and various methods have since been proposed by Salzer, Kronlein, Mikulicz and others. The method devised by Horsley, and preferred by Mr. Rose, of London, con- sists in deepening the sigmoid notch, and is thus described by the latter surgeon:— Commencing about the middle of the zygoma, the knife is carried backward and downward over the parotid region to the angle of the jaw, and then for a short distance along the horizontal ramus. A semilunar flap, consisting of skin and subcutaneous tissue only, should be raised and turned forward, and for con- venience temporarily stitched across the opposite side and carefully protected. This flap must be so dissected as not to injure any of the branches of the facial nerve. By this means are exposed the masseteric fascia, the branches of the facial nerve, Stenson’s duct, and a portion of the parotid gland. The deep fascia and masseter muscle are then divided by a transverse incision below and parallel to Stenson’s duct, cutting directly down to the bone about a centimetre below the sigmoid notch. Great care must be taken not to wound any of the lobules of the parotid while so doing, for although the main duct may not be divided a salivary fistula may ensue, leading to interference with the healing of the wound. The outer surface of the jaw is next denuded of periosteum by means of raspa- tories, and the soft parts held aside by suitable retractors to allow of the applica- tion of a trephine, the diameter of which should be not less than £ inch. It should be so applied as to leave between it and the sigmoid notch a narrow bridge of bone which can be subsequently clipped away by cutting pliers, and a sufficient amount of bone in front and behind to preserve the continuity of the jaw with the articular and coronoid processes. At this stage, the inferior dental artery may be cut through by the trephine and give rise to troublesome hemorrhage. The disc of bone having been lifted out and the bridge of bone between the condyle and coronoid process clipped through with bone pliers, so as to increase the space in which to work, some loose fatty tissue presents itself, and should be carefully picked away with two pairs of dissecting forceps. The tendon of the temporal muscle is thus more clearly defined, and must be held forward if necessary. Nar- row spatulse are useful at this stage, not only to keep the wound open, but also by their pressure to arrest hemorrhage from divided muscular branches. The inferior dental artery, if still intact, is usually first seen, and may be secured by passing two ligatures around it with an aneurism needle, and dividing it between. The lowest fibres of the external pterygoid muscle are seen running transversely across the wound, and require to be held upward or carefully divided to demon- strate the two nerves passing from behind. The trunk of the inferior dental nerve can then be raised upon an aneurism needle and the lingual found a little internally and in front; indeed it occasionally happens that the nerves lie in such close proximity to one another that they are picked up together. A silk or catgut ligature may be advantageously passed 390 INJURIES AND DISEASES OF NERVES. around them in order to he able to make traction. It is now easy, by a little manipulation with the handle of a scalpel, to trace them up to the foramen ovale, which can even be seen if the external pterygoid muscle be held well out of the way. The nerves can then be divided close to the skull, either by scissors or knife, and the meningeal artery should be in no danger if the nerves have been sufficiently isolated. Peripheral traction is also employed so as to draw up as much of the nerve as possible, and thus a considerable portion, more than an inch, of the trunks can be readily removed. Removal of the Gasserian Ganglion and Intracranial Neurec- tomy.—The fact tliat after the previous operation the pain almost in- variably returns, has led surgeons to devise more radical measures for relief, and Mr. Rose and Professor Andrews have resorted to the re- moval of the Gasserian ganglion. Mr. Rose’s operation is as follows:— An incision is made from near the external angular process of the frontal bone, along the zygoma, then in front of the ear to the angle of the inferior maxilla, and along the lower border of the mandible to the anterior edge of the masse ter; this flap is then dissected up without injuring Stenson’s duct or the branches of the seventh nerve. The periosteum and temporal fascia are detached from the zygoma, and this is divided at both ends with a saw; previous to divid- ing the bone, it is drilled for the purpose of inserting wire and holding it in place. The zygoma and the attached masseter muscle are then turned downward, after dividing the fibres of the masseter which arise from the malar bone; the coronoid process of the lower jaw is next divided, and, with the temxioral muscle, is raised up. After going through some fat and areolar tissue, the external pterygoid muscle will be exposed; now the internal maxillary artery can be seen and divided between a double ligature. The lower aspect of the great wing of the sphenoid and the outer surface of the external pterygoid plate are then cleared by separat- ing from them the external pterygoid muscle, and the foramen ovale is sought for; this lies a little posterior and external to the base of the external pterygoid plate; the lingual and inferior dental nerves may, of course, aid the surgeon in locating the foramen if they have not been divided by a previous operation. A long-handled trephine with a blunt-pointed centre-pin,’which projects in the foramen ovale, is then applied and a disc of bone removed; in his last operation Mr. Rose removed the disc of bone from the great wing of the sphenoid in ad- vance of and outside of the foramen; the trephine opening, which is $ inch in diameter, may then be enlarged if need be; the proximity of the carotid canal and Eustachian tube should be remembered. The third division of the trifacial is now traced up to the ganglion, the latter loosened from its bed, and its connection with the brain divided with a hook, sharp upon its concave edge. The opening in the base of the skull is enlarged and the superior maxillary nerve severed in advance of the ganglion; after this the ganglion is scraped or curetted out. The wound is next irrigated and the parts brought into apposition; the coronoid process may be wired to the maxilla, or removed; the zygoma is wired and the external wound sutured. Mr. Rose’s results in this operation have been very encouraging, five patients having remained free from pain after the operation; a sixth, however, died as the result of the treatment. There is great danger of destruction of the eyeball, probably as the result of trophic disturbances; in fact, this accident has occurred in one or two cases. Andrews, of Chicago, has also removed the ganglion, operating prac- tically in the same way. The incision was in the shape of a letter “ H,” the vertical limbs being over the ends of the zygoma, and the transverse one along the arch. The trephine opening was -f inch in diameter and was made just outside the oval foramen; a specially con- OPERATIONS PRACTISED UPON NERVES. 391 structed rongeur was used to connect the two openings, and the gan- glion was scraped out with a small sharp spoon. Professor Andrews has operated upon four cases; in two complete relief continued at the end of a year; one patient died from shock. Hartley, of New York, has performed intracranial neurectomy of the second and third divisions of the fifth nerve by the following method:— An omega, or horseshoe-shaped incision was made with its base at the zygoma, beginning at the external angular process, carried up to the temporal ridge, and ending at about the position of the tragus; after resecting the skin and muscle, the pericranium was divided in the same line; the bone was severed with a grooved chisel, in the upper part the groove in the bone extending through both tables, in the lower part only to the inner table; then, using a periosteal elevator as a lever, the bone was broken on a line corresponding to the base of the incision, and the entire flap was turned downward; after ligation of the middle meningeal artery, the dura was raised with the brain from the middle fossa of the skull, using for this purpose broad, highly polished retractors, and the foramina of exit of the second and third divisions of the nerve were exposed; these nerves were then divided with a tenotome, and the portions between the respective foramina and the ganglion were excised; the cut ends were pushed through the openings so as to separate them as far as possible from the ganglion. The flap was then replaced and the pericranium and scalp sutured. The operation thus consists of an osteoplastic resection. If thought desirable, the ganglion may also be scooped out. Fedor Krause has operated by a similar method, as have also Mc- Burney (2 cases) and Roberts. In Hartley’s case the pain had not re- turned after 18 months. In all the other cases there has been relief from pain, and, though of course they are too recent to speak definitely as to the value of the operation, there has been no fatal result. Krause in three cases also tore aw’ay the entire trifacial root with the Gasserian ganglion. Horsley says that complete removal of the Gasserian ganglion is impossible without tearing the wall of the cavernous sinus. He there- fore determined to divide the nerve behind the ganglion, and operated in the following manner:— A large flap was raised from the temporal region, the incision beginning at the an- terior end of the zygoma, following the temporal ridge, and ending at the junction of the temporal, parietal, and occipital bones; the flap was turned up, and, by trephining and chiselling, the squamous portion of the temporal bone was removed. The dura was then opened, exposing thus the temporo-sphenoidal lobe; the middle meningeal artery was ligated. By means of a broad retractor the brain was care- fully raised from the floor of the skull, and the cavity was illuminated by electric light. The dura mater over the nerve was slit open, a hook was inserted, and the nerve was torn away from the pons varolii. The patient thus operated upon, however, died of shock. The following cases of intracranial neurectomy have occurred in my own practice:— Case I.—Intracranial Neurectomy of the Superior Maxillary Nerve.— M. S., female, admitted to the German Hospital (private room) March 16, 1894, with the history of having suffered for a number of years from neuralgia of the supe- rior maxillary nerve. The parts supplied by the three terminal branches of this nerve were so sensitive that it required but a slight draft of air upon the surface to excite both pain and spasm. She had had two operations previously (Carno- 392 INJURIES AND DISEASES OF NERVES. chan’s) followed by a period of relief lasting a year, when there was a return of the pain. The cicatricial tissue in the line of the original operation was now removed with the hope of affording relief, but while this procedure was followed by some improvement, it was not permanent. The more radical operation of intracranial neurectomy of the affected nerve was then carried out. The steps of the operation consisted in making a semicircular incision over the right tem- poral region, extending to the bone, which was chiselled through in the line of incision through the soft parts. The bone with its coverings was next turned down as one flap, exposing the dura mater with the anterior branch of the middle meningeal artery. The dura was separated from the middle cerebral fossa, when with the handle of an ordinary table-spoon the brain was lifted up far enough to give a good view of the superior maxillary nerve. Meckel’s space was next opened, exposing the Gasserian ganglion, when that portion of the superior max- illary nerve which intervened between the ganglion and the foramen rotunduin was excised. The stump of the uerve occupying the site of the foramen rotun- dum was dislodged by a blunt hook, making the foramen patulous. The osteo- plastic flap was now replaced, and the skin wound brought together with inter- rupted silkworm-gut sutures. Recovery was uneventful. The electric head-light was at first used, but owing to failure of the battery natural light had to be depended upon, and was perfectly satisfactory. Case IT.—Intracranial Neurectomy of the Superior and Inferior Maxillary Nerves.—A. N. F., male, aged 44, was admitted to the German Hospital (private room) July 18, 1894. For several years the patient had suffered from a most obstinate neuralgia of the inferior dental nerve. In the summer of 1892, in the same hospital, I had trephined the inferior maxilla and had excised a portion of the affected nerve; this had been followed by relief for one year, when there was a return of pain referred not only to the distribution of the inferior dental but to that of the superior maxillary nerve as well. On July 20, two days after his admission to the hospital for the second time, I performed intracranial neu- rectomy of both the superior and inferior maxillary nerves. The technique of the operation was the same as that in the case of M. S., with the exception that in this instance two nerves instead of one were excised. The patient was dis- charged cured on August 3. Tic convulsif, or epileptiform tic, in contradistinction to tic douloureux proper, or trifacial neuralgia, may exist as an indepen- dent and painless condition, or may be present as a symptom of the latter affection. The operation for the relief of this form of tic is stretching the facial nerve. One of two methods can be used to expose the nerve, namely, Baum’s and Hiiter’s. In Baum’s method, the best, a vertical incision, two and one-half inches in length, is carried behind the ear and parallel with the anterior border of the sterno-mastoid muscle. The posterior border of the parotid gland, the first important structure seen, is displaced forward, when the aponeurosis of the sterno- mastoid is brought into view. The dissection is carried down and be- tween these structures until the layer of fascia covering the prevertebral muscles is exposed, directly in front of which the nerve will be seen closing the space between the mastoid and the vertical ramus of the jaw. Should there be any difficulty in recognizing the nerve, the electric light and the forehead mirror, in addition to the use of the-faradic current, will be found of material benefit. The superiority of this method over that of Hiiter is, that the scar is hidden by the ears, that the nerve is more readily exposed, and that all of the branches given off beyond the stylo-mastoid foramen are influenced by the stretching. In Hiiter’s method a vertical incision is carried in front of the ear into the sub- VASOMOTOR AND TROPHIC NERVE CHANGES. 393 stance of the parotid gland, until either the cervico-facial or the temporo- facial branch is found, when it is traced back to the main trunk. Vasomotor and Trophic Nerve Changes. Angeio-Neurotic CEdema.—Certain vasomotor and trophic disturb- ances of nerves are deserving of the surgeon’s attention; among them are: Angeio-neurotic oedema (Quincke and others), or acute circum- scribed oedema, manifesting itself by the rather sudden appearance of localized oedematous swellings of the skin and subcutaneous tissue, which may subside again in a few hours or less, or may persist for several days. The disease, as a rule, first appears in early life, and Osier and others have observed a seeming hereditary tendency in a number of cases; a more or less distinct periodicity has also been noticed. The hands, feet, lips, eyelids, and genitalia are most commonly affected. The color of the part is usually pale, and the local temperature is somewhat lower than normal; the patient often experiences a burning and tingiing sensation, with stiffness, and sometimes pain. The mucous membranes may be affected, and rarely oedema of the larynx has been seen. Vom- iting and gastralgia may accompany the attack. Acromegaly.—In this rare disease there are also trophic changes manifesting themselves by a gradual increase in size of the hands and feet, the bones as well as the soft parts being affected. The nose, chin, and lips also increase in size. The subjective symptoms consist chiefly in general weakness and various neuralgic pains. The exact cause of acromegaly is unknown; enlargement of the pituitary body has been found in a number of cases. Morvan’s Disease.—In this peculiar affection there occur painless whitlows and ulcerations of the fingers, preceded often by neuralgic pains, and accompanied by complete insensibility of the parts and atro- phy of the muscles. The lesions of neuritis of the peripheral nerves are found after death, and changes in the gray matter of the cord have been described. Recent investigations seem to show that the disease has a certain relation to syringomyelia. The disease has been chiefly observed in Brittany. Raynaud’s Disease, or Symmetrical Gangrene.—In this affection there is a “local asphyxia” or contraction of the capillaries of the fingers and hands, supposed to be of neuro-tropliic origin and often leading to gangrene. The parts are white and bloodless, there is analgesia, and the local temperature is lowered; subsequently the extremities may become dusky red in color. The disease occurs most commonly in elderly wo- men, and in cases of chlorosis and hysteria, and is met with particularly in winter. Pitres, Vaillard, Affleck, and others have found peripheral neuritis of the affected extremities; syringomyelia and lesions of the brain have also been found after death. The treatment consists in endeavoring to stimulate the circulation by warm baths, friction, and electricity. 394 INJURIES AND DISEASES OF NERVES. Erythromelalgia.—This disease, first described by Weir Mitchell in 1872, manifests itself by flushing, pain, and local rise of temperature, affecting most often one or more extremities; the symptoms are made much worse when the part is in a dependent position, and when the pa- tient’s weight rests upon the limb. It is believed that the lesion consists in a “terminal neuritis.” Women are much less often affected than men. Treatment is unsatisfactory in its results; in a recent case, however, recorded by Weir Mitchell, great improvement followed neurectomy of the musculo-cutaneous and branches of the internal saphenous nerves, and stretching of the plantar nerves; the excised portions of the nerves were found to be absolutely normal. DISEASES AND INJURIES OF l!l l!S E. BY CHARLES B. NANCREDE, A.M., M.D., PROFESSOR OF SURGERY AND OF CLINICAL SURGERY IN THE UNIVERSITY OF MICHIGAN; PRO- FESSOR EMERITUS OF GENERAL AND ORTHOPAEDIC SURGERY IN THE PHILADELPHIA POLYCLINIC AND SCHOOL FOR GRADUATES IN MEDICINE. General Remarks on the Treatment of Bursitis. While those points will be specifically mentioned in regard to which experience, resulting from the. advance in scientific wound treatment, has modified the advice given ten years ago, a few general statements, more or less applicable to all cases, must necessarily preface further remarks. The bursae being, as previously mentioned,1 merely en- larged spaces of the connective tissue which is condensed to form their walls, when these sacs become inflamed the process is very prone to extend to the adjacent connective tissue, and thence to all the cellular planes of the part. Even in youth many bursae open into contiguous joints, while as age advances those which at first did not communicate with an articulation often do so. Before the full confidence which we now feel in aseptic methods was warranted, the following advice, under the heading “Acute Bursitis of the Prepatellar Bursa”2 was emi- nently proper: “I would caution against the use of the knife, unless pus is certainly present, as death has thus more than once resulted.” Again, the statement that nothing beyond aspiration or subcutaneous discission should be employed in the treatment of deep-seated bursae, with the absolute prohibition of any cutting operation for the relief of synovial lierniae, requires modification to the effect that these restric- tions are now only binding if the strictest asepsis cannot be attained, but that, this being secured, incision and drainage, or complete or partial extirpation, are justifiable. Treatment of Acute Bursitis.—With the advance in aseptic and antiseptic methods, many of the recommendations formerly given under this caption require additions or modifications. Thus, after the appli- cation of leeches, a light antiseptic dressing should be applied to the bites before either dry cold is employed,3 or evaporating lotions are resorted to, while the latter applications should contain some un- irritating but efficient germicide, or germ-inhibitor. Poultices are 1 See Yol. III., page 135. 2 Ibid., page 161. 3 Ibid., page 138. 396 DISEASES AND INJURIES OF RURS.E. only permissible when pus is forming, before an opening is made by nature or art, after which moist antiseptic gauze, covered with rubber tissue or oiled silk, should be substituted. WTien pus has formed—best determined in all doubtful cases by an aseptic exploring needle or by the aspirator—prompt incision with the strictest aseptic precautions should be adopted, followed by moist antiseptic dressings. The warn- ing given against incisions into inflamed but not suppurating tis- sues still holds good unless strict asepsis be maintained, because sep- tic infection—local or general—is apt promptly to occur, owing to the diminished resistance of the tissues to microbes, but with the proper precautions no such objection exists, and, on the contrary, incisions will in proper cases relieve, not add to, the existing trouble. Sinuses will be of infrequent occurrence under antiseptic treat- ment, but when present should be laid open with the knife where their anatomical relations do not forbid, their tracks being thoroughly cu- retted, and asepsis secured by solutions of zinc chloride (grs. x to f 3 i) or mercuric chloride (1-500) when possible, deep or “etage” suturing should be employed, complete rest being insured by a plaster-of-Paris bandage fixing the whole limb; if all these measures cannot be adopted, curetting, disinfection as just advised, and the use of a gradually shortened drainage-tube, its track being effaced by proper compresses, should be tried. The oakum seton formerly advised should be dis- carded, curetting being preferable. Treatment of Subacute and Chronic Bursitis.—The only change requisite is a condemnation of any method of employing the seton, ex- cept that formed of catgut threads with the strictest of aseptic precau- tions ; horsehair may also be used, but, being non-absorbable, must be removed as soon as it is believed that no more fluid will be effused. Incised and Punctured Wounds of Burs.#:. With aseptic precautions these may heal without causing oblitera- tion of the bursal cavities. Rest, drainage if deemed requisite, and effective antisepsis are imperative. If either primary or secondary in- fection occurs, an attempt should be made, under amestliesia if deemed necessary, to render the parts aseptic, due provision being made by ap- propriate incisions for the escape of pent-up fluids or those likely to be subsequently effused. When the injured bursa is a deep-seated one, it so often communicates with its related joint that it is safer to con- sider this to be the fact in any given instance, and to treat the case as one of wounded joint. While all surgeons recognize the evils of the un- necessary use of drainage, still, in the injuries under consideration, the chance of the subsequent infection of an important joint through the medium of a communicating bursa is so great, that after thorough dis- infection I certainly think that capillary or in doubtful cases tube drainage is indicated, with absolute fixation of the articulation by suit- able splints, or preferably by a plaster-of-Paris bandage. Subsequently, if the joint unquestionably becomes involved, free antiseptic incisions, 1 If large surfaces are involved, all remainders of such strong solutions should be freely washed away with sterilized water. HEMORRHAGIC BURSITIS. 397 the introduction of a sufficient number of drainage-tubes, and fixation of the joint, are imperatively demanded.' Treatment of Bursae Communicating with Joints, and of Synovial Hernle. The positive injunction not to adopt any more active treatment than aspiration of the contents of these sacs, should be modified with our knowledge of the safety of aseptic procedures. Certainly aseptic inci- sion into joints is, in competent hands, a safe operation, so that where the anatomical relations permit, and the disability warrants some slight risk, I do not see why the synovial or bursal sac may not properly be dissected out, either wholly or in part, and the opening through the capsule, when accessible, carefully sutured with fine catgut; indeed the first part of these suggestions has now been successfully adopted in a sufficient number of cases where bursae have communicated with ar- ticulations, to strengthen the opinion here expressed, to which I had in- dependently been led by a priori consideration of the subject. Mani- festly, when synovial hernise complicate decided chronic articular disease, as of the knee, an operation for their relief is contra-indicated. Hemorrhagic Bursitis. Under this title Lejars2 has described a chronic condition analogous to pachysynovitis hemorrhagica, where, without traumatism, the con- tents of a bursa become sanguineous, being blackish, thick, and mixed with yellowish clots. Occasionally pure red blood or clots ma}r occupy the sac; in a recent case of my own, where under my direction my assistant, Dr. Darling, opened a chronically enlarged ilio-psoas bursa, this condition was found. Volkmann has detected in at least one similar case conditions apparently identical with those found in pachy- meningitis and in lisematocele of the tunica vaginalis testis. Diagnosis.—This can perhaps be made by recognizing during man- ipulation the crepitation produced by the mutual friction of clots, when these are present, but in most instances incision or puncture first shows that the tumor is not an ordinary chronic enlargement of a bursa. 1 For the result of temporizing instead of employing the holder but safer methods advocated, see Lancet, 1880, vol. i., p. 427. Enlargementof semi-membranosus bursa after injury ; sup- puration extending to knee-joint; aspiration ; amputation. 2 A. J. Silcock reports three cases of disease of the gastrocnemio-semimembranosus bursa, in two of which he dissected the sac free and tied off the pedicle with chromicized gut, in the remaining case merely excising the cyst-wall as far as possible ; in all three instances the bursa communicated with the knee-joint. He also mentions a similar case reported by Johnson Smith, but the reference is incorrectly given and I cannot verify it (Brit. Med. Jour- nal, 1889, vol. i. p. 474). H. H. Clutton mentions two bursal tumors closely related respec- tively to the shoulder and knee joints, viz., the supraspinatus and that under the outer head of the gastrocnemius, which he successfully dissected out, but which he believed did not com- municate with the joints. More cases need not be cited in support of the position taken, although many more such could doubtless be found by careful perusal of the literature of the subject. 398 diseases and injuries of burs.e. Recurrence of Chronic Bursal Enlargements after Excision. Volkmann has reported two cases of this accident after removal of a prepatellar bursa. This is explained, as well as the bilobed form of certain cases of “housemaid’s knee,” by the long-known fact that the prepatellar bursa is often multilocular, the spaces at times communicat- ing, at others forming separate sacs. Gruber, Luschka, and Linhart have described two or three superimposed sacs in this region which may or may not communicate. Treatment.—As recurrence has been reported after excisions of the prepatellar bursa only, when the operation is done the dissection should be carried down to the fibrous layer covering the surface of the bone and serving as its periosteum. Fungous Bursitis. This disease, incidentally mentioned in the article on Diseases of the Bursse,1 has been since proved, by numerous observers, 2 to be tubercular, first by the detection of giant-cells, formerly the only criterion for determining the presence of this disease, but more recently and beyond question by the discovery of the bacillus tuberculosis in certain cases of the malady.3 Volkmann first taught the tubercular nature of this disease in 1865, and was followed by Kuester; but it was Charles Nelaton who in 1883 reported a case of Terrier’s, clearly proving the correctness of previous teaching. Tuberculosis of bursae occurs in two distinct forms, viz. : (1) fungous bursitis, caseous bursitis, or cold abscess of a bursa; and (2) bursitis with riziform or melon-seed bodies. Caseous Bursitis.—This form of bursitis may develop near either a tubercular tumor or a focus of tuberculous osteo-myelitis, but is more often primitive, being a local tuberculosis of the bursa itself. Brief ab- stracts of the histories of a few typical cases will best serve to render clear the diagnosis and treatment of this condition. Terrier had under his care a male patient, aged 29 years, who, with- out any previous tubercular history, presented a rounded swelling of the size of two fists situated over the inferior angle of the left scapula, beneath which it seemed to extend. The tumor was indolent, soft, fluctuating, non-reducible, and unaffected by coughing. The contents 1 See Vol. III., p. 144. 2 Lancereaux, Labbe and Coyne, Trelat, Terrier, Charles Nelaton, Roswell Park, Annals of Surgery, vol. i., p. 241. 3 Editorial Article, Annals of Surgery, vol. i., pp. 233-256, founded on the following articles : Charvot, Rev. de Cliirurg., Mai, Juin, Aout, Sept., 1884, Des Conditions favorables on defavorables it la tuberculose osseuse; Charpy, Ibid., Sept., 1884, p. 689; Contrib. it l’lStude des Tumeurs blanches et des Abcesfroids dans leurs Rapports avec l’lnfectio.n Tuber- culeuse, Menard, These de Paris, 1884; Tuberculose der Knochen und Gelenke, Prof. Dr. Konig, S. 170. Berlin, 1884; Ueber chirurgische Tuberculose, Mogling, Mittlieilungen aus d. cliirurg. Klinik zu Tubingen, Zweites Heft, S. 248, 1884: Ueber Drllsentuberculose und die Wichtigkeit friihzeitiger Operationen, Garre, Deutsche Zeitsclirift f. Chir., Bd. xix., Hft. 6, S. 529. ANOMALOUS BURSAL 399 were grumous pus, and Malassez proved by a microscopic examination of a fragment of the cyst-wall its tubercular nature. I have had a case which I believe to be identical with this, but microscopic evidence is lacking. It was operated upon in my presence and at my request, by my assistant, Dr. Darling. Reclus relates the history of an abscess of the subcutaneous bursa over the external malleolus, and believes that certain cold abscesses of the buttock, which are commonly supposed to be of osseous origin, arise in the large serous bursae of this region. Demurs reports an interesting case of tuberculosis of the bursae beneath the semitendinosus, sartorius, and gracilis tendons (“patte Note”), which was at first believed to be a gumma, but which on punc- ture gave vent only to a yellowish fluid. Palpation now detected crepi- tation, resulting from the presence of rice-seed bodies, and upon this symptom a diagnosis of tubercular bursitis was founded. Incision con- firmed this opinion, the cavity was scraped, and eight days afterwards a cold abscess was discovered amid the muscles of the forearm. Haemoptysis promptly supervened, and in twenty-five days the patient was dead. Bursitis with Riziform Bodies.1—Nicaise, Poulet, and Vaillard studied the case of a very large bursal tumor of the right thigh, crammed with rice-like bodies to the exclusion of all fluid, in which they for the first time demonstrated the presence of tubercular nodules, con- taining Koch’s bacillus, etc. The tumor followed a blow, was sub-apo- neurotic, and gave a sensation of pseudo-fluctuation, making the ob- server think of that given by a myxo-sarcoma. The same authors report a similar case affecting the bursa over the external malleolus'. Probably some of the cases of chronic bursitis described by Volkmann and Fischer, the bursa being lined with a fibrinous coating and often containing numerous melon-seed bodies, were in reality tuberculous. Diagnosis.—Tubercular bursitis can only be confounded with tertiary syphilitic or simple chronic bursitis, and the peculiarities of the affection given in the histories of the cases here related, together with what has been or will be said of the other conditions, should suffice for the dis- crimination. Treatment.—Total ablation, when possible, should always be adopted. If too diffused for a clean dissection, free curetting, irrigation with iodine water, and rubbing into the tissues of iodoform, should be em- ployed, never hesitating to promptly repeat these procedures should any relapse manifest itself.2 Anomalous Bursae. Chassaignac has described a rare condition under the name of “ lipo- mcitous hygroma of the nape of the neck,” where a bossellated tumor, composed of fatty tissue with a central cavity, has been met with by him in individuals who carried burdens resting habitually or frequently upon t.his portion of the body. 1 These are not identical with those described as occurring in chronic bursitis, the latter not being tubercular, as will be seen by consulting the article in Yol. III. 2 I am much indebted for many of the foregoing facts to the article by M. Lejars on Dis- eases and Injuries of the Bursoe ; Duplay et Iieclus, Traite de Chirurgie, tome i., Paris, 1890. 400 DISEASES AND INJURIES OF BURSA). Many7 authors, as Berard, Roux, Massot, and others, have related cases where bursae were developed beneath malignant growths, such as scirrhus of the mamma, sarcoma of the axilla, etc. Broca reports the existence of a bursa upon the inner side of the labium majus, toward its anterior extremity7, which, if attacked by suppurative inflammation, gives rise to an abscess differing from those arising in cysts of the vulva or of the vulvo-vaginal gland. So with the submucous hy7groma of the anterior portion of the nasal septum, the disease arises in the bursal sac sometimes found here. Chassaignac has also contended that certain marginal anal abscesses originate in the small submucous bursse not uncommonly present in the anal region. Tumors of BursvE. Exostosis Bursata.—This rare condition was first described by Bill- roth in 1863. The abstracts of two cases which follow, give briefly all in the way of pathology, diagnosis, prognosis, and treatment which has not been previously given when speaking of bursal diseases in a general way. Rindfleiscli contended that this condition had arisen by the growth of an ecchondrosis from the articular cartilage, pushing ahead of it a portion of the articular synovial membrane, the opening into the joint cavity subsequently becoming obliterated. The case re- ported by Fehleisen to the 14tli Congress of the Deutsche Gesellschaft fur Chirurgie, held in Berlin in 1885, with cases observed respectively by Yolkmann and Erliardt, prove that these growths cannot arise from the epiphyseal cartilages, while the absence of any communication with the knee-joint is regarded by Fehleisen as proving that exostosis bursata cannot arise from the articular cartilage. Fehleisen believes that these growths originate from relics of misplaced foetal cartilage—in fact, are teratomata of the knee-joint—but Yolkmann has pointed out that he has found numerous free cartilages in a case of pseudarthrosis of the femur, and considers that these bursal exostoses arise either from the epiphyseal or articular cartilage according to whether they7 are within or without the joint. I can see no reason for these recondite theories. Growths from bone may conform to any7 of the ty7pes of the connective tissues: bone, fibrous tissue, cartilage, etc.; certain cases of pseud- arthrosis show a cartilaginous coating on the ends of the fragments —nay further, as Yolkmann has shown, free cartilages may be present— so that the simplest explanation of exostosis bursata would appear to be that a bony outgrowth, initiated by some irritation or injury, re- mains partly7 cartilaginous on its surface, and that over this an adven- titious bursa forms with unusually developed fringes, which, undergoing hypertrophy and becoming detached, are then the free cartilages com- mon in this affection. Case I.—Felileisen’s case, already mentioned, occurred in Bergmann’s clinic in the person of a man, aged 43, in whom a painless tumor gradually developed upon the outer side of the left femur until it reached the size of an infant’s head. By relaxing the outer portion of the extensor cruris, beneath which the tumor lay, distinct fluctuation was readily detected; in addition, a fixed tumor and several free bodies were recognized. An incision gave exit to much thick, tenacious fluid and 48 free bodies. The adherent capsule was dissected out, no opening TUMORS OF BURSA:. 401 intp the joint being discovered, and the bony growth was removed. The capsule was lined with endothelial cells, and two pedunculated bodies hung from the edges of the cartilage-covered exostosis, while around its margins were numerous villi with constricted bases, that is, bodies which when detached would constitute “free cartilages.” 1 Case II.-—A healthy man, aged 20, avas admitted in March, 1888, into the Montreal General Hospital, with a tumor located upon the inner side of the femur, which was of nine years’ duration, and which when first noticed had been of the size of a marble, and movable. He stated that it had become fixed and firm about four years before. Never painful or tender, during the last few months he had experienced inconvenience in the muscles when going up or down stairs or from overexertion. Upon examination, an apparently pedunculated tumor the “size of a base-ball,” with indistinct outlines, Avas discovered on the inner side of one femur. Upon operation, April 4, 1888, fifty-five free bodies varying in size from that of a pea to that of a large bean Avere evacuated Avith much tenacious fluid. The irregular exostosis, covered Avith a continuous mosaic of cartilage plates, Avas attached to the “ linea aspera beloAv the epiphyseal line by a pedicle one-half inch in diameter and three-fourths of an inch Jong.” The sac, which Avas dissected out, did not communicate Avith the knee-joint, but Avas identical in structure Avith an articular synovial membrane; the exostosis Avas also removed.2 Hygroma Proliferans Endothelialis.—Morisani reports a case of this rare disease attacking the bursa at the attachment of the tibialis posticus. The wall consisted of two layers, the internal being evidently neoplastic, and presenting microscopic evidences—according to the author—which excluded the idea of its being of either a simple in- flammatory, a tubercular, or a sarcomatous nature.3 The number of cases of neoplasms originating from either bursae themselves or the scars left after their removal by the knife, is very small. In ad- dition to those mentioned in the article in Vol. III., and one of alleged carcinoma of the bursa beneath the tendo Achillis, mentioned by Platner, I would refer to \7on Ranke’s article, where he either describes or quotes references to the following cases: Myxoma (sarcomatous ?) of the prepatellar bursa; round-celled sarcoma of the pretibial (?) bursa (mentioned by Ranke as reported by A. Smith, but it is not clearly stated which bursa was involved); sarcoma over the patella4; hem- orrhagic sarcoma (?) of subquadricipital bursa; angeioma from the scar of an obliterated prepatellar hygroma. Holsclier refers in a vague way, in his translation of Brodie on Diseases of the Joints, to hemor- rhagic sarcoma originating after treating hygroma by the seton; Schuh’s case of cystic hygroma5 Avas probably only a relapse of the original condition, viz., hygroma; Dollinger reports a papilloma of the prepatellar bursa originating from a fistulous track leading dovvm to an old suppurating bursa;8 Mikulicz reports a similar instance.7 These cases show that some communicating track leading to an epi- thelial-covered surface is a requisite antecedent before an epithelioma- >l Archiv f. klin. Chirurg., 1886, Bd. xxxiii, Heft I. (Annals of Surgery, vol. iv., p. 78). 2 James Bell, Annals of Surgery, vol. ix., p. 112. See also Orlow, Annals of Surgery, vol. xv., p. 400, or Deutsche Zeitschr. fiir Chirurg., Bd. xxxi., Heft 3, 4. Only ten cases of this rare disease have, as far as I can ascertain, been placed on record. 3 Progresso Medico ; Rivista clinica dell’ Universita di Napoli, No. 6, 1890. 4 Gurlt, Path. Anat. der Gelenkkrankheiten, S. 580. 5 Path, unci Therap. der Pseudoplasmen, 1854, S. 201. 6 Archiv f. klin. Chirurgie, Bd. xxii., S. 697. 1 Separat-Abdruck aus den Verhandlungen cles XIV. Chirurgen-Congresses, S. 5-19. 402 DISEASES AND INJURIES OF BURSA). tous growth can develop from any bursa, that is, a structure originating solely from connective tissue. Tuffier describes a fibro-myxoma of the ischiatic bursa,1 and E. Estor a primary sarcoma of the prepatellar bursa.a Chavasse reported a case of cystic myxoma of the deep pre-tibial (?) bursa to the Societe de Chirurgie.3 Nicaise has seen two sarcomata of the prepatellar bursa grafted upon old hygromata. One case occurred in the service of Dolbeau, the other was his own.4 I have myself re- moved from over both olecranon processes of the same individual, fibro-cartilaginous tumors which arose from the bursae in this region. From the diversity of these bursal growths and the small number of cases possible to deal with, no useful conclusions can be drawn, while for similar reasons, and because each variety of growth eventually pur- sues the course of the class to which it belongs, nothing special need be said as to their diagnosis. Bunion.—When suppuration has taken place in those cases of bunion in which marked deformity of the metatarso-phalangeal joint of the great toe exists (hallux valgus), Riedel has recently in four cases se- cured a good functional result, the first toe being brought into a fairly normal position, although the remaining toes remained abducted. The bursal sac is carefully excised and the exostoses are removed from the head of the metatarsal bone and base of the phalanx, after which the head of the metatarsal bone is chiselled down until smooth, and of such a form as will admit of an approximate restoration of the member to its normal axis.5 1 Progress Med., 1884, tome xii., p. 545. 2 Gaz. Hebd. de la Soc. Med. de Montpellier, 1888, tome x., p. 53. 3 Traite de Chirurgie, tome i., p. 893. 4 Ibid. 5 Annals of Surgery, vol. v., pp. 162, 163; Centralbl. f. Cliirurg., 1886, No. 44. INJURIES OF BONES. BY JOHN H. PACKARD, M.D., SURGEON' TO THE PENNSYLVANIA HOSPITAL AND TO ST. JOSEPH’S HOSPITAL, PHILADELPHIA. Since the publication of my former article there have been, as will appear in the following pages, very considerable additions to the rec- ords of experience in fractures and their treatment. The general adoption of the antiseptic system will be found to have influenced this, as it has all other departments of surgery. Thus in compound frac- tures, the sterilization of the wound goes far toward setting aside the chief danger, and making a conservative course possible. And any operative procedure, as, for instance, in dealing with failures of union, or with cases where union has taken place with deformity, may be much more safely undertaken. So much has been said and written on this topic, that it need not be further dwelt upon here, especially as it will be referred to occasionally in connection with the fractures of cer- tain bones. In the arrangement of the subject, the order followed will be in the main that of my former article. Fragility of the Bones. Some curious cases of fragility of the bones have been reported. Pritchard 1 mentions a child who two days after its birth was found to have fractures of the left humerus and femur; next day the right humerus gave way, from very slight cause, and three weeks after- ward the right femur was found to be broken. Union was progress- ing well at the time of the report. The father had been one of eight children, two of whom had had fractures in infancy; his brother had four children, the first of whom had had a fracture of the arm, the third one of the femur, and the fourth fractures of all four limbs. In every instance the bones had given way spontaneously at or soon after birth. Graham 2 publishes a letter from a patient (age not stated, nor sex) who says that within his own recollection he had suffered eighteen frac- tures; his right arm had been broken nine times, his left twice; his right leg twice, his left leg three times; his clavicles once each. Sev- eral other fractures had occurred in his early infancy. His father had had broken bones fourteen times; a cousin, twenty-one times (in his case not until advanced life); his grandfather had had a brother who 1 Lancet, September 1, 1883. 2 Boston Medical and Surgical Journal, May 15, 1884. 403 404 INJURIES OF BONES. was also a “bone-breaker.” A boy aged 13, who had had twenty- seven fractures of the bones of his lower extremities, was recently ex- hibited by Roddick to the Medico-Chirurgical Society of Montreal.1 The first fracture was of the right femur at 1 year of age. All the earlier fractures had united readily, with abundance of new bone; but not so the more recent ones, and there was a pseudarthrosis at the middle of the left femur. So useless and atrophied were the limbs, that amputation was proposed. The family history was good. Two cases in which the humerus gave way from very slight cause are reported by Sinclair.2 One of the patients was a man aged about 30, the other a woman of about the same age. In another instance, recorded by Greenwood,3 a policeman 30 years old, who “had always been a delicate man,” was throwing a cricket-ball, when he felt some- thing snap, and was found to have a fracture in the lower third of the humerus. Berbez4 saw a girl of 18, the subject of atrophic infantile paralysis of the left arm, which limb had several times been the seat of spontaneous fractures. Mollities Ossium. Cases of mollities ossium have been reported by Davies-Colley5 and by Bennett.6 Davies-Colley’s patient was a rachitic girl aged 13; she had fractures of the left humerus, right femur, and right tibia; all her bones were bent, deformed, and flexible. Bennett’s case was that of a woman aged 39, who had had spontaneous fracture of the left clavicle, which united, and then gave way again; one hu- merus had been repeatedly broken in its upper portion; and the left femur had been fractured. All her bones were much softened, and she suffered greatly from pain. In this instance the disease did not, as has so often been noted in adults, begin in pregnancy. Almost all the recorded cases of this disorder have been in women. But Rigby 7 saw one in a man aged 43, who had for eight years suf- fered from what was regarded as rheumatism; his hands and his chest were deformed, and both his femora were bent. Two years before he came under observation he had had a fracture of the right humerus, and then of the right femur, from slight causes. He had none of the constitutional symptoms of rickets. In another instance, reported by Barwise,8 a man aged 31 had had fractures of the left humerus and femur; he had pains in his muscles and bones, and the latter were bent. Of his five children, the last two, aged 3 years and 1 year respectively, were rachitic, and the elder one had been operated upon for bow-legs. Fractures in Persons Already Diseased Ill a case reported by Dollinger5 a man aged 41 was affected with icterus, and had pains in the legs. These pains became concentrated 1 New York Medical Journal, Oct. 18, 1890. 2 British Med. Journal, Feb. 1, 1890. 3 Ibid., Nov. 22, 1890. 4 Ibid., April 2, 1887. 6 Transactions of London Pathological Society, 1884. 6 Lancet, January 16, 1886. 7 British Med. Journal, July 3, 1886. 3 Ibid., April 9, 1887. 9 Centralblatt fur Cliirurgie, 6 Juni, 1891. FRACTURES IN PERSONS ALREADY DISEASED. 405 in the right hip, and at length the neck of the femur gave way. On the twenty-fourth day it was exposed and sutured at two points with silver wire; the soft parts were brought together with catgut, and a plaster bandage was applied to the limb. In eight weeks healing was complete, with one dressing; and nine months after operation the patient had good use of the limb, with free movement in every direction. An instance is recorded by H. Jackson,1 in which a woman aged 52 was the subject of subcortical disease of the left-leg-centre, the limb being paralyzed; on the twenty-third day the left femur gave way near the trochanters as she was being lifted off the bed-pan. At her death twenty days later there was found cancerous disease of the femur, ovary, and brain. As to fragility of the bones in disorders of the nervous system, T. Christian 2 asserts his belief that in the case of general paralytics this is a mere coincidence, and not a direct consequence of the disease.3 Benham 4 reports a case of acute mania in a man aged 54, upon whose death all the left ribs from the 3d to the 7th were found fractured three or four inches from the sternum; they were so softened as almost to break under the finger. Nothing is said as to the state of the rest of the skeleton. Charpy 5 thinks that fractures may occur in the syphilitic either as the result of a general change in the- skeleton as a whole, impairing its power of resistance, or by reason of a local lesion, such as a simple or gummatous osteitis with rarefaction. He found the bones of syphili- tics deficient in resisting power, in density, and in weight. One con- stituent, the fluoride of calcium, was in the bones of such subjects only 1.99 per cent., as against 2.43 per cent, in healthy persons, and 2.92 in the phthisical. Tavernier6 gives an account of a married woman who, besides cuta- neous syphilides, had nodes on the clavicle and on both humeri; that on the left humerus had been painful for several days, when the bone gave way as she lifted a pillow. Under specific treatment union was complete in three months’ time. Picque7 mentions a syphilitic woman aged 57, who had an extra-cap- sular fracture of the cervix femoris; she had had also a fracture of one tibia, and one of the clavicle, the latter still ununited. As to cancer, the same author refers to a case in which a woman aged 53 had a fracture of the right humerus, ununited at the end of five months; the left breast had been removed two years before, and the arm had become the seat of the recurrent disease six months after the operation. He quotes from Verneuil the case of a woman aged 35 who had cancer of the breast and of the left femur, when the right femur gave way; death ensued on the seventh day, but at the autopsy no tumor was found at the seat of fracture. He also cites from Despres two instances in which union took place; and says that this is the rule in osteo-sarcomata but not in carcinomata. W. Roger Williams 6 has 1 Lancet, March 5, 1887. 2 Journ. of Mental Science, January, 1886. 3 The same view is taken in an interesting paper by T. Claye Shaw (St. Bartholomew1 s Hosp. Reports, 1890) as the result of a number of experiments on the cadaver. 4 Journ. of Mental Science, April, 1885. 6 Annales de Syphiligraphie et de Dermatologie, 25 Mars, 1887. 6 Ibid. , Gaz. Med. de Paris, 2 Mai, 1885. 3 Diseases of the Breast, pp. 200 et seq. 406 INJURIES OF RONES. recorded a number of additional cases of fracture from slight causes in persons affected with breast-cancer; in one the patient was a man aged 45, and the humerus on the diseased side gave way. Polaillon 1 gives two instances in which fracture occurred in femora affected with cancer, and one of fracture in a woman with cancer of the breast. A number of additional cases of so-called spontaneous fracture have been put upon record. Rosenthal2 mentions that a girl 18 years old, after a nap in a field, had pain in her right thigh and was unable to stand; there was found a transverse fracture in the lower third of the femur, which was put up in plaster of Paris, and united readily. Pan- tiiikhoff3 saw a young soldier who had had rheumatic pains, and felt intense pain and a cracking in his right leg while at drill; a sim- ple transverse fracture of the tibia was detected; it united in a month’s time, but four days afterward the bone gave way again at the same point as he was going down a staircase. Humphry/ gives the case of a woman aged 56, who had pain in the right thigh, and in whom the bone gave way in walking; a year later the same thing happened in the opposite limb; after her recov- ery she had pains in both arms, but nothing further was known of her. Humphry mentions also a case of fracture of the forearm in a child from convulsions in whooping-cough. Reference is made 5 to the case of a woman aged 26, who for eigh- teen months had had obscure pains in the upper third of her right arm; she was in the last month of her third pregnancy, when the bone gave way just “at the insertion of the pectoralis major and del- toid muscles.” There was still some mobility at the end of two months. Khlamoff thinks that this was perhaps a case of incipient osteomalacia. Poncet8 gives the history of a man aged 45, who had spontaneous fracture of the left femur; the bone had formerly been the seat of inflammation, which had, however, for sixteen years been apparently cured. Polaillon 7 mentions the case of a man aged 67, ataxic for several years, in whom the tibia gave way at its upper part during a slight movement; no union occurred, bedsores formed, and death ensued on the forty-second day. Intra-Uterine Fractures. On this subject an excellent paper has been published by Prof. J. H. Brinton,8 containing two new cases, and fifty-one collected from va- rious sources. Beck9 lias recorded the case of a girl born with a fracture of the leg united at a right angle, for which a successful osteotomy was performed when she was ten months old. In another instance, reported by Branfoot10 the mother had been for six weeks under treatment for acute articular rheumatism; her child was born dead, having fractures of both femora and of both bones of each leg;. 1 Statistique et Observations de Chirurgie Hospitali&re, p. 289. 2 London Med. Recorder, July 15, 1886. 3 Ibid. 4 British Med. Journ., November 15, 1884. B London Med. Recorder, December 15, 1886. 6 Gaz. Hebdomadaire de Med. et de Chir., 20 Avril, 1888. 1 Op cit., p. 144. 8 Trans, of Am. Surgical Association, vol. ii., 1884. 9 Jahrbuch fur Kinderlieilkunde, 1886. 10 British Med. Journal, January 21, 1888.. VARIETIES OF FRACTURE. 407 the broken bones were united at right angles, new bone being in each case deposited in the angle. Hofmokl,1 apropos of a case of united intra-uterine fracture of the thigh observed by him, says that among 117,918 births recorded in fourteen years at the Maternity and Found- ling Hospital in Vienna there was not one positively established case of such injury. Sophus Meyer2 gives two instances: in one the left femur had been broken about the middle, and the right one was bent, probably from a united fracture; in the other both femora were broken, the right at about the line of the lower epiphysis, the left somewhat higher up; union took place well. In the former case there was suspicion of rachi- tis, and the mother three weeks before her confinement had struck her abdomen against the corner of a table. Jones3 reports a case of intra-uterine fracture of the femur, seen by him when the child was three weeks old; the mother had fallen down- stairs when six months pregnant. The left thigh measured 2% inches in length, the right 4 inches; there was also \ inch shortening below the knee. He says that he has seen two other instances, one occurring in the clavicle, the other in the humerus; in neither of these was there any history of injury from without. An interesting case of multiple intra-uterine fractures has been re- corded by Linck,4 and references are given to eleven other instances. Of fractures produced during birth, Meyer found in the records of twenty years at the Copenhagen Maternity 13 cases, 5 of the clavicle and 8 of the humerus. He thinks this a small proportion of the actual number, since fractures are apt to be overlooked in dead-born children, and only 2 of these 13 were born dead. In 4 instances (3 of the clavicle and 1 of the humerus) the labors were natural; in the other 9 version was performed. Meyer quotes with disapproval Wehn’s suggestion that the bones give way under strong uterine contractions. He says that union is usually perfect in three weeks; callus forms in excess in a few days, but is absorbed, and disappears entirely in a period of some months. Farnsworth5 reports a case of fracture of both thighs in delivery of a female child; union was firm on the seventh day, but with lateral curvature requiring correction by splints. Five months afterward there was no trace of the injury. In a case reported by Wyeth,6 a fracture of the femur at the tro- chanter, produced by two fingers of the accoucheur in delivering the child, was treated in flexion, with a plaster-of-Paris bandage, and was perfectly united in three weeks, without deformity. Varieties of Fracture. According to Kroell,7 a good many so-called oblique fractures are in reality spiral; and he thinks that these, which have been generally de- 1 Archiv fur Kinderlieilkunde, Bd. iii. 2 Schmidt’s Jahrb., 1884, No. 1, from Hosp. Tidende, 1883. 3 Liverpool Med.-Chirurgical Journal, July, 1892. 4 Archiv fllr Gynakologie, Berlin, 1887. 5 Med. and Surg. Beporter, Sept. 26, 1891. 6 New York Med. Journal, July 4. 1891. 1 Deutsche Zeitschrift fur Chirurgie, 24 Mai, 1888. 408 INJURIES OF BONES. scribed as peculiar to the femur and tibia, but which may also occur in the clavicle, ribs, humerus, and forearm, should be recognized as a distinct class. As a rule they affect the weakest and thinnest por- tions of the bone'. One of their marked features is pain, extend- ing upward and downward, and increased by pressure so as to he unbearable; there is often effusion of blood at the painful spots, and if the injury is near a joint, this is apt to be swollen and tender. Such fractures, Kroell states, are attended with special danger of fat-em- bolism, of septicaemia, and of gangrene; and when they unite, they do so but slowly. The subject of fractures penetrating joints has been ably discussed by Oberst.1 He says that these injuries are too apt to be followed by anchylosis. Such a result may be due either (1) to too prolonged con- finement of the joint at rest; (2) to inflammatory processes from trau- matism; (3) to excessive deposits of callus; or (4) to intra-articular and extra-articular extravasation of blood. On the other hand, ab- normal mobility, with weakness and instability, may be the conse- quence of too prolonged rest. Either of these conditions will generally yield to massage and passive motion, or may subside spontaneously with time. The indications for treatment are clear: withdrawal of blood by puncture, if necessary; even and methodical compression, if this will serve to cause absorption, and subsequently a merely reten- tive bandage; and massage, with careful and painless passive motion, from the first. Fractures in Aged Persons. Humphry2 has collected 19 cases of this kind, the oldest patient having reached the age of 100, while the youngest was 68; the aver- age being a trifle over 80. In two of these, a man aged 86 and a woman aged 68, a fatal result ensued; in the remainder, or nearly 90 per cent., good union was obtained. One of these cases, reported by Groom,3 was that of a woman 81 years of age, who sustained a fracture of the femur and a luxation of the shoulder; in six weeks she was able to walk with a stick, and at the end of five months she walked a distance of four miles. Conditions Attending and Consequent upon Fractures. According to Verchere,4 phosphaturia and polyuria are apt to attend fractures, as well as other lesions of hone; he cites cases in which the former condition seemed to have predisposed to fracture, but not to have impeded union. Sometimes, however, it has delayed consolida- tion. The influence it exerts is not yet clearly defined. Grossich 5 has noted a rise of temperature in cases of fracture, and in other lesions and operations affecting the bones; his observations confirm those of Stickler, formerly quoted. He has also remarked an 1 Schmidt’s Jalirb., 15 Juli, 1888, from von Volkmann’s Samml. klin. Vortrage, Iso. 311, 1888. 2 Brit. Med. Journ.., July 12, 1884. 4 Gaz. Med. de Paris, 26 Sept., 1885. 3 Lancet, April 12, 1884. 6 Med. Times (London), June 6, 1885. TREATMENT OF FRACTURES. 409 increased amount of indican in the urine under such conditions, but this does not perhaps possess any practical significance. In an article 1 on the occurrence of sudden death after fractures, Bruns mentions the case of a woman aged 55, who broke her right fe- mur; on the fifteenth day the limb became oedematous; ten days after- ward she died after a brief attack of precordial anguish; an autopsy showed blocking of the pulmonary artery and of other vessels. He has collected 35 cases of thrombosis in the neighborhood of fractures, in 23 of which sudden death occurred. The third and fourth weeks would seem to be the usual period of danger from this source. Bruns thinks that there may be many such cases, but of slighter severity, which end in recovery. Tumors Developed at the Seat of Fracture. In a case recently seen by Professor Ashhurst and myself, in consul- tation with Professor Brinton, a gentleman aged 58 had, apparently as the result of a fracture of the head and anatomical neck of the right humerus, a central sarcoma of that bone. He had also a well-marked hypertrophic deforming osteitis of the right femur. Amputation at the shoulder was performed by Professor Brinton, the only difficulty en- countered being the necessity of tying a very large number of vessels. The patient did well for a week, when a rubeoloid dermatitis broke out over the body and limbs, with high fever; death ensued at the end of forty-eight hours. Deakin 2 has reported a case in which a young man sustained a double fracture of the humerus, in which, six months afterward, a myeloid tumor was developed, causing complete absorption of the shaft of the bone; the growth was excised, but death took place from exhaustion on the next day. Eustace 3 met with a case in which after a fracture of the femur there was a formation of hydatids, and refracture a year subsequently; amputation through the hip-joint was performed, but with a fatal result. Phelps4 mentions the case of “an old man” who had broken his humerus forty years before, and presented a large tumor developed at the back of the arm at about the seat of fracture. Treatment of Fractures. As to the general treatment of fractures, Lucas-Championniere 5 ad- vocates the employment of massage and mobilization. By this method, proposed b}r him in 1S86, he claims that the formation of callus is fa- vored and regulated. He regards the exact restoration of the shape of the limb as of less consequence to function than the preservation of muscular tone, the suppling of the joints, and the prevention or relief of pain. 1 Gaz. Med. de Paris, 22 Mai, 1886. 2 Am. Journal of tlie Med. Sciences, April, 1884. 3 Brit. Med. Journal, May 26, 1894. 4 Med. Record, December 1, 1888. 5 Journal de Medecine et de Chirurgie Pratiques, Dec., 1889. 410 INJURIES OF BONES. Similar views have been expressed by Franks.1 I do not think that they have met with any favor in this country, except in the later stages of treatment; yet I think that with certain limitations they might well be accorded some weight. My own belief in the value of early passive motion has been more and more confirmed by experience, and along with this it is very easy to combine kneading of the muscles, and such gentle friction of the skin as may render the circulation more active. To very many patients such manipulations are produc- tive of much comfort. Especially in fractures near joints, I believe that rigid confinement is a frequent source of long-continued if not permanent lameness and stiffening. Local anaesthesia by means of hypodermic injections of cocaine is recommended by Conway2 as an aid in the examination of fractures and luxations. Divided doses up to 10 or 15 minims of the usual four- per-cent. solution are used, the circulation being checked by an elastic band around the limb above the seat of injury. The treatment of compound fractures has, as a matter of course, been greatly modified by the modern method of dealing with all open wounds. The thorough cleansing and sterilization—rendering aseptic —of every portion of the exposed tissues, and the application of aseptic protective dressings, are the essential features of the system. Complete discussion of the details of such procedures, and of the results obtained, may be found in articles by Dennis,3 Davies-Colley,4 and Burrell and Dwight.6 Senn has proposed 6 to fix the fragments together by the use either of an aseptic perforated bone tube, inserted into the medullary canal, or of a ferrule or ring of the same material surrounding them. He cites three instances in which he tried the latter plan, but not with very good results; and there are certain difficulties in its application, which it would seem must limit its employment to exceptional cases. Non-Union and False Joint. For the mechanical restraint of the exposed ends of the fragments in ununited fractures, Estes7 recommends a device somewhat similar to one long in use, and generally credited to Langenbeck. He employs a steel plate three-eighths of an inch wide, one-sixteenth of an inch thick, and two and one-half inches long, and with several holes drilled through it on either side of the mid-point. This is applied directly to the fractured bone, so that it may be secured to the fragments by driving ivory pegs through the holes into corresponding holes bored into the bone. The ends of the pegs are left long, so that they project through the linear wound, and can be withdrawn after about three weeks, when the plate is removed also. According to Estes, this plan has answered very well 1 Dublin Journal of Med. Science, Nov. 2, 1891. Other articles on this subject have been published by Rosenblith, in the Journal de Medecine de Paris, for March 21, i891; by Lan- derer, in the Centralbl. fur die gesammtlicbe Therapie, for June, 1891; and by Huyberechts, in La Presse Med. Beige, for Nov. 16, 1891. 2 New York Med. journal, Dec. 5, 1885. 3 Journal of the Am. Med. Association, June 21, 1884. 4 Guy’s Hospital Reports, vol. xxix., 1887. 6 Boston Med. and Surg. Journal, Sept. 8, 1892. 6 Trans. Am. Surgical Association, vol. xi., 1893. ’Trans. Med. Soc. of Pa., 1892. FRACTURES OF THE BONES OF THE FACE. 411 in 18 cases. He refers to Schede’s use of a similar method, but with a plate made of aluminium. He observes the strictest antiseptic pre- cautions, and employs a plaster-of-Paris splint to keep the limb im- movable. Good results have been obtained by Halsted, of Baltimore, by the application of silver splints to the fragments, closing the wound over them, and allowing them to remain permanently in place. As to the general treatment of failure of union DelVaille1 records good results from the administration of phosphide of zinc, i to i grain daily. He first experimented with it on animals, and then used it on eighteen patients, all of whom made exceptionally rapid recoveries. Stocks2 treated a boy aged 10, with an ununited fracture of the leg, operated on without success three years previously; he gave him for a month a diet of meat and milk, with strychnia and superphosphate of iron; another operation was then performed, and in three months perfect union was obtained. By Menard,3 a ten-per-cent, solution of chloride of zinc has been in- jected between the fragments of a tibia and fibula, ununited after five months of treatment, in a man aged 43; one month afterward, con- solidation was complete, and the patient was able to walk. Moore 4 speaks highly of glacial acetic acid, which he says has for many years past been used in cases of non-union at the Melbourne Hos- pital. Two cases have been reported in which portions of the femora of rab- bits have been transplanted successfully for the relief of ununited frac- tures of the bones of the forearm. In one, by McGill,6 a young man of 20 had non-union of the radius; an incision was made and thirteen pieces of the femur of a 6-weeks-old rabbit were inserted; on the tenth day the wound was examined and found almost healed; on the fortieth the man was discharged with perfect union. The other case was re- corded by Sherwood;6 both bones were involved, and the forearm and hand were atrophied and useless. The ends of the fragments were ex- cised, and nine pieces of a rabbit’s femur were wedged in; some sup- puration ensued, and four pieces came away, but about four months afterward union was sound. Nothing is said as to the ultimate useful- ness of the hand. Brief reference may be made to an extraordinary attempt of Phelps 7 to engraft the bone of a living dog’s leg directly into that of a boy, for the relief of an ununited fracture. The ends of the fragments were excised; the dog’s bone, separated, but still connected with its nutri- ent artery, was fastened in place, and boy and dog, bound together, were placed in bed. At the end of ten days the experiment was aban- doned as a failure. Fractures of the Bones of the Face. A case which came under my care in 1892 seems to me worthy of record here. A boy, aged 15, was brought in to the Pennsylvania Hospital, having sustained a “smash” of the face by the bursting of an 1 Lancet, Sept. 27, 1890. 2 Manchester Medical and Surgical Reports, 1870. 3 Revue de Chirurgie, 10 Mai, 1893. 4 Australian Med. Journal. Aug. 15, 1892. 5 Lancet, Oct. 26, 1889. 6 Med. Record, Sept. 13, 1890. 7 Med. Mirror, April, 1891. 412 injuries of bones. emery wheel. I was trying to get the fragments in place, when his respiration ceased, and it was evident that blood had run down into the air-passages. I instantly performed tracheotomy, and a large amount of blood, partly clotted, was evacuated through the wound. Perfect recovery ensued. Fractures of the Laryngeal Apparatus. Lane 1 found in a woman aged 80, a subject in the dissecting-room, the cornua of the hyoid bone separated from the body of the bone; the left greater cornu had been obliquely fractured, and united by fibrous tissue; the thyroid cartilage was deformed, its angle widened out, and its aim bent so that their posterior surfaces looked inward. The injury was thought to have been caused by a blow on the neck. Berry2 reports the case of a man aged 21, struck by a piece of wood thrown off by a circular saw; there was no spitting of blood, but he died from asphyxia in about twelve hours. At the autopsy the wings of the thyroid cartilage were found to be separated and splintered, the angle of one being broken off. Devernine3 saw in 1887 a young man aged 24, who nine years pre- viously had struck on his throat upon a trapeze-bar, sustaining a frac- ture in the middle line of the thyroid and cricoid cartilages, and of the upper four rings of the trachea. Union had taken place well, but the patient was suffering from phthisis, which proved fatal in the follow- ing year. In a case reported by Sokolovski,4 a woman was struck across the throat by “the strap of a mill,” and had a fracture of the thyroid car- tilage and of both sides of the cricoid. Tracheotomy was performed on the second day ; pieces of necrosed cartilage came away in the fourtli week, and a month later both halves of the thyroid cartilage were re- moved. The patient made a good recovery. Other cases of severe injuries of the larynx are reported by Knaggs,6 by Manby,6 and by Jeanmaire.7 Deakin 8 states that in fourteen cases of judicial hanging in India he found, as a rule, either rupture of the epiglottis or fracture of the hyoid bone or laryngeal cartilages. Fractures of the Ribs, Costal Cartilages, and Sternum. The first rib alone has been seen fractured in two cases by Lane.9 In one, union bad failed to occur. Another instance is reported by Marsh,1’ who cites three additional cases, and thinks that in all the mechanism was direct violence applied through the clavicle. In a case given by Messiter,11 a man aged TO was run over by a cart, and died of shock; the sternal end of the right clavicle was luxated 1 Trans, of Pathological Society of London, 1884. 3 British Medical Journal, May 24, 1890. 6 Brit. Med. Journal, Nov. 8, 1884. I Arch, de Med. et de Pharm. Militaires, 1890. 9 Brit. Med. Journ., Jan. 10. 1885. II Brit. Med. Journal, Feb. 19, 1887. 2 Lancet, May 23, 1885. 4 Lancet, June 8, 1889. 6 Lancet, Jan. 9. 1886. b Lancet, Jan. 5, 1884. 10 Lancet, June 30, 1888. FRACTURES OF THE RIBS, COSTAL CARTILAGES, AND STERNUM. 413 forward, and the first rib broken where the artery crossed over it; the second rib was broken at its mid-point, and the third and fourth behind their angles, wounding the lung. Here the above-mentioned explanation seems clearly applicable. I have lately had under my care at the Pennsylvania Hospital a man aged 21, in whom the impact of a wagon-pole had driven the cartilage of the left third rib directly back- ward, separating it from its connections. The only symptoms were those of shock; and perfect recovery ensued, but with the fragment in its abnormal position. Lane1 found in a dissecting-room subject, a man aged*56, fractures of the seventh rib (incompletely united), of the eighth (the inner wall only), and of the ninth (the outer wall only). Several new cases of fractures of ribs by muscular action have been put upon record: from sneezing (eighth right rib) by Wyman;2 from coughing (second left rib) by Brown,3 (eighth left rib) by Masser,4 (place not stated) by Desnos,6 in a man aged 30, an asthmatic, and in a man aged 60, the subject of bronchitis;6 from vomiting (ninth right rib), in a woman aged 31, by Hawley;7 from missing in making a hammer-blow, in a very strong man aged 54, by Underhill;8 in this last case three ribs, the sixth, seventh and eighth of the left side, gave way. In one curious case reported by Bird,9 a lady made a great effort in lifting, and fracture of the second left rib took place. Apropos of two other instances, observed by himself and Dr. E. Martin, Tunis10 has given a very good resume of the literature of this subject. Annandale 11 has reported the case of a man aged 29, who by an explosion sustained a compound comminuted fracture of the tenth and eleventh ribs on the left side, wounding the spleen and pleura; pericarditis supervened, for which paracentesis was performed, but death ensued on the thirteenth day. Other instances of fractured ribs have been recorded by Cantlie,12 by Neal,13 and by Sheild.14 In the last-mentioned case, a man aged 47 was crushed against a wall by a wagon-pole, and had fracture of the third and fourth left ribs, with complete rupture of the left bronchus. Rolles- ton 15 reports three cases of extensive and fatal crushes of the chest, in one of which the right bronchus was torn entirely across, and the lung wounded; in another there was fracture of the scapula, and rupture of the spleen and left kidney. In all, the first and several other ribs were broken. Barth 16 saw a case in which a man aged 46 died suddenly on the ninth day after sustaining a fracture of the sixth right rib by direct violence; the pleura was found to have been torn, and an enormous effusion of blood had occurred from a ruptured intercostal artery. 1 Trans, of Pathological Society of London, 1884. 2 Journ. of Am. Med. Association, Nov. 7, 1885. 3 Indian Med. Record, Dec. 1, 1890. 4 Brit. Med. Journal, April 26, 1890. 6 La France Medicale, 20 Oct., 1885. 6 Another case, also from coughing, in a man aged 60, a heavy drinker, is reported in the British Medical Journal for July 5, 1894, over the signature “B. S.” Crepitus is said to have been felt “ over several of the lowest ribs. ” I Medical Standard, May, 1890. 8 Lancet, June 28, 1864. 9 Australian Med. Journal, May 15, 1889. 10 University Med. Magazine, Nov., 1890. II British Med. Journal, Jan. 8, 1885. 12 Ibid., March 9, 1889. 13 Ibid., March 23, 1889. 14 Ibid. 15 Trans, of Path. Society of London, 1891. 16 La France Med., 18 Dec., 1888. 414 INJURIES OF BONES. In a case reported by Gill,1 a man about 50 years old fell, while drunk, a distance of twenty feet; he had a simple fracture of the ninth and tenth right ribs, and a fracture of the sternum just below the junction of the first and second portions; the pleura was wounded, causing emphysema; he suffered from profound shock, but recovered, fibrous union taking place. A very similar case, the fracture being, however, at the junction of the second and third portions, with an angular projection forward, is recorded by Eames;' the result is not stated. Bennett3 reports the case of a man crushed against a wall, who had a fracture of the sternum running downward and backward, beginning in front at the level of the cartilages of the second ribs, and ending below that of the cartilages of the third pair; the second and third ribs were broken on both sides, and on the right the fourth and fifth also; the trachea was ruptured transversely, its upper and lower portions being an inch apart. Porter4 gives a case in which a young man of 21 had a separation, apparently epiphyseal, between the second and third pieces of the gladi- olus, the lower overriding the upper. Lyman 0 saw the gladiolus driven backward from the manubrium, the second rib on each side remaining attached to the latter. In both the cause was direct violence; in both reduction failed, but took place spontaneously in the act of coughing. Another case, successfully treated with a plaster bandage, is reported by Cale.6 I have recently had under my care at the Pennsylvania Hospital a man, aged 60, who had fallen a distance of three stories, sustaining a fracture of the right upper angle of the manubrium and of two or three ribs; the right tibia was also broken in its upper fifth. There was very marked shock, and next day emphysema, which extended up the neck and across to the left side. For about two weeks he lay in a stupor; then he improved very much, but a week later became delirious, espe- cially at night. This condition gradually subsided; about the sixth week he was out of bed, and at the end of nine weeks he was discharged well. Fractures of the Clavicle. Cathcart7 calls attention to the fact that the weight of the upper limb is supported by the trapezius muscle, acting through the clavicle, which is a lever with its fulcrum at the sterno-clavicular joint. He cites in evidence of this some observations by Duclienne and by Cleland in cases of paralysis of that muscle. When the lever is broken, the limb tends to fall inward and downward. I may say that further experience has confirmed my belief in the cor- rectness of the theory which I have formerly maintained as to the action of the serratus magnus and pectoralis minor in producing the displacement in these injuries. I have repeatedly demonstrated it to my classes at the Pennsylvania Hospital, and have shown the good re- sults of treatment based thereupon. 1 New Orleans Med. and Surg. Journal, Oct., 1885. 5 British Medical Journal, Nov. 20, 1886. 4 Boston Med. and Surg. Journal, April 12, 1888. 6 International Journal of Surgery, August, 1890. 1 Brit. Med. Journal, Aug. 30, 1884. 3 Ibid., March 10, 1888. 5 Ibid. FRACTURES OF THE CLAVICLE. 415 McKee 1 has recorded a case of fracture of the right clavicle 2\ inches from the middle of the supra-sternal notch, by muscular action, in a man aged 49, who was trying to lift a heavy weight. A false joint had formed, hut no treatment was instituted. Kohler2 met with a case in which, among other fractures, there was one near the sternal end of the clavicle, which was itself luxated up- ward ; the short inner fragment was drawn upward by the sterno- cleido-mastoid muscle, so that its broken end was close to the edge of the jaw. A case is recorded by Bennett3 in which a young man aged 19, crushed under a mass of masonry, had in one clavicle two fractures, a complete one at the sternal end, and an incomplete one at the middle. Compound fracture of this bone is reported by Russell ;4 cases of non- union, successfully treated by resection and wiring, are recorded by Barker5 in a boy of 12, by Pollard6 in a girl months old, and by Powers.7 In this last case, that of a man aged 29, the deltoid muscle was atrophied; abduction was limited, and rotation, flexion, and exten- sion were practically lost. The fragments having been wired together by Bull, complete union ensued, and the functions were almost entirely restored under massage, faradization, and exercise. In an instance reported by Twynam,8 a young girl was thrown from a horse, and sustained a fracture of the right clavicle; five days after- ward an aneurismal swelling was noted, became very large, and on the 31st day was treated by operation. An incision was made in the median line, and a ligature was placed on the innominate, supposed to be the carotid, which latter vessel was afterward found and tied. Death ensued in eighteen hours, preceded by coma, and by paralysis of the left side of the face and right side of the chest. It seemed probable that there was pressure on the phrenic nerve, as well as cerebral em- bolism. A case is recorded9 in which, in a girl aged 8, a bandage and axillary pad were applied on the third day, and gangrene ensued by the seventh, necessitating amputation ten days subsequently. A suit for damages, brought against the surgeon, fell through because of the proof of negligence on the part of the parents of the child; but the costs were divided. In an article10 on nervous disturbances consecutive upon fractures of the clavicle by indirect violence, Chavier asserts that these may result from an ascending neuritis set up by contusion of the nerves, inde- pendently of any irritation by splinters, by callus, or by the pressure of apparatus. Cases of fracture of both clavicles simultaneously have been recorded by Bennett,11 in a girl aged 6 years; in adults, by J. Wm. White,12 by Owen,13 by Page,14 and by Boger.15 Good results were obtained in all these cases except Bennett’s, in which other injuries proved fatal, and Boger's, in which the patient was intractable. 1 Occidental Medical Times, March, 1890. 2 Berliner klin. Wochenschrift, 1886, No. 38. 3 British Med. Journal, Nov. 24, 1883. 4 Ibid., May 16, 1885. 6 Ibid., Jan. 30, 1886. 6 Ibid., March 26, 1887. I New York Medical Journal, May 24, 1890. 8 Lancet, June 21, 1890. 9 British Med. Journal, May 29, 1886. 10 Gaz. Medicale de Paris, 24 Aout, 1889. II Lancet, Jan. 22, 1887. * 12 University Medical Magazine, Jan., 1890. 13Lancet, July 5, 1890. 14 Ibid., July 12, 1890. 15 Ibid./July 26, 1890. 416 INJURIES OF BOXES. Fractures of the Scapula. Two additional cases in which this lesion was due to muscular action have been reported: one by Dobson,1 and the other by Leidy.3 R. W. Parker3 has recorded three cases affecting the neck of the hone, two in men aged 55 and 68 respectively, and one in a woman aged 44; in another case, that of a man aged 24, the injury appeared to be a contusion merely, followed by wasting of the neighboring mus- cles, but the diagnosis was at first obscure. Another instance, in which the injury at first seemed to be a luxation of the humerus, has been re- ported by Hemenway.4 I had myself in 1887, at the Pennsylvania Hospital, a boy said to be two years old, but very large for that age, who had fallen out of a third-story window, sustaining a fracture in the shoulder-joint, proba- bly through the glenoid cavity; the crepitus was very distinct, but could not be certainly located. On the sixteenth day all trace of the injury had disappeared. In a case reported by S. C. Smith,5 a man aged 35 sustained by a crushing force a fracture of the scapula and upper three ribs on the left side, with rupture of the subclavian artery and vein; death ensued in sixteen hours, from shock. Robson 0 saw a miner, aged 31, who had had a fracture of the scapula by direct violence; there was a gap of an inch between the two portions of the spine near the root of the acromion, and the muscles were wasted. The fragments were exposed, freshened, and wired together, and five months afterward the strength and movements of the part were com- pletely restored. Cases of fracture of the coracoid process have been reported by Huse,7 Bennett,5 Gabb,9 Morgan,10 Young,11 Greene,13 Field,13 and Hupp.14 Field’s case was that of a boy only 5 years old, and it seems to me to be perhaps open to some doubt, on account of the extremely small size of the process at that early age. Yet in Bennett’s case, and in one seen by Durham,15 the former in a boy of 6, and the latter in a boy of 12, the diagnosis was verified by dissection after death. In Durham’s case there was no history of injury, and nearly the whole of the scapula was lying bare in an abscess, which had involved the shoulder-joint; the assumption that “ the probable sequence of events was a blow on the coracoid process with partial or entire separation, followed by acute inflammation and formation of pus,” seems to me therefore scarcely warranted. I am more inclined to believe that the epiphysis was hathed in pus, and separated by maceration. 1 Lancet, Nov. 27, 1886. 2 University Medical Magazine, March, 1891. 3 British Med. Journal, Aug. 22, 1885. 4 Journal of the Am. Med. Association, Feb. 5, 1887. 5 Lancet, Jan. 24, 1891. 6 British Med. Journal, Nov. 1, 1884. 7 Chicago Med. Journal and Examiner, Aug., 1879. 8 British Med. Journal, Nov. 24, 1883. 9 Ibid , Nov. 30, 1889. 10 Ibid., Dec. 14, 1889. 11 Ibid., Dec. 21, 1889. 12 Ibid., Jan. 25, 1890. 13Boston Med. and Surg. Journal, April 24, 1890. 14 New York Medical Journal, Dec. 10, 1892. is Mentioned by Tubby, Guy’s Hospital Reports, 1889, p. 270. This paper contains a very interesting discussion of the subject of traumatic separations of the epiphyses of the upper extremity. 417 FRACTURES OF THE PELVIS. Fractures of the Pelvis.1 A case of separation of the right anterior superior spine of the ilium by muscular action has been recorded by Brown;2 the patient, a boy aged 17, recovered completely in eight weeks. In another instance, reported by Nickerson,3 the boy walked without crutches in three weeks. In Joy's case,4 a good recovery ensued in two weeks. In two other cases, reported by Hyde 6 and by Sealy,6 the injury was in the nature of a sprain-fracture, the anterior inferior spine being torn off by the pull of the head of the rectus muscle attached to it. A case of fracture of the pelvis on either side of the symphysis pubis, with rupture of the urethra and extravasation of urine, followed by repeated attacks of retention, and by the formation of perineal fistulse, but ending in recovery, has been recorded by Dunn.7 In another in- stance, reported by J. B. Deaver,8 a fracture at one side of the pubic arch, in a boy 3 years old, gave rise to a urethro-rectal fistula which persisted twenty-one years, and was then closed by a plastic operation. Battle,9 in the case of a girl aged two and a half years, with compound fracture of the left side of the pelvis through the transverse and as- cending rami of the os pubis, close to the symphysis, and with separa- tion of the sacro-iliac synchondrosis, made an incision in the groin, and wired together the fragments, which were separated one and a half inches. Perfect recovery ensued. In a case reported by Browne 10 the epigastric artery, and in one by Mason 11 the obturator artery, was torn across; in both the bladder and urethra were ruptured; death took place in the former in four hours, in the latter not until the seventeenth day. Allis 12 argues that in considering the injuries of the pelvis, it should be regarded as a bony ring, and not as composed of its several parts. He thinks that when the anterior portion suffers, the urethra is torn across, not cut by fragments; and that the vessels are similarly dragged upon when there is expansion of the posterior part of the ring by vio- lence from without. Holmes 13 met with a case in which a man fell fifteen feet, striking on the greater trochanter, and died in a few hours; the head of the femur was found to have been driven through the fractured acetabulum into the pelvis. I have myself recently had in the Pennsylvania Hospital a man aged 54, who fell a considerable distance, and fractured the lip of the acetabulum, allowing the head of the femur to slip up upon the dorsum ilii. After reduction shortening was noticed, easily overcome, with crepitus, and as easily recurring; extension was carefully and 1 The reader is referred to an interesting article by Kloos, “Znr Casuistik der Beckenfrac- turen” (in Beitrage zur klinischen Chirurgie, 1888, Band iii., Heft 3). The author gives 4 cases, 3 fatal, the autopsies showing injuries either of the bladder or of the urethra. 2 British Med. Journal, Aug. 16, 1884. 3 Boston Med. and Surg. Journal, March 6, 1890. 4 Canada Med. Journal, Aug., 1870. 5 British Med. Journal, Nov. 2, 1872. 6 Ibid., Nov. 16, 1872. 7 Guy’s Hosp. Reports, vol. xxix., 1887. 8 Trans, of Am. Surgical Association, vol. x., 1892. 9 Trans, of the Clinical Society of London, vol. xxvii., 1894. 10 Lancet, May 15, 1886. 11 Ibid., Jan. 22, 1887. 12 Trans, of Am. Surg. Association, vol. viii., 1890. 13 British Med. Journal, Dec. 24, 1887. 418 INJURIES OF BONES. continuously applied, and at the end of about three months the man was discharged, walking well, and with the limb apparently of normal length. Ilian instance reported by Bull,1 a man aged 30 fell through a hatch- way, sustaining a compound fracture of the innominate bone, opening the hip-joint; he recovered with a useful limb. I have recently had at the Pennsylvania Hospital a case in which suppuration occurred about a fragment, comminuted fracture of the ilium having taken place ten years before; healing took place promptly after the splinter had been removed. Pollock 2 gives a case in which a man aged 55, run over by an engine, had a fracture of the pelvis, and a spicula of bone wounded the left internal iliac artery, causing his death in seven hours; he had also two or three upper ribs broken. Sir Charles Bell;i mentions an Irish laborer who fell from a height, injuring his right hip; a swelling ensued, ex- tending from the lower ribs half-way down the thigh; on incision, blood only flowed, and after death it was found that there was a frac- ture into the sciatic notch, the gluteal artery being wounded, with for- mation of a false aneurism. A fracture of the sacrum is reported by Hirst.1 A woman, aged 32, with six children, the youngest being 3 years old, had fallen three stories, striking on the sacrum. When seen by Hirst, it was found that the bone had been broken transversely at the level of the posterior inferior spinous processes, and that the fragments had united at an angle 90 degrees salient forward; the outlet of the pelvis was reduced to inches in its antero-posterior diameter. Fractures of the Humerus. Pollosson 5 has reported a case in which a woman died after suffering severely with eclampsia, and the head of each humerus was found to present a deep indentation apparently made by the anterior edge of the glenoid cavity; the cancellous structure beneath was infiltrated with blood. A number of cases of separation of the upper epiphysis have been put upon record. Tubby, in the paper before referred to, cites an instance in a boy aged 14, under the care of Mr. Durham, and another in a girl aged 17, a patient of Mr. Davies-Colley; in both the cause was direct violence, and a good result was obtained. Eollet6 reports two cases of Poncet’s. In one, that of a girl aged 15, the projecting edge of the lower or shaft fragment was resected on the thirty-ninth day; in the other, that of a boy aged 17, the operation was performed on the forty- first day; perfect union was obtained in both. Knox,7 in the case of a boy aged 16, where the end of the diaphysis protruded through the deltoid muscle, effected reduction, applied an antiseptic dressing, a felt slioulder-cap, and an inside angular splint; complete recovery ensued. Clark,8 in a similar case, was obliged to amputate, the limb becoming gangrenous from injury to the axillary artery. 'New York Med. Journal, Jan. 17, 1885. 2British Med. Journal, March 14, 1885. 3 Principles of Surgery (1826), vol. i., p. 383. ••Boston Med. and Surg. Journal, Jan. 5, 1893. 5Revue de Chirurgie, Nov., 1888. 6 Lyon Medical, 29 Mars, 1891. •Medical News, Dec. 5, 1885. 8 Glasgow Medical Journal, Sept., 1886. FRACTURES OF THE HUMERUS. 419 Detachment of this epiphysis has sometimes been followed by failure of development of the bone. Such cases have been recorded by Bruns,1 by Bryant,2 and by Shearar.3 As to the treatment of ordinary cases, enough has already been said. Besides the operations above referred to, Helferich,4 in a successful case shown to the Society of German Surgeons, cut down upon the fracture, reduced the displacement, and secured the fragments by passing through them a long steel pin, which was left in place for two weeks. Bruns stated that in two instances he had excised the detached epiphy- sis, and Wolder had had one like experience. Todd 5 reports a case in which an old woman who had fallen down a flight of stairs, was thought to have sustained a fracture of the ana- tomical neck of each humerus. In another case, recorded by Croft,6 a man aged 33 fell about eighteen feet, breaking the neck of the bone, and displacing its head into the axilla, whence it was excised; the re- sult is said to have been better than might have been expected. Poi- rier 7 has reported another instance. Clutton 8 relates that in the case of a boy aged 13, with subclavicular dislocation and fracture of .the surgical neck of the humerus, reduction was accomplished by incision and direct pressure, after which an ivory peg was driven through both fragments. Recovery ensued, with perfect movements of the joint. A specimen was shown by Little9 to the Royal Academy of Medicine in Ireland, in which the greater tuberosity of the humerus was detached, the head of the bone being luxated. In a case reported by Fenwick 10 a woman aged 41 was struck by a falling timber, and had a fracture of the surgical neck of the humerus, with a wound of the brachial artery; the vessel was exposed and tied above and below, with success, the radial pulse returning in less than forty-eight hours. A less fortunate result is recorded by Angerer." A woman, aged 32, fell down-stairs, landing on her face, with her left arm adducted and flexed across her chest. Sensation and motion were at once lost, and there was great pain in the shoulder. Gangrene of the limb ensued; disarticulation at the shoulder was performed, and it was found that there was a V-shaped fracture of the surgical neck of the humerus, the radial (musculo-spiral) nerve being torn off, and the other nerves and the vessels strongly compressed by the shaft-end driven up beneath the pectoral muscle. Powell12 saw in a child four days old a fracture at the middle of the arm, due to rough handling on the part of a nurse. Stamforth 13 is reported to have shown to the Sheffield Medico-Chirur- gical Society a girl 21 years of age, in whom atrophy of the deltoid, supra-spinatus, infra-spinatus, biceps and brachialis anticus, was ascribed to “ a green-stick fracture of the humerus over nineteen years previously.” 1 Archiv fur klinische Chirurgie, 1882. 2 Manual for the Practice of Surgery, 4th ed., 1885, p. 877. 3 British Medical Journal, Oct. 10, 1885. 4 La Semaine Medicale, 11 Avril, 1888. 5 Med. and Surg. Reporter, Nov. 22, 1890. 6 Lancet, March 29, 1890. I La Semaine Medicale, 24 Sept., 1892. 8 Lancet, Nov. 17, 1894. 9 British Medical Journal, April 24, 1886. 10 Ibid., Sept. 29, 1888. II Archiv fur klinische Chirurgie, Berlin, 1889. Medical Bulletin, Jan., 1884. 13 Lancet, May 25, 1889. 420 INJURIES OF BONES. Cases of non-union of the shaft, treated by wiring, have been put upon record by Wright,1 by Keeling,2 by Sibthorpe,3 and by Symonds.4 I have myself met with two cases in which the ends of the frag- ments, instead of being dense and hard, were so softened that they could not hold the wires, and the patients were obliged to be content with such advantage as they could gain from prothetic appliances. Cases of paralysis of the parts supplied by the musculo-spiral nerve, from angular deformity or excess of callus after fracture of the shaft of the humerus, have been reported by Puzey,5 Nicolson,6 and Murray.7 The last-named author quotes Bruns as having collected 77 instances of the kind. Lunn8 records the case of a woman aged 38, who had a compound comminuted fracture of the right humerus, and six months after union was complete had pain which was relieved by the removal of a spicula of bone pressing up under the fibres of the musculo-spiral nerve; at another operation a mass of callus was gouged away from beneath the median nerve, after which recovery was complete. In a case recorded by Wheeler,9 a boy aged 12 sustained a transverse fracture just above the condyles, and the pressure of the end of the shaft of the bone against the brachial artery caused the death of the limb. Puzey 10 saw a man who a year previously had had his upper extrem- ity crushed in some machinery; he had oblique fracture of the upper third of the humerus, ununited by reason of fascia caught between the fragments; a united fracture at the middle of the shaft; another, un- united, at the junction of the middle and lower thirds; incomplete an- kylosis of the elbow; comminuted fracture of both bones just below the joint, ununited; fracture of lower third of the ulna, the upper fragment united to the radius. , Various means having been vainly employed to effect union, and suppuration having occurred in the wrist-joint, amputation at the shoulder was performed, and the man recovered. An unusual case has been reported by Stimson,11 in which a man about 50 years old had his elbow crushed under a heavy stone, and had the lower end of the humerus broken into three fragments, the condyle and trochlea forming one, the epicondyle a second, and the epitrochlea a third. Of detachment of the lower epiphysis of the humerus, Tubby 12 cites two specimens and five cases. In one of the cases amputation was necessary, and in two temporary occlusion of the arterial current was noted. Clark 13 mentions having seen a separation of this epiphysis in a new- born child. In my former article, allusion was made to the recommendation by 1 Lancet, Jan. 5, 1884. 2 British Medical Journal, Jan. 17, 1885. 3 Ibid., March 10, 1888. 4 Lancet, Dec. 2, 1882. 6 Liverpool Medico-Cliirurgical Journal, July, 1889. 6 Gaillard’s Medical Journal, Jan., 1890. I New York Medical Journal, June 25, 1892. 8 Transactions of the Clinical Society of London, vol. xxv., 1892. 9 Trans, of Royal Academy of Medicine in Ireland, 1889. 10 British Medical Journal, Jan. 10, 1885. II New York Medical Journal, June 30, 1888. 12 Loc. cit. 13 Glasgow Medical Journal, Oct., 1886. FRACTURES OF THE BONES OF THE FOREARM. 421 some surgeons that fractures of the humerus close to the elbow should be treated in the straight rather than in the flexed position. This idea has lately been advocated, especially in the case of children and young persons, by Berthomier,1 by Lauenstein,2 and by Nunn.3 Roberts, in a paper read at the meeting of the American Surgical Association in 1892,4 expressed himself in favor of the straight position, and found fifteen other surgeons who agreed with him by letter in answer to written queries; but sixty-five preferred flexion, and seven “used both.” There can be no question that the angle on which the “carrying function” depends can be maintained more conveniently and with more certainty with the elbow in extension; but this is not the only object to be sought. When ankylosis does occur, a straight arm is absolutely useless for anything else; I had in December last to excise an elbow to remedy just such a result, in a boy about 14 years old, and Dr. Ashhurst in- forms me that he has twice had the same experience lately. Much de- pends upon the condition of the soft parts; if they are extensively torn, ankylosis in the flexed position, and with the forearm in semipronation, may offer the best, and indeed the only, chance for a useful limb. If on the other hand the muscles and ligamentous structures seem to be intact, or nearly so, and if there is no evidence of inflammatory action within the joint, threatening adhesions, there is no doubt that a good result may be obtained with the elbow either straight or at a very ob- tuse angle. My own experience has led me to trust in extreme care, early and cautious passive motion, and a very guarded prognosis. Fractures of the Elbow. Cheyne 5 has recorded an interesting case in which a boy, aged 13, fell a distance of about ten feet, striking on his elbow; the posterior part of the condyle was chipped off, and the coronoid process was broken into several pieces; these fragments were removed, and the olecranon, which was fractured, was wired, on the fourth day. Four months afterward the wires were removed, as they annoyed him; the movements of the joint were good, and steadily improving. Fractures of the Bones of the Forearm. Tubby, in the paper before referred to, cites two instances of separa- tion of the epiphysis of the olecranon; one in a child 2 years old, who was run over by a cart, and died of pyaemia; the other in a boy of 14, from a fall on the elbow, suppurative arthritis ensuing and demanding excision. Very possibly a case reported by Eames,6 that of a child 4 years of age, may have been of the same nature. A case in which fracture of the olecranon was the result of slight muscular action, in a miner who “put out his hand to stop a coal-tub, and felt something give way,” has been recorded by Symes.7 Laver," in a case of two months’ standing, the fragments being two 1 Revue de Chirurgie, Avril, 1888. 2 Deutsche med. Zeitung, 19 Apr., 1888. 3 Trans, of the Clinical Society of London, vol. xxv., 1892. 4 Transactions, p. 15. 5 British Med. Journal, March 7, 1891. 6 Ibid., July 16, 1887. 7 Ibid., April 28, 1888. 8 Lancet, Nov. 18, 1882. 422 INJURIES OF BONES. fingers’ breadths apart, scraped, drilled, and wired them together; the patient was discharged after four months, “with perfect union and full power.” An instance is reported by Wright1 in which a boy of 17 had a frac- ture of the olecranon, and suffered from atrophy, loss of power, and neuralgia in the muscles and region supplied by the ulnar nerve. A splinter was found detached and pressing on the nerve; it was re- moved, the fragments were freshened and wired together, with a good result. Excision of the elbow-joint was performed by Lloyd 2 in a man aged 27, who had a fracture of the ulna from the upper end of the olecranon downward and forward to the middle of the sigmoid notch, the frag- ment being driven forward so as to narrow the cavity and prevent the reduction of the humerus into it. The result is not stated. Fractures of the coronoid process led to excision of the joint in a case recorded by Lediard,3 and in three b}r Annandale.4 In all these the elbow was luxated backward. Holmes, discussing Lediard’s case, said that there was in the museum of St. George’s Hospital a specimen of fracture of both the coronoid processes in the same subject. In two of Annandale’s cases the detached portion was found adhering to “the posterior aspect of the inner condyle” (epitrochlea?). Two cases are mentioned by Tubby in which there was separation of the upper epiphysis of the radius. Several cases of fracture of the head or neck of the radius have been put upon record. Annandale5 has reported three. In one, a man aged 48 struck his wrist against his knee; three months later, his elbow being disabled, an incision was made, and the loose fragment was removed. In another, a young woman fell and struck her elbow; nine months afterward, the joint being firmly fixed in the straight position, the head of the radius, broken off and split into two pieces, was excised, with a good result. The third case was similar to the last, the specimen only being mentioned. Stimson 6 gives the case of a man in whom this injury was compli- cated with a fracture of the coronoid process; in the third week arthrot- omy was performed, and the head and neck of the radius were re- moved; a good recovery ensued, with flexion to 45°, pronation complete, but supination limited. Another like case, in a lady aged 26, is re- corded by Cheyne.7 Delorme6 saw a case diagnosed as “partial longi- tudinal fracture of the head of the radius,” in which perfect recovery ensued. In a case reported by Felkin9 the patient, a woman aged 21, fell with her whole weight on her elbow, and sustained a fracture of the radius an inch below its head; the ulnar nerve was also dislocated for- ward, and had to be replaced by operation. Stimson 10 mentions a curious case in which a boy of 13 had the outer half of the head of the radius detached by a blow from the runner of a sled. The diagnosis was verified upon the excision of the joint, made necessary by suppurative arthritis. Another instance, in which the 1 New York Med. Journal, May 7, 1887. 3 Lancet, May 3, 1884. 6 Ibid. 1 British Med. Journal, March 7, 1891. 9 Edinburgh Med. Journal, July, 1887. 2 British Med. Journal, March 17, 1888. 4 Edinburgh Med. Journal, Feb., 1885. 6 New York Med. Journal, Nov. 24, 1888. 8 Gaz. des Hopitaux, 17 Mars, 1891. 10 Treatise on Fractures, p. 433. FRACTURES OF THE BOXES OF THE FOREARM. 423 head of the bone was broken into three portions by great violence, in an adult, is recorded by Adams.1 Fracture just below the insertion of the biceps, in a man aged 22, who fell on a floor, has been noted by Bird.2 The forearm was kept in supination, and it is stated that recovery was perfect. Fracture of both bones of the forearm is said by Humphry3 to have been seen by him as the result of convulsions in whooping-cough, in a child. Several instances of serious consequences from these injuries have been reported. In one, by Puzey,4 a boy aged 15 had a compound fracture, the union of which was delayed, and there was progressive paralysis of the ulnar nerve, with wasting, and “clawing” of the fin- gers; the nerve was freed by operation, and function was gradually but completely restored. In another, by Lane,6 a simple fracture of both bones gave rise on the twentieth day to extensive thrombosis, with much oedema, pain, and tenderness; another attack occurred in three weeks, and still another two weeks later involved the innominate and internal jugular veins, threatening life; this gradually subsided, but came on again in twenty-five days, and once more seven weeks after that. Union failed in the radius. Molitor6 quotes from Jungst a case in which a simple fracture of both bones of the forearm by machinery caused occlusion of the brachial artery, and gangrene of the limb. The resulting deformity is sometimes troublesome, as in a case re- corded by Gayraud,7 in which a girl 8 months old had both forearms broken; when seen by him twenty months later, on the right side union had taken place with the fragments at a right angle “like a second elbow;” on the left side the angle was less marked. Straightening was successfully accomplished. Robson 8 saw a boy 6 years old, who four years before had been run over by a cart, and had probably sustained a fracture of both bones; he had had no treatment, but the only trace of the injury was a pro- jection of the radius upward and inward just below its head; supination was impaired. Dr. H. R. Wharton has mentioned to me that in 1888 he saw a boy aged 12, who by a fall from a horse had sustained “a fracture of the lower end of the radius, with great deformity, the hand being markedly drawn inward, and the ulna being decidedly curved in the same direction, the point of greatest curving being about two inches above the styloid process. In making pressure to reduce the deformity, the ulna gave way with a snap at the point above mentioned.” Reduction was then easy, and the boy recovered “with a very perfect arm.” Three years ago I had at the Pennsylvania Hospital a boy aged 8 years, who some months previously had had both bones of his right forearm broken about an inch above the wrist. Necrosis of the frag- ments followed, and I removed the end of the ulnar diaphysis and part of the radial, leaving the epiphyses in place. 1 Trans, of the Pathological Society of London, 1871. 2 Australian Med. Journal, May 15, 1889. 3 British Med. Journal, Nov. 15, 1884. 4 Ibid., May 16, 1885. 5 Medical Times and Gazette, May 3, 1884. 6 Beitriige zur klin. Chirurgie, 1889. 1 Gaz. Hebdom. des Sciences Med. de Montpellier, 3 Sept., 1887. 8 Lancet, March 21, 1885. 424 INJURIES OF BOXES. Of fracture near the lower end of the radius, a number of cases have been reported.1 In one, seen by Hinshelwood,2 both wrists were broken by a fall down-stairs; in the right there was the ordinary deformity, but in the left it was reversed, a hollow existing on the dorsum, and a corresponding prominence in front. A point which seems to have hitherto been unnoticed is the effect of obliquity of the line of fracture upon the deformity. This I have sev- eral times seen; an illustration of it has been given by Lockwood.3 Curtis4 has reported the case of a man aged 41, who sustained a Colies’s fracture, which did well, and he returned to work; two days afterward he made a sudden grasp with the injured hand, and the bone gave way again, apparently in exactly the former line. A fatal case of tetanus after an injury of this kind, in a boy aged 15, has been recorded by Waitz;5 also another case, in which the symp- toms subsided upon resection of the bulky callus, and freeing of the radial nerve, in a boy of the same age, by Brunner.6 These fractures are generally said to be infrequent in early life; but it has occurred to me to have at the Pennsylvania Hospital, within a period of forty-eight hours, four cases in patients between 5 and 12 years of age. All these were from simple ordinary falls on the hand; there was no ice on the ground, nor any other circumstance to account for the coincidence. I lately had a very striking instance of separation of the lower epi- physis of the radius, in a boy 10 years old, who had fallen on the ground; under ether the fragment went into place with a click plainl}* heard by the bystanders. In a case recorded by Wickes,7 a boy 12 years old fell a distance of twenty-five feet, and had a compound separation of the lower epiphysis of the radius, the shaft protruding; the ulna was broken about 1£ inches higher up. On the third day gangrene ensued, necessitating amputation above the elbow; the boy recovered. Here, as elsewhere, failure in the growth of the bone has sometimes been observed as the result of these epiphyseal disjunctions. The sub- ject has been recently discussed by Stehr," with records of three new cases, and reference to those previously reported by Hutchinson, Goy- rand, Poncet, and others. As to the treatment of fractures of the lower end of the radius, there has been nothing wholly new proposed. I have m}Tself found entire satisfaction in the use of a small splint carefull}7 fitted so as to fill up the normal hollow of the anterior or palmar aspect of the ra- dius, in order to maintain reduction after this has once been thoroughly effected, this splint being kept in exact place by a broad band of rub- ber plaster firmly applied. 1 St. Bartholomew’s Hospital Reports, 1887; Trans, of Pathological Society of London, vol. xxxviii. - British Med. Journal, Nov. 3, 1888. 3 Trans, of Pathological Society of London, 1884. 4 New York Medical Journal, Feb. 21, 1891. 6 Report of Esmarch’s Clinic, Archiv ftir klin. Cliirurgie, 1877. 6 London Medical Recorder, July 15, 1886. 1 Med. Times and Gazette, Dec. 22, 1883. 8 BeitrHge zur klin. Cliirurgie, v., 1889. FRACTURES OF THE FEMUR. 425 Fractures of the Femur. Cases of separation of the upper epiphysis of this bone have been re- ported by Noble Smith,1 by Robson,2 by Maylard,3 and by Davies-Colley.4 I had in my wards at the Pennsylvania Hospital, in 1889, a case which I believe to have been of this character. It was that of a boy 14 years old, who had been knocked down in a scuffle, striking on his hip; he had some shortening and eversion of the limb, with pain, and a muffled crepitus in the neck of the bone. He was treated with ex- tension and sand-bags, and recovered perfectly in nine weeks, with a limb apparently of normal length. Whitman 6 thinks that fractures of the cervix femoris are not un- common in children, and that when the diagnosis is doubtful the pre- sumption is in favor of this form of injury rather than of epiphyseal separation. He gives five instances, in children from 2\ to 8 years old, in which the neck of the bone was thought to be broken, all resulting in cures. In either case the indications are to make extension and to prevent rotation, so that the question is one of no great practical im- portance. With regard to fractures of the neck of the femur, the views pre- sented in my former article are those which I still entertain. Senn’s proposition,6 that the distinction between intra-articular and extra-artic- ular fractures should be abandoned, was long ago made by Bigelow,7 and may be accepted without question, since practically the diagnosis can rarely be made during life. Some cases there undoubtedly are, in which a degenerated bone breaks across at its narrow part, near the head; and in other cases the age and the general condition of the patient pre- clude the hope of repair. I have now under my care at St. Joseph’s Hospital a woman 92 years old, who a week ago sustained a fracture of the femoral neck, who has already, in spite of every care, a large bedsore. To apply any apparatus in her case would have been simply cruelty. But in the vast majority of instances the fracture is oblique, the line running down toward the lesser trochanter; and in very many there is more or less impaction. Such was clearly the character of a case reported and figured by Raven.8 The practical deduction is, that if the necessary restraint can be borne, an effort should always be made to obtain union. For this purpose the ordinary and well-known dress- ings, applied with due care, are sufficient. Senn proposes the encase- ment of the patient, from the level of the cartilages of the eighth ribs down to the knees, in a plaster apparatus; into this on the injured side is let in a bracketed metal splint, the bracket perforated for a screw carrying a flat pad, which shall press against the trochanter, and thus hold the outer fragment closely in contact with the inner. Eight cases are adduced in which good results attended upon the employment of this apparatus; results, however, certainly not any better than those 1 Lancet, March 20, 1886. 2 Ibid., Aug. 21, 1886. 3 British Med. Journal, April 2, 1892. 4 Trans, of Clinical Society of London, vol. xxv., 1892. 5 Medical Record, Feb. 25, 1893. 6 Journal of the Am. Med. Association, Aug. 3, 1889. 1 The Mechanism of Dislocation and Fracture of the Hip, p. 126. (Quoted in my former article.) 8 Lancet, Aug. 6, 1887. 426 INJURIES OF BONES. which I am myself accustomed to obtain, or than those which I have seen in the practice of others. Nor does this method seem to shorten appreciably the duration of treatment. Blaker 1 claims to have had a case of recovery in one month, from an impacted fracture of the femoral neck, in a woman aged 57, treated merely with extension. Cheyne2 gives the case of a woman aged 52, in whom the fragments were pegged together with ivory, there being no impaction, but a shortening of inches; the dressings were finally removed on the 01st day, and on the 131st she was dismissed; a month after she was again seen, and the result was reported to be “fairly good.” In a case of non-uniori of the femoral neck in a robust man, aged 36, injured nineteen months previously, Loreta3 is said to have obtained success by opening the joint from behind, dividing the fibrous tissue be- tween the fragments, scraping the ends of the latter, and introducing eight or ten metallic wires between them for five days; union took place by first intention, in less than a month there was no pain, and on the fifty-fifth day the patient walked with only the aid of an attend- ant’s hand. The use of the wires here would seem to have been merely as a sort of seton, and there must have been great risk of setting up an arthritis. Allis has discussed 4 the causes of difficulty in the treatment of frac- tures in the upper third of the femoral shaft, which he thinks have hitherto been misapprehended. He argues that the shortening is due to angular displacement, only aggravated by extension; and proposes to resort to an operation, laying bare the fragments and securing their apposition by means of metal screws, in all such cases. Bold as this suggestion may seem, it is supported by very strong arguments, and certainly merits full consideration. Fractures of the shaft of the femur by muscular action have been reported by Burr5 (two cases, both in paretics), by Ewing,6 by Lydston,7 and by Beck 8 (in a boy only 6i years old, who was trying to lift a play- mate on his back). I have myself recently seen a similar case in a man aged 30, apparently quite healthy, whose femur gave way as he slipped on the ice and tried to avoid a fall. The subject of the treatment of fractures of the shaft of the femur, and of the results to be expected, was discussed by Dr. Stephen Smith in an excellent paper presented to the American Surgical Association in 1890.9 A committee was appointed to consider the matter, and re- ported 10 at length, with the following conclusions: A satisfactory result has been obtained when— “1. Firm bony union exists. “ 2. The long axis of the lower fragment is either directly continuous with that of the upper fragment or is on nearly parallel lines, thus preventing angular deformity. “ 3. The anterior surface of the lower fragment maintains nearly its normal relation to the plane of the upper fragment, thus preventing undue deviation of the foot from its normal position. 1 British Med. Journal, Nov. 28, 1885. 3 Ibid., Aug. 25. 1888. 6 Medical Standard, December, 1889. 1 Physician and Surgeon, Oct., 1892. 9 Transactions, vol. viii., p. 39. 2 Ibid., March 7, 1891. 4 Medical News, Nov. 21, 1891. 6 British Med. Journal, March 21, 1889. 8 Jahrbuch fiir Kinderheilkunde, 1886. 10 Ibid., vol. ix., p. 81. FRACTURES OF THE FEMUR. 427 “ 4. The length of the limb is either exactly equal to its fellow, or the amount of shortening falls within the limits found to exist in 90 per cent, of healthy limbs, viz., from one-eiglith to one inch. “ 5. Lameness, if present, is not due to more than one inch of short- ening. “ 6. The conditions attending the treatment prevent other results than those obtained.” Dr. Smith’s paper, with the discussion upon it, and the full report of the committee, are well worthy of study. Thiriar is said 1 to have devised a combination of the starched band- age with extension by weight and pulley. He first applies one section of the bandage, with the extension, to the leg; a second section is then put on the thigh, overlapping the former in telescope-fashion. The thigh-part may be slit up so as to expose the limb, and when closed may be kept so by means of straps and buckles. Mention majr perhaps be appropriately made here of a report by R. W. Parker2 of five cases of intentional fracture of the femur for the correction of deformities. Kennedy 3 reports the case of a man aged 38, who was carried down thirty feet in the wreck of a scaffolding, sustaining among other in- juries a comminuted fracture of the right femur at the upper part of its middle third. About two weeks afterward, the shortening amount- ing to three inches, an incision was made exposing the bone, when the lower fragment was found at the outer side of the upper, both, with some splinters, being embedded in a mass of callus. Resection was performed, and the ends wired together. Ten weeks later union was firm, and the patient could bear almost his entire weight upon the limb, which, however, was shortened two and three-quarter inches. An interesting case is recorded by Collings4 in which a sailor aged 30 had had, fifteen months previously, a fracture of the shaft, badly united, with a shortening of six inches. By resection and subsequent extension the deformity was corrected, and union was obtained with only two inches of loss of length, and good use of the limb. Other instances have been reported by Heath 6 and Lorenz.6 In the latter case the frac- ture, in a boy aged 10 years, was situated in the upper third of the shaft, and had occurred five and one-half years previously. Union had taken place with an angle outward. By chiselling the fragments apart, and free division of muscles and tendons, a very good result was secured. Cases of non-union successfully treated by wiring have been recorded by Tobin,7 Robson,8 Owen,9 and Leeming.10 In two other cases, one re- ported by Jacobs11 and the other by Treacy,12 the lesion was seated in the lower third of the bone, and in each the distal fragment was tilted down into the popliteal space by the gastrocnemius muscle. In each case, suturing of the ends with silver wire resulted in firm union, but with two inches of shortening of the limb. Marks13 has recorded the case of a girl aged 14, who at the age of I Editorial in the Lancet, July 2, 1887. 2 Med. Times and Gazette, Dec 29, 1883 3 Med. Record, Dec. 19, 1891. 4 Lancet, April 5, 1890. 5 Ibid., March 15, 1887. 6 Wiener med. Wochenschrift, Bund 10 Jan., 1891. 7 Lancet, July 5, 1884. 8 British Med. Journal. Dec. 6, 1884. 9 Ibid., Nov. 21, 1885. 10 Lancet, Jan. 29, 1887. II Medical Record, Jan. 14, 1888. 12 New York Med. Journal, Nov. 5, 1892. 13 Journal of American Medical Association, Nov. 6, 1886. 428 INJURIES OF BONES. two and one-half years had a fracture of the femur at two points; it did not unite for six months, when a fragment was removed from the lower portion; the muscles shrank, and the knee became stiff. At thir- teen years and seven months, a new fracture occurred at the junction of the middle and lower thirds; plaster-of-Paris was applied for three months, and then the fractured ends were rubbed upon one another; the plaster was reapplied, and she got up upon crutches; union was finally obtained with inch shortening. Rehn 1 reports a case of chipping off of the external condyle in a man aged 29, who was crushed under a falling wall; sixteen years afterward he had a slight injury of the foot, followed by suppuration of the knee- joint, within which the fragment was found. Dr. Mynter, of Buffalo, N. Y., has shown me two specimens of the same kind, the separated fragments having become smoothed and nodulated, but whether by abrasion or by deposit of new material could not be certainly deter- mined. Another case has been reported by Wickes.2 In a case reported by Wills,3 a boy aged 12 sustained, by a railroad accident, a fracture of both femora, a compound fracture of the nasal bones with concussion of the brain, and severe general contusions; yet he made a good recovery. Barclay4 saw a man aged 22, crushed by a fall of earth, who had a fracture of the femur, and laceration of the scrotum with protrusion of the testis, followed by tetanus, but who recovered, and was discharged cured on the seventy-fourth day. Bull& gives an account of a man aged 56, who had a comminuted fracture of the lower end of the femur. “A large slice of bone had been broken off the lower end of the femur from the anterior surface, the condyles being split laterally and longitudinally; the fracture had become united by callus.” It is further stated, however, that “sup- puration in the knee-joint ensued on the hemorrhage into the joint due to the injury,” and amputation became necessary. In another case, reported by Annandale,6 a man aged 50 had a sim- ple fracture about two inches above the condyles; on the third day, the limb having become gangrenous, amputation was performed, and it was found that the popliteal artery and vein had been ruptured, and both crucial ligaments torn through. A somewhat similar case has been recorded by Mudd,7 and another by Peraire,8 in which, however, the amputation was postponed until the forty-eighth day. Kennedy9 records the case of a boy aged 13, who had his left leg caught in the wheel of a wagon, and who sustained a fracture of the femur close to the knee-joint. The lower fragment was displaced forward, its fractured surface resting upon the anterior surface of the upper fragment. Reduction was effected, but could not be maintained; the lower end of the upper fragment projected in the popliteal space, and became necrosed. Four weeks after the accident, the parts were ex- posed by an incision along the outer border of the biceps tendon; the necrosed part of the bone was removed, and the other fractured surface 1 Verhandl. der Deutschen Gesellschaft fur Chirurgie, 1889. 2 Med. Times and Gazette, Dec. 22, 1883. 3 British Med. Journal, June 21, 1884. 4 Ibid. 5 Lancet, Dec. 24, 1887. 6 Ibid., July 2, 1887. 7 Journal of the Am. Med. Association, March 31, 1888. 8 Revue de Chirurgie, Fevrier, 1889. 9 Loc. cit. FRACTURES OF THE FEMUR. 429 freshened. Ultimately the boy recovered with a useful limb, the knee- joint being supple, and the shortening amounting to only an inch. Separation of the Lower Epiphysis of the Femur.—On this subject a very excellent paper has been published by Delens,1 with an account of a case seen by him, and citations at more or less length of 27 others from various sources. In 1889, a case occurred under my own care at St. Joseph’s Hospital; and in preparing a report2 of this I collected over 30 additional instances, making in all nearly 70. In my own case, and in 26 others, the injury was due to entanglement of the leg in a moving wheel. In 3 of these, and in 6 cases due to other causes, the subjects were girls. In 45 of the cases the age of the patient was given, showing an average of 7 years. In 14 cases reduction was effected; 2 of the children are said to have had good motion; 1 had a stiff knee; of 7 it is merely said that they did well, or had useful limbs, and in 2 the only statement is that consolidation occurred. One death occurred, from “ purulent infection. ” Resection of the end of the shaft was performed in 6, successfully in 4; 1 case was doubtful at the time of the report, and in 1 the result is not stated. Amputations were resorted to in 29 cases, 13 primary, 9 secondary, 5 very late, 2 not stated. In 2 resection of the knee was followed by amputation.3 1 Archives Generates de Medecine, Mars et Avril, 1884. 2 Annals of Gynaecology and Paediatrics, Nov., 1890. 3 For the convenience of those who may wish to examine them, I append a list of references, embracing all the writings on the subject which have been within my reach. Delens, in the paper before referred to, mentions two or three theses to which I have not had access. Fontenelle, Archives Generates, etc., Oct., 1825; C. Bell, Observations on Injuries of the Spine and Thigh-bone. London, 1826, p. 42; B. Alcock, Medico-Chirurgical Transac- tions, 1840, p. 311; Liston, Elements of Surgery. London, 1840; C. Hawkins, Lancet, May 7, 1842; White, Ibid. ; James, Ibid. ; II. Adams, Todd’s Cyclopaedia of Anatomy and Physiology, art. “ Knee-joint, ” vol. iii., p. 69, London, 1839-47; Quain, Lancet, March 11, 1848; Jarjavay, Traite d’Anatomie Chirurgicale, 1852, tome i., p. 70; Trelat, Archives Generates, etc., Juillet, 1854; also, Le Progres Medical, 21 Aout, 1875; Canton, Lancet, Aug. 28, 1858; also, Trans, of Pathological Society of London, 1860; Hilton, Med. Times and Gazette, Feb. 12, 1859 ; Holmes, Trans, of Pathological Society of London, 1862 (two cases), also, Surgical Treatment of Children’s Diseases, London, 1868; Hutchinson, Trans, of Pathological Society of London, 1862, also, Ibid., 1864; Little, New York Journal of Medicine, Nov., 1865, also, Illustrated Medicine and Surgery, New York, 1862; Voss, New York Journal of Medicine, Nov., 1865; Buck, Ibid. ; Yolkmann, Virchow’s Jahres- bericht, 1866, Bd. ii., S. 337; Gay, Lancet, Oct. 12, 1867; Rougon (reported by Dolbeau), Bull, de la Societe de Chirurgie, 1867, p. 120; Hey, British Medical Journal, Dec. 4, 1869; Wheelliouse, Ibid. ; Maunder, Lancet, Feb. 5, 1870; Leisrink, Arcliiv fur klin. Chirurgie, 1872, S. 436; Chauvel (quoted by Spillmann), Diet. Encyclopedique, art. “ Cuisse, ” 1872; Callender, St. Bartholomew’s Hospital Reports, 1873; Tapret et Chenet, Bull, de la Societe Anatomique, 8 Janv., 1875; St. Thomas’s Hospital Reports (statistical table), 1875; Marcano, Bull, de la Societe Anatomique, 3e serie, tome x., 1875, p. 228; Richet, L’Union Medicate, 16 Mars, 1876; Sheppard, St. Thomas’s Hospital Reports, 1877; Simon, Ibid, (quoted by Sheppard) ; Smallwood, Hamilton on Fractures and Dislocations, 1877; Reeve, Cincinnati Lancet and Clinic, Nov. 16, 1878; Allis, Trans, of Pathological Society of Phila- delphia, 1878, p. 7; Turgis, Bull, de la Societe de Chirurgie, 1878, p. 787; Holthouse, Holmes’s System of Surgery, vol. i., 1880; Menard, Revue de Chirurgie, 1881, p. 738; Davison, Gross’s System of Surgery, 1882; Puzey, Brit. Med. Journal, Oct. 21, 1882 ; Bruns, Archiv fur klinische Chirurgie, 1882, S. 254; 'Delore, Ibid, (quoted in Bruns’s tables) ; McBurney (quoted by Little) Illustrated Medicine and Surgery, 1882; Halderman, Med. Record (New York), June 3, 1892; Atkinson, Brit. Med. Journal, July 14, 1883; Robson, Liverpool Medico-Chirurgical Journal, July, 1883 ; Black, Ibid, (quoted by Robson) ; Rathbun, St. Louis Courier of Medicine, March, 1884; Verneuil, Memoires de Chirurgie, tome iii., 1884, p. 400; Broca, Bull, de la Soc. Anatomique, 4e serie. tome ix., 1884, p. 407; Winslow, Mary- land Med. Journal, June 21, 1884; Bryant (reported by Rhys), Brit. Med. Journal, May 31, 1884; Bryant (reported by Walker), Ibid. ; Wheelliouse, Ibid., May 24, 1884; McGill, Ibid. ; Delens, Archives Generates, etc., Mars et Avril, 1884; Broca, Bull, de la Societe Anatomique, 430 INJURIES OF BONES. Mansell Moullin 1 has reported the case of a boy aged 15, who had a vertical fracture through his epiphysis, which united by bone; a slight obliquity of one fragment caused pressure upon the popliteal artery, which gave way, and suppurative arthritis of the knee led to amputa- tion a year afterward. On maceration, the epiphysis separated at the line of junction with the shaft. Fractures of the Patella. During the last ten years the additions to the literature of this sub- ject have been very voluminous, chiefly with reference to methods of treatment and their results. Two cases are reported in which the patella has been excised; in one, by Dodd,2 for disease, and in the other, by Altham,3 for compound com- minuted fracture. Both patients recovered with useful limbs; so that it would seem that the bone is not indispensable. A Russian surgeon, Geier, is said4 to have met with an instance of nearly longitudinal fracture of this bone by muscular action, in a man who made a great effort to lift a heavy sack. There is no mention of the treatment pursued, nor of the result. A unique case has been recorded by Parke.5 A miner, aged 22, had his leg caught between two cars, so that the patella was split vertically from side to side, the anterior half remaining attached to the ligamen- tum patellae, while the posterior was drawn upward by the quadriceps; so that there seemed to be a bone of double the normal length, and half the normal thickness. Dressings were applied to correct the dis- placement, and at the time of the report a good result seemed probable. In a case recorded by Clarke6 a man, aged 28, struck his knee against a step; the internal semilunar cartilage was found to be loosened, and in operating for its suture, it was noted that a piece of the cartilage on the under surface of the patella had been knocked off; it floated up into view, and was found to fit accurately to the abraded surface. Alderson 7 describes a specimen taken from a man who died of apo- plexy, having broken his knee-cap twenty-three years before; he had been treated with pads and adhesive strips, and a gum-and-chalk band- age ; the bond of union between the fragments was chiefly ligamentous, but in its centre there was a complete bridge of -bone. The extent of separation of the fragments is not stated. One of the adverse conditions met with is illustrated in a case re- ported by Gem.8 In a man aged 60, the fragments could not be prop- erly brought together; on his death, three months after the accident, the knee-joint was found to contain three ounces of clotted blood, which pushed up the fragments and kept them wholly apart. 4e serie, tome x., 1885, p. 228; Reverdin, Revue de la Suisse Romaine, 15 Mai, 1886; Hutchinson, Illustrations of Clinical Surgery, vol. ii., 1888; John H. Packard, Annals of Gynaecology and Paediatrics, Nov., 1890; John H. Owings, Medical Record, Jan. 31, 1891; McDiarmid, Northern Lancet and Pharmacist, April, 1892. 1 Lancet, Nov. 18, 1887. 5 British Med. Journal, March 22, 1884. 3 Ibid., April 9, 1887. 4 Edinburgh Med. Journal, Feb., 1890. 6 New York Med. Journal, March 18, 1893. 0 Trans, of the Pathological Society of London, 1892. 7 British Med. Journal, April 23, 1887. b Ibid., Sept. 1, 1883. FRACTURES OF THE PATELLA. 431 Limn records the case of a man aged 44, who in 1S69 had sustained a fracture of the left patella, which united well, but gave way again six months afterward; no union could be obtained, and the fragments were four and a half inches apart; the knee became the seat of gnawing pains, and the limb would give way in spite of careful splinting. The joint was therefore excised in 1885, and the man made an uninterrupted recovery. Upon the subject of treatment, I shall first cite the recorded results of experience with various methods, and then the opinions derived therefrom. Thomas2 claims excellent results from his “indirect” method of fix- ation of the knee, by means of a wire frame extending from the pelvis to the sole of the foot, with bands in front of the leg and thigh, and behind the ham. He attempts no control of the fragments, thinking that “neither position nor nicety of adaptation during treatment is in any way essential to a good result.” Another plan, brought forward as new by Masing 3 and said to have been successfully used by him in four cases, is essentially the same as the one described in my former article as employed at the Middlesex Hospital in London. Heath4 recommends the immediate application of plaster-of-Paris bandages, and is in favor of aspiration of the knee-joint. Malgaigne’s hooks have been advocated by Treves.5 He prefers straps of webbing to keep the limb fixed upon the splint, and advises that the knee should be exposed to the air, believing that the confine- ment in a close and heated atmosphere may account for the slow healing of injuries of the lower extremity. Myles8 passes steel pins transversely through the fragments, and then draws them together by figure-of-eight turns of thread or wire about their free ends. Hobson 7 draws the skin well up from the upper fragment, and down from the lower, and then passes steel pins across through the quadriceps tendon and the ligament of the patella; the pins are then clipped off about half an inch from the skin, and the knee enveloped in antiseptic gauze. The pins are left in place about three weeks; plaster-of-Paris is then applied, and afterward a Thomas’s splint. Horne8 believed that he obtained bony union in a case thus treated. In discussing Robson’s method, R. W. Parker raises the question whether it is worth while to try to get bony union, citing another instance in a woman who broke both patellse at different times; the first fracture healed by bone, the second with fibrous union and considerable separa- tion, but with just as good use of the limb. Haward mentioned a case in which a patient with fibrous union was able to ride on a bicycle. McLaren9 reported the case of a man who fractured his right patella in 1864, and his left in 1867; in each the fragments were connected by a fibrous band, three inches in length on the right side, one inch on the left, but both limbs were capable of free use. The curious statement 1 British Med.‘ Journal, May 8, 1886. 2 Provincial Med. Journal, Aug. 1, 1889. See also Med. Press and Circular, Oct. 11 and 25, 1882. 3 St. Petersburg med. Wochenschrift, 10 Juni, 1889. 4 British Med. Journal, May 17, 1884. 5 Ibid., July 24, 1886. 6 Ibid., March 16, 1889. 1 Ibid., March 80, 1889. 8 Lancet, Jan. 18, 1890. 9 Edinburgh Med. Journal, March, 1885. 432 INJURIES OF BOXES. is made that this man’s father, brother, and sister had each sustained fracture of the right patella. Richelot is quoted 1 as urging the importance of maintaining the tone and nutrition of the quadriceps muscle, rather than of bringing the fragments together. He says that many persons with nearly four inches of separation can walk well, and go up and down stairs. I have myself, in cases under my care, found advantage in securing control of the quadriceps muscle by means of a sheet of rubber-plaster, closely applied at the lower half of the thigh, and with a crescentic edge exactly adapted to the upper margin of the patella, the fragments being first brought as nearly as possible together. Another long strip of rub- ber-plaster may be carried along down each side of the leg so as to hold the first in place. When my former article was written, the idea of exposing and sutur- ing the fractured patella had been suggested, and carried out in a few instances. But soon afterward, in a paper2 read before the Medical Society of London, Lister made an urgent plea for its general adoption; exhibiting six patients on whom he had successfully employed it. His views were freely discussed, and the propriety of such operations ques- tioned, by Holmes, Heath, Bryant, Morris, Sydney Jones, Gant, and Morrant Baker. Turner3 reported a case in which a man, aged 39, had his left patella broken in 1859; early in 1881 he fell, and the already stretched fibrous union yielded so that the separation was over inches. The frag- ments were then wired together, but suppuration ensued and the knee became stiff. In connection with this report there is an analysis of 50 cases of wiring of the patella; anchylosis, or at least a stiff knee, resulted in 8, and in 3 the issue was fatal. Abbe4 exhibited to the New York Surgical Society the patellae of a man aged 60, who some years ago had been operated on by wiring, by Dr. Markoe. Suppuration had occurred on both sides; bony union had been obtained, but with anchylosis of both knee-joints. Hardie0 reported four cases, fn all of which the patients were able in four months to walk well and to bend the knees to 90°. He thought Lister’s operation “one of the finest examples of modern high-class surgery,” and advocated its adoption as the routine treatment. Against this view Davidson 0 cites the case of a man aged 40, in whom the suture of a patella fractured four months previously was followed by necrosis, suppuration, bedsores, and death. Favorable results have been recorded by Page,7 Ceci,8 Lammiman,3 Pickering,10 Rockwell,11 and Wight.12 The last-named surgeon gives four cases, and expresses his confidence that this procedure will become the established practice. He thinks only one suture necessary, (and that the best time for applying it is between the tenth and the fif- teenth days. Dennis,13 from a review of reports from various sources, embracing 1 London Med. Recorder, July 15, 1885. 9 British Med. Journal,' Nov. 3, 1883. 3 Ibid., Nov. 17, 1883. 4 New York Med. Journal, Aug. 10, 1889. B Ibid., Nov. 28, 1885. «Ibid., Dec. 12. 1885. I Lancet, April 12, 1884. 8 Deutsche Zeitschr. fur Chirurgie, 1888, S. 245. 9 British Med. Journal, Oct. 3, 1885. 10 Ibid., Feb. 23, 1889. II Brooklyn Med. Journal, June, 1888. 19 Ibid., Feb., 1888. 13 New York Med. Journal, April 3 and 10, 1886. FRACTURES OF THE PATELLA. 433 186 cases, argues in favor of operation under certain favorable condi- tions, and with rigid attention to asepsis. Phelps 1 advocates it without reserve, citing 42 cases so treated within five years. He would take no account of age, habits, or constitutional state; thinks it better that the suture should enter the joint; but lays stress on closing this cavity and isolating it from the skin wound. He regards four weeks as the limit for the confinement of the patient to bed. In the discussion on the paper, these views were opposed by Abbe, Bryant, Leale, Stimson, and Stephen Smith. Bogdanik 2 sutured a recent fracture of the patella, and thought that he had obtained bony union. The patient dying of pneumonia eighteen months afterward, the fragments were found to have between them a strip of whitish substance like cartilage, 2 or 3 millimetres in width, but no bone; in the lower fragment, which was broken into several pieces held together by the periosteum, bony union had taken place. In another instance, mentioned by Grandclement,3 an autopsy showed in a patella “long before” sutured, the union only fibrous, and the sutures far from the place of their application. Ollier4 would divide fractures of the patella into three categories: recent or immediate; old cases, in which there are adhesions with atrophy and retraction of the muscles; and intermediate cases, at the sixth or eighth month. In the first set he regards cutting operations as premature; in the others, to be adopted or rejected according to cir- cumstances. Kirmisson 6 reports three cases. He thinks suturing a grave proced- ure to be employed in view of the condition apt to be obtained without it, and would restrict it in recent cases to those involving the knee- joint, and in old cases to those in which the approximation of the frag- ments is either extremely difficult or altogether impossible. Bruns6 says that the mere degree of separation is not the criterion of a bad result. Every writer speaks of cases in which “ to his aston- ishment” there is almost unimpaired function in spite of unsatisfactory healing. Such instances, to the number of ten, he cites from Bardele- ben and other well-known surgeons. Beck7 after an analysis of twenty-eight cases, takes ground decidedly against bloody operations; the local result, he admits, is better, but the risk is very great, notwithstanding the claims made by Lister and others. The results of the older methods, he says, are so good that the exposure and suturing of a recently fractured patella can only be jus- tified when there is at the same time a wound of the soft parts, opening into the joint. Another method, that of passing a suture of silver wire subcutane- ously around both fragments, was proposed, I believe, by von Volk- mann.8 Silk has been substituted by Kocher and others, and many successes have been claimed for the procedure, the details of which will at once suggest themselves. Other measures have been resorted to in special cases. Sonnenberg9 1 New York Med. Journal, May 31 and June 7, 1890. 2 Centralblatt fur Cliirurgie, 12 Feb., 1887. 3 Lyon Medical, 8 Fev., 1891. 4 Ibid. 5 Gaz. des Hbpitaux, 2 Oct., 1888. 6 Beitrage zur klinischen Chirurgie, Band iii., Heft 2, 1888. 7 Ibid. 8 Ashhurst, Principles and Practice of Surgery, 5th edition, 1889, p. 279. 9 Beilage zum Centralblatt fur Chirurgie, 1888, No. 24. 434 INJUEIES OF BONES. had a patient in whom the ligamentous union of a patella, fractured in 1884, had given way in 1887; the quadriceps was somewhat atrophied. The tubercle of the tibia was chiselled away, and attached higher up; it was still very difficult to approximate the fragments, but finally bony union was obtained, with active extension of the joint, and flexion to 90 degrees. Fowler,1 in a boy 17 years old, whose patella had been broken and closely united, but who by a fall had stretched the bond of union to inches, found it difficult to bring the fragments together; he therefore made an incision 8 inches long over the front of the thigh, made four oblique cuts through the quadriceps muscle, in the shape of the letter W, and by drawing downward opened these out so as to gain enough length in the muscle. The fragments were now freshened and sutured together, with a good ultimate result. The above device is credited to MacEwen of Glasgow. I believe the reader will obtain from the foregoing pages a just idea of the current of opinion, and of the recorded experience, on the sub- ject of the treatment of fractures of the patella. I would say that, thoroughly convinced of the value of antiseptic or aseptic methods, I feel bound to modify somewhat the views expressed in my former ar- ticle. My own personal experience has abundantly satisfied me that by these modern safeguards the risks of the operative surgery of the knee-joint are materially lessened if not wholly set aside. I have repeatedly laid the joint open and washed it out, in cases of gunshot injury, of incised wound, and of compound fracture, with entire success. For this rea- son I should not hesitate, in dealing with a limb rendered useless by the non-union of a broken patella, to advise the exposure and suturing of the fragments. Nor should I dread the use of the subcutaneous cir- cumpatellar suture, in cases of slight separation, if a speedy cure were specially desirable. But the pivot of the whole matter lies in the absolute accuracy and completeness of the asepsis. Without this, the risks are unchanged. Any defect or imperfection in this regard, whether from ignorance, from carelessness, or from mere inadvertence, may lead to the most serious disaster. The surgeon, therefore, who opens the knee-joint, or operates in its close neighborhood, does so in absolute dependence upon the thoroughly aseptic condition of the parts concerned, as well as of his hands, instruments, appliances, and dressings; and the risk of fail- ure in this essential point should forbid the recognition of operative measures as the routine practice in simple fracture of the patella. For I cannot agree with those who assert that the results obtained by the less brilliant methods are on the whole unsatisfactory. During thirty years of hospital and private practice, it has often occurred to me to have three or four cases of this kind under my care at one and the same time; and I am very sure that some at least of them would have again sought relief, if they had found themselves permanently crippled. Of my private cases I can say positively that not one has failed to get good use of the limb. I have repeatedly seen old frac- tures of the patella which, according to the patients themselves, gave no trouble. And in view of the frequency of these injuries, it seems to 1 New York Med. Journal, July 17, 1886. FRACTURES OF THE BONES OF THE LEG. 435 ine that unsatisfactory results, if as common as they are now claimed to be, would be matters of constant observation. In conclusion, I think that in ordinary simple fractures of the patella the treatment pursued should be non-operative, but that an attempt should be made to control the quadriceps muscle, and to bring the frag- ments as close together as possible. The circumpatellar subcutaneous suture may be used, with the strictest asepsis, if special reasons exist for seeking a speedy union. Malgaigne’s hooks, properly applied, I believe to be safe and efficient, but not time-saving. In compound fractures, where the fragments are from the outset widely separated, and espe- cially if there is reason to suspect great laceration of the lateral fibrous tissues; when the joint is persistently swollen from effusion of blood within it; at a later period, if the prospect of usefulness of the limb is doubtful; or when in old cases the limb is actually useless, I think the opening of the joint by a suitable incision, and the suturing of the fragments and fibrous tissues, with the most careful asepsis, fully warranted by experience. Fractures of the Bones of the Leg. A somewhat curious case is reported by Thomson.1 A heavy man fell from a height, alighting on his feet; at his death a week afterward it was found that the tibia had given way at two points, and that the sharp upper end of the middle fragment had acted as a wedge, splitting the upper into two principal portions; the head of the bone was broken up into five fragments, apparently by the impact of the condyles of the femur. Additional cases of tearing off of the tubercle of the tibia have been recorded by Will,2 by Muller,8 and by Landsberg.4 Besides his own, which was noted in Bruns’s clinic, Muller cites six other instances, ob- served by Lauenstein, von Pitha, Vogt, Sistach, Weinlechner, and Sta- bell. In seven of the total of nine, the accident occurred to young men from 16 to 18 years of age, in the act of vaulting. In two, Will’s and Landsberg’s, the fragment was reduced and secured in place by a metal pin; both made good and rapid recoveries. In the other seven, the treat- ment seems to have consisted simply in the use of retentive apparatus, and was very successful in five; the remaining two were old cases when seen by von Pitha and Sistach. Hodges5 has recorded a case of compound green-stick fracture of the tibia, in a boy aged 6 years, from the passage of a wheel over the limb; there were a transverse and two vertical fissures. A good re- covery ensued by the thirtieth day. Separation of the upper epiphysis of the tibia, in a boy aged 8, whose case is reported by Heuston,6 was followed by acute synovitis of the knee-joint, and seven months afterward by suppuration, which was successfully treated by erasion and by drainage through the popliteal space. Compound disjunctions of the loiver epiphysis have been re- 1 London Med. Recorder, July 15, 1885. 3 Beitrage zur klin. Chirurgie, 1888, Bd. iii. 4 Centralbl. fur Chirurgie, 28 Sept., 1889. 5 New York Med. Journal, Oct. 10, 1891. 2 British Med. Journal, Jan. 22, 1887. 6 Lancet, June 29, 1889. 436 INJURIES OF BONES. corded by Albec 1 and by Clark,2 who refers to sixteen other published cases. Instances of non-union in early life have been reported by Bradford 3 and by Parker.4 In the latter case, after nearly three years of treat- ment, amputation was performed. I myself saw at the Pennsylvania Hospital, in 1889, a girl only 13 months old, with pseudarthrosis of both bones about an inch and a half above the ankle; the mother stated that the child had in some way been caught under a street-car about six weeks before; there was a small sinus probably communicating with the false joint. The mother was anxious that I should operate at once, became impatient because I wanted to get the child in better condition, and took her away. Berger6 saw a man aged 57, who when nine months old had a fracture of the bones of the leg, with pseudarthrosis, and failure of development of the limb; there was a regular capsular ligament connecting the fragments, lined by synovial membrane. The skin over the toes was anaesthetic and congested. A curious idea is said 6 to have been carried out with success by Hahn, in an ununited fracture of the tibia. He cut through the fibula, and implanted its lower portion into the upper fragment of the tibia. It is stated that “ there was scarcely any movement of the lower fragment of the tibia.” Padieu7 relates the case of a woman who sustained a fracture of both bones of the leg, just after becoming pregnant; union failed to occur until after her confinement, when it began at once, and in a month was complete. Mere deformity sometimes calls for operative interference. I have myself chiselled away a wedge from the tibia, united at an angle salient inward, in a boy aged 15, with good result. Jones,8 in the case of a boy aged 16, who eleven years before had sustained a Pott’s fracture, excised the inner malleolus and upper surface of the astragalus, cor- rected the deformity, and effected a cure with a movable joint. In a case reported by Ashhurst,9 an enormous mass of callus formed at the seat of fracture, both bones of the leg having been involved, and caused bowing outward, with excessive pain from pressure upon the nerve; removal of the callus was effected, wTitli a good ultimate result. Fractures of the upper part of the fibula have been observed by Weir.’0 by Marchant,11 by McCosh,12 and by Chapin 13 (in a boy only 6 years old). In one of McCosh’s cases, in Weir’s and in several instances cited by him, and in Chapin’s, the bone gave way to muscular force. In Weir’s, Marchant’s, and several others, the external peroneal nerve was damaged, pinched between the fragments, or stretched by exuberant callus. The symptoms so produced have been discussed by Blin and Damaye,14 in connection with a case in which paralytic anaesthesia was 1 Transactions of Maine Med. Association, 1886. 2 Glasgow Med. Journal, November, 1886. 8 Boston Med. and Surg. Journal, April 12, 1888. 4 Medical Times, Jan. 17, 1885. 6 Lancet, May 8, 1886. 6 Practitioner, Aug., 1884, from Centralblatt flir Chirurgie, 24 Mai, 1884. 7 British Med. Journal, Nov. 5, 1887. 8 Ibid., March 13, 1886. 9 Medical News, June 20, 1891. 10 New York Med. Journal, May 26, 1888. 11 La France Medicale, 21 et 23 Fevrier, 1889. 12 Med. Record, Nov. 15, 1890. 18 New York Med. Journal, Sept. 12, 1891. 14 Des troubles nerveux consecutifs aux fractures de la t6te du perone; in Nouvelle Ico- nographie de la Salpetricre, tome i., 1888. fractures of the bones of the foot. 437 the principal phenomenon. They regard the condition as amenable to electricity, unless the cause is mechanical, when an operation is required for its relief. It has been suggested by Lane1 that fracture of one or other malle- olus, by forcible rotation of the astragalus in a horizontal plane, may not unfrequently occur, but escape recognition by reason of the non- displacement of the fragments. He adduces in support of this idea three specimens obtained by him in a limited number of dissecting- room subjects; in one both bones were concerned, in one the outer, and in the third the inner malleolus alone. In a case recorded by Jones,2 a man, aged 29, sustained a fracture of both bones at the junction of the middle and lower thirds of the leg; on the ninth day a small traumatic aneurism was detected at the seat of injury; compression of the common femoral artery was instituted on the eleventh and twelfth days, with entire success. Exactly which vessel was thought to be involved, the account does not state. In an- other instance, reported by Borclieim 3 the posterior tibial artery was concerned; ligation of the superficial femoral was performed, and re- covery, with union of the fracture, took place readily. Fractures of the Bones of the Foot. Fracture of the Astragalus.—Humphry,4 in the case of a boy, aged 16, who fell on his feet and sustained a longitudinal fracture of this bone, removed the outer fragment by a secondary operation, sup- puration having occurred; the result was favorable. Fractures of the Calcaneum.—Gussenbauer5 has reported the case of a man, aged 49, who fell into a ditch, alighting on his feet, and frac- turing one calcaneum; tenotomy was performed, and the fragment was brought down and secured in place by a metal pin, which was taken out at the sixth week. Two cases of fracture of both calcanea have been reported by Wight.6 In one, in a man aged 50, complete recovery took place; in the other, in a man of 25, amputation became necessary in one foot, but good union resulted in the other. 1 Guy’s Hosp. Reports, vol. xxix., 1887, p. 395. 2 Lancet, April 19, 1890. 3 Med. Record, Dec. 30, 1882. 4 British Med. Journal, Sept. 26, 1885. 5 Prager medicinische Wochenschrift, 2 Mai, 1888. 6 Brooklyn Med. Journal, Jan., 1888. DISEASES OF THE BONES. BY CHARLES W. DULLES, M.D. LECTURER ON THE HISTORY OF MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE RUSH HOSPITAL, SURGEON FOR OUT-PATIENTS TO THE PRESBYTERIAN HOSPITAL, PHILADELPHIA. Preliminary Remarks. A comprehensive study of the surgery of the skeleton would include a consideration of all the deviations from the normal state to which its various parts are liable, including (A) deformities, by defect, by excess, or by distortion (congenital, or acquired as the result of disease, ac- cident, or surgical procedure); (B) defects of nutrition and develop- ment; (C) strains; (D) contusions; (E) wounds and fractures; and (F) the different diseases which may affect any part of a complete bone—the periosteum, the solid or cancellated tissue, or the medulla. Certain of these are treated of in other articles of this volume, and I shall, therefore, limit the present study to a consideration of what may be considered specifically as diseases of the bones. Before taking up the study of these divisions of the subject systemat- ically, it may not be amiss to rehearse briefly a few facts in regard to the structure and function of the bones. The formation of bone in vertebrates begins at a very early stage in embryonic life, among the earliest recognizable structures being the rudiments of the vertebrae and the base of the skull, which are distin- guishable only by their situation and shape from the other structures to be formed out of' the mesoblastic layer. They soon acquire a cer- tain degree of hardness and a cartilaginous character, afterward under- going ossification by the deposit of various salts, and the transforma- tion of their cartilage-cells into bone-cells. Some of the flat bones are often cited as exceptions to the rule of development from cartilage, and are called (quoad hoc) intramembranous, as contrasted with intracarti- laginous bones. But this is a question of terms; for all bones are de- veloped from the same layer of the germinal vesicle, and they may, by nature or by disease, demonstrate their similarity of capabilities with other structures formed from the same layer, as is seen in the familiar instance of the bony structure of the tendons of fowls, and in the de- velopment of osteophytes. The base of the skull is, like most of the bones, developed from cartilage; the sides and roof are mostly devel- oped within a membrane. In both varieties, the formation of com- 439 440 DISEASES OF BOXES. Fig. 1612. pleted bone tissue takes place from centres of ossification and proceeds until the full stage of development is reached. A typical bone is made up of a covering which is called periosteum, a compact layer, and a cancellated layer, which is in part occupied by a cavity, called the medul- lary cavity, for the lodgment of the medulla (marrow). When one bone is connected movably with another, the two exhibit modifications of form and arrangement of their several parts, which supply the conditions neces- sary to the formation of a joint. This portion of a bone is called its articulating por- tion ; and the fibrous capsule which surrounds a joint may be regarded as a modification of the periosteum, to which it is attached, and with which it blends at its points of insertion into the bone. An example of the appear- ance of a bone exhibiting at an early stage of develop- ment all the peculiarities just mentioned, may be seen in Fig. 1612, taken from Quain’s Anatomy. The flat bones differ from all the other bones in having no movable joint surfaces when they are fully devel- oped; and they contain no true medullary cavity, al- though their cancellated structure—as, for example, in the body of the sphenoid, in the scapula, and in the ilium—may occupy a consid- erable part of the bone and make it relatively porous and light. A peculiar expansion of the bone substance is found Longitudinal Section of Decalcified Humerus of Foetal Sheep. Magnified 30 diameters. (Quain.) bv, Blood-vessel; p, subperiosteal (intramembranous) layer encroaching on cartilaginous end; of, osteogenic fibres: »/, interlacing fibres; c, groups of carcilage-cells; ic, bone formed in car- tilage ; im, bone formed in membrane. PRELIMINARY REMARKS. 441 in the articular portions of all long bones, and is one of their most in- teresting architechtonic features. By this distribution of the solid part of the bone a large surface is gained for the purpose of articulation, without any sacrifice of strength. The amount of substance present in a portion of the femur an inch long is practically the same, whether taken from the solid part of the shaft at the middle or from the open meshed part near the upper or lower end. This open-meshed structure, which looks so fragile in a dry bone, not only contains as much hone tissue in a given length as is found in the denser parts of the bone, but in addition its arrangement is such that interlacing lines constitute a species of arcs and chords, by which it is strengthened in accordance with mechanical principles, similar to those taken advantage of by engineers in constructing bridges and extensive roofs, so as to secure strength without sacrificing lightness. But this architectural arrangement makes the expanded portions of bone especially liable to diseases which may result from irritation or infection, because these parts are more richly supplied with blood-ves- sels, lymph spaces, and nerves, and the vital processes in them are more active than in the denser portions. For the same reason bones in gen- eral are more liable to disease in the early stages of their development. At this time the interchange of matter everywhere in the body is going on very rapidly, and infection more quickly finds its way from part to part, and irritation is more strongly propagated. This is why so large a proportion of diseases of the bones is found in the young, and why dis- ease is found so often in the neighborhood of joints at all ages. A correct understanding of diseases of the bones involves a full ap- preciation of the fact that they are not essentially different from those of any other tissues. The bones, it is true, present mechanical con- ditions which modify the results of such a process as that of simple inflammation, but the process involves precisely the same physiological or pathological principles, no matter where it occurs. The changes which take place in bone under the influence of disease are precisely analogous to those which are found in a soft part similarly affected. There are simple impairments of vitality, which may result in interrup- tion of growth or weakening of structure, or actual disintegration under the influence of forces to which a proper vitality would oppose a successful resistance. Or there may be an increase of the activity of vital processes, resulting in the formation of an excess of tissue of a character showing the signs of hasty workmanship in instability and weakness, or possessing a sort of vicious disposition to rapid growth and to the deposit of material which remains permanently or for a long time in the shape of homologous excrescences. In these processes, that which is active is, of course, the living tissue, namely, each cell for it- self, while the salts of lime which make up so much of the substance of a mature bone are passive and take no active part in the vital processes. Although the substance of the cells is made up of chemical molecules just as truly as are the lime salts, the cells are living individuals with characteristics which bring them out of the exclusive category of mate- rialism—the nature of which characteristics is utterly unknown, but which we designate as vital. The activity of these living parts of bone has its effect upon what we call the lifeless portions, in increasing or diminishing their quantity, 442 DISEASES OF BONES. or in rearranging the distribution of the material of which they are con- stituted. The constant flow of blood and lymph through the various channels and spaces of the bone acts upon the unvitalized portions as the movements of a stream, like the Nile, the Ganges, or the Missis- sippi, act upon the country through which it flows, making and un- making land by its deposits and its washings, cutting new channels and deserting old ones, and taking up or depositing material good or bad. As the result of these processes, two large divisions of osteitis have been described, that is, condensing osteitis and rarefying osteitis, the one brought about by a deposit of an unusual proportion of bone salts, with resulting increased density and generally hardness—eburnation; the other brought about by a solution of the bone tissue and removal of bone salts, which result in increased porosity and fragility—osteoporosis. But this is a purely mechanical distinction. So also is that which con- trasts caries with necrosis: caries being a form of disintegration like that of an ulcer in the soft tissues, proceeding by the destruction of very mi- nute portions at one time, perhaps cell after cell, while necrosis is a proc- cess in which a more or less considerable portion of tissue is deprived of its vitality at once. In bone, this results in the formation of a slough, which is. called, according to its situation, a sequestrum or an exfolia- tion. The sloughing process in soft tissues is sphacelus or gangrene. Modern terminology, however, ignores the mere results of pathologi- cal processes, in the matter of classification, and is constructed in ac- cordance with the processes or causes of disease, and not with the ap- pearance of their work. An etiological or ontological classification of diseases and disorders of the bones might be made as follows: A. Disorders of development (deformities). B. Disorders of nutrition (dystrophies). C. Disorders of physiological processes (diseases). A. Disorders of Development (Deformities). Disorders of development are purely mechanical variations from the normal standard, taking place before or after birth, and consisting in relative excess, diminution, or irregularity of development. The results of these disorders are: (1) deformities by excess, (2) deformities by deficiency, (3) deformities due to irregular (heterotopic) develop- ment. I shall not undertake any discussion of those diseases of the bones which come under the head of disorders of development, according to the classification proposed in this article. Deformities due to ante- natal defects of development are of very large variety, and are syste- matically discussed in works on teratology. Indeed, it is very hard to do more than refer to them, because their varieties are so numerous and so remarkable. Deformities occurring after birth belong to a dif- ferent class of affections, and as the results of traumatism or pathologi- cal processes are considered elsewhere. DISORDERS OF NUTRITION. 443 B. Disorders of Nutrition (Dystrophies). Disorders of nutrition include all forms of atrophy or hypertrophy, or of unequal growth, due to interference with the normal process of nu- trition, whether caused by mechanical influ- ences or functional dis- turbances. Of this class are various disorders called neurotrophic: de- formities due to (1) pa- ralysis or (2) ataxia, to- gether with (3) acro- megaly, (4) rachitis, (5) osteomalacia, (6) osteitis deformans (Paget’s dis- ease), (7) gouty and rheumatic osteitis, and (8) hypertrophy follow- ing general diseases. I. Deformities from Infantile Paralysis. —Many cases of infan- tile paralysis of the ex- tremities have, as one of their features, a sup- pression of the proper growth of the hard as well as of the soft parts of the body. This defect of growth is usually uniform and universal in any part, although at times it is irregular. In some cases the degree of defective development is very remarkable. The same is true of the results of what is known as cerebral spastic paralysis. The ordinary infantile spinal paralysis consists in an anterior po- liomyelitis with changes in the anterior column of the cord. Cerebral spas- tic paralysis is a condition in which there is loss of energy of motor cells in the brain. In infantile spinal paralysis, there are atrophy, paralysis of mus- cles, and impairment of the nutrition of the bones, partly from inaction, and partly as a direct result of the lesion in the nerves or nerve centres. In the spastic form of paral- ysis there are rigidity, paralysis with muscular spasm, irregular con- Fig. 1613. Infantile Paralysis. Locomotion on all fours. (Willard.) Fig. 1614. Excessive Lateral Curvature with Rotation: legs absolutely use- less from infantile paralysis. (Willard.) 444 DISEASES OF BONES. tractions, and comparatively little wasting of the limb. An interesting example of the appearance of a child who has suffered with infantile paralysis is seen in the accompanying illustration, taken from a paper read by Dr. De Forest Willard before the American Orthopmdic Asso- ciation in 1891. (Fig. 1613.) Another is furnished by the same author, showing general distortion, including curvature of the spine—lordosis. The patient, a boy, could not rise, but was compelled to lie on the floor or bed, and had extreme flexion of the thighs and knees, with talipes of both feet. (Fig. 1614.) II. Osteitis in Locomotor Ataxia.—In locomotor ataxia, spontane- ous fractures of bones often occur. These are dependent upon a form of osteoporosis, which results from the nervous disorder present, and of which the bone disease is usually regarded as simply a manifestation. The bones in such cases are spongy and friable, as seen in a case de- scribed by Ricliet, in which a man broke his femur while pulling off his boots. Voisin speaks of a man who in four months broke, without appreciable cause, his clavicle, and both bones of the leg at the upper third. Hagen recorded in 1876 an observation of three successive frac- tures of the same bone. Blanchard found in bones of this sort the lesions of rarefying osteitis. According to Charcot, this form of bone disease is dependent upon disease of the medulla spinalis, and especially of the anterior horns, in both infantile paralysis and progressive muscular atrophy, and in the osteo-artliropatliies of the tabetic. He thinks also that the spinal ganglia may be affected in such cases. Westphal and Seeligmuller attribute only a moderate importance to disease of the medulla, but think that the nerve lesion is situated rather in the part close to the origin of the pneumogastric nerves. It has been noted that osteo-arthropathies sometimes follow lesions of peripheral nerves, and lesions which injure a nerve rather than those which completely divide it. Injury to a nerve-centre or to a nerve re- sults in an interference with the normal progress of nutrition in the bones, and in a deposit of fat in place of healthy osteoblasts—a process analogous to the fatty degeneration which takes place in muscular fibres. In brief, the change is one of osteoporosis, which is fully de- scribed in the articles of Ollier, Vincent, and Poncet, in Vol. III. Attempts to produce by means of experiment such results as are seen in ataxia have failed, although simple atrophy has been brought about; and this corresponds to clinical experience, there being very rarely any change in the bones observed after an accidental division of a nerve. III. Acromegaly has recently received considerable study, without much increase of knowledge in regard to its nature, although new cases are nowadays frequently recorded. It was first described by Marie, although its occurrence seems to have been noted by Saucerotte in the last century. In this disorder, which is probably to be classed with nervous disorders, there are many manifestations of disturbance of a psychical or nervous sort, accompanying enlargement of the bones and the overlying tissues, especially of the hands, feet, and face. IV. Rachitis.—The subject of rachitis has been so thoroughly treated elsewhere in the Encyclopaedia that not much remains to be said about it. DISORDERS OF NUTRITION. 445 It has been quite completely discussed recently in a monograph by Comby,1 whose opportunities for studying it clinically have been very large. He inclines to the opinion that the disease is the same as osteo- malacia, differing from the latter only in consequence of its occurring at a different period of physiological activity. Notwithstanding this, it is well to bear in mind that a good practical definition makes rachitis to consist in a softening of bone due to deficient deposit of bone salts, while osteomalacia is a softening of the bones due to a removal of bone salts already deposited. Rickets belongs, therefore, to the period of active growth of the bones, while osteomalacia belongs to the period of maturity. Rickets is a disease of children; osteomalacia is a disease of adults or of adolescents. In fact, the latter occurs most frequently in women in connection with pregnancy or lactation. To this distinc- tion between rickets and osteomalacia I shall in this article adhere, more for convenience than because I fail to appreciate the arguments of those who hold that the two conditions are practically the same, and that their sole difference depends upon the periods of physiological activity at which they respectively occur. It is a disputed question whether or not rachitis is hereditary. Most authors think that it is not; and indeed it is probable that children who develop rachitis inherit nothing but a diathesis which makes them liable to this manifestation of their general weakness. Rickets has occurred before birth (intra-uterine). In such cases infants have come into the Avorld with multiple fractures, as in a case recorded by Peter. In regard to heredity, it is a fact that many women of apparently vigor- ous development, with vigorous husbands, give birth to children that are rachitic; and, on the other hand, rachitic women have children whose bones are strong and well developed. At the same time there are some families in which rachitic members are found in several suc- cessive generations. The cause of rickets appears to be bad food and bad hygienic condi- tions, especially during the period of nursing and in the earliest years of life. Artificial feeding is held to be responsible for a large proportion of the cases of rachitis occurring in Europe. Guillot says that the nurs- ing bottle has killed more infants than gunpowder has killed adults. Experiments conducted upon animals have shown that deprivation of lime salts may result in softening and atrophy of the bones. Puppies fed on raw meat developed rachitis with digestive disturbances; while their brothers, who were allowed to suckle, developed naturally. The ingestion of an excess of lactic acid contributes to the development of rachitis. The great prevalence of rachitis in Europe and its comparative rari- ty in America are due to the fact that the way in which infants of the poor are sometimes brought up in Europe, differs from that in which the children of almost or quite equally poor persons in America are brought up. With us, the administration of alcohol in any form to little chil- dren is almost unknown, and—contrary to theories of digestion believed and taught pretty generally even yet—the children in our alleys who are allowed to eat bread and butter, and potatoes, and even meat, when they are very young, in many cases grow up strong and healthy, and compare favorably in weight and appearance with the children of well- 1 Le Rachitisme. Paris, 1892. 446 DISEASES OF BOXES. to-do parents. In large European cities, however, it is not uncommon for children still in their infancy to be given wine or beer, which is the common drink of the parents. This, I believe, has something to do with the digestive disturbances of these children, the general impair- ment of their nutrition, and the development of rachitis. No study of rachitis is complete which overlooks the serious character of the digestive disturbances which are found in this disorder. Indi- gestion and irregularity of the bowels and imperfect assimi- lation are often associated with absolute dilatation of the stomach, and with dropsy. With these there are often se- rious disturbances of the re- spiratory organs; and bron- chitis, broncho - pneumonia, and spasm of the glottis are frequent accompaniments of the bony de- formities seen in rickets. In rachitis the bones are softened because the cartilage cells do not take up and dispose in the customary trabeculae a proper proportion of the earthy salts which make up the inorganic part of a bone. In bones in which the process of growth is actively going on, bone salts are physiologically being constantly carried off while new supplies are de- posited in their place; in rachitis, the process of deposit being im- paired, that of removal is relatively in excess, and bones which formerly seemed of sufficient firmness lose their firmness and become more or less flexible. The appearance of a bone in which rachitis is clearly developed may be seen in Figures 1615 and 1616. Such bones are unusually spongy in appearance, and have an unusually large medullary canal, and their epi- physes are unusually well developed. This feature of rachitis is especially noticeable at the lower end of the radius. Certain students of this disease, as for example Kasso- witz, look upon the proc- ess of rachitis as one of osteitis—a rarefying oste- itis. This is a matter of definition, however, for the general belief is that rachitis is not an irrita- tive disease, as osteitis is. Fig. 1615. Cancellation (osteoporosis) of Compact Tissue in Rachitis. (Lannelongue; Comby.) Fig. 1616. Cancellation and Curvation of Rachitic Tibia. (Beylard; Comby.) Y. Osteomalacia.—Osteomalacia, as before stated, is a disease of nutrition in which already hardened bones lose their firmness by losing their bone salts. Recent years have not added materially to our knowl- edge of this subject. One of the most interesting recent contributions to its literature is that of Eisenhart,1 according to whose investigations osteomalacia is, as has already been stated, a disorder of nutrition, and not strictly a disease. It is not hereditary; it is not limited to any race, nor to any part of the world. Notwithstanding the expectation 1 Deutsch. Archiv fur klin. Med., Bd. xlix., 1892. DISORDERS OF NUTRITION. 447 of Kehrer and Klebs, no bacterium has been found regularly associated with osteomalacia. Osteomalacia occurs in both sexes and at all ages, and osteitis deformans is sometimes regarded as a form of this disease. Poor nourishment, damp dwellings, and deficient clothing contribute largely to the development of the disorder. Furthermore, the use of unduly large quantities of lactic acid seems to induce the disease. All these conditions act largely through disturbances of the digestive or assimilative functions. Osteomalacia is observed so frequently in the states of pregnancy and lactation that these are believed to predispose to or cause it. Eisen- liart, however, after a careful review of the statistics of the subject, comes to a conclusion the very reverse of that just stated, namely, that persons with osteomalacia are predisposed to frequent conception. Fur- thermore, he finds a large proportion of cases of abortion among osteo- malacic women. In 112 cases, the records of which he studied, he found 32 instances, or 28 per cent., of premature delivery by abortion or miscarriage. In regard to the blood, Eisenhart carefully studied this in a case which he describes in detail, and found that it was in a condition of moderate chlorosis, and that its alkalinity was decidedly diminished. The result of his studies brings him to the conclusion that in women certainly osteomalacia is closely connected with, and he thinks dependent upon, disturbance of the ovaries, and associated with periodi- cal or continuous liypersemia of the pelvic organs. This opinion is partly founded upon clinical observation, and partly upon the reported success in the treatment of osteomalacia by castration. This treatment is said to have been first suggested by Fochier in 1879, and has been specially urged by Fehling, who has secured the best results in eight cases in which he has operated. In like manner—although the expla- nation adopted by Eisenhart may be disputed—the Porro operation has been followed by the cure of osteomalacia. Eisenhart found, in his investigations, 8 cases of osteomalacia in men, and 12 non-puerperal cases in women, some of them girls 12 or 13 years old. Von Jaksch says that propeptone, or hemialbumose, has been found in the urine in osteomalacia, but he failed to discover it in two severe cases treated by Nothnagel. VI. Osteitis Deformans (Leontiasis, PageVs Disease).—This mal- ady was first observed by Sir James Paget, and is well described in this Encyclopaedia by Vincent.1 It is a question whether it should not be classed with rachitis and osteomalacia, all being practically similar processes, due to a disturbance of the ratio of deposit and of excretion of bone salts. Vincent inclines to this view, but Condamin finds some objection to it, because of the occurrence of hyperostosis in ostei- tis deformans. Pozzi has suggested for this disease the name of senile pseudo-rachitis. English investigators have traced a connection be- tween osteitis deformans and various disorders attributed to hyperacid- ity, so called, such as arthritis, gravel, and gout. Some French authors have attributed considerable importance to the presence of rheumatism in certain cases. Schiff has caused somewhat similar disturbance of the bones by section of the nerves, and there is not wanting a writer— Hutchinson—who attributes the whole to the work of a bacterium. 1 Yol. Ill, page 865. 448 DISEASES OF BONES. VII. Rheumatic Osteitis.—Rheumatic disease of the bones is peculiar in its cause rather than in its effects. The disorder is usually propagated from the joint-structures to the bones themselves, and re- sults in the development of a simple osteitis, with congestion, swelling, heat, and pain upon pressure. In this osteitis there is no formation of pus or of sequestra. The subject of rheumatic osteitis has been well studied by Adams in England and by Cadiat in France. Adams believes that rheumatic os- teitis is consecutive to a rheumatic affection of a joint. Cadiat believes that it arises in the epiphyses and goes from these to the joints. The truth is, probably, that the first seat of the disease is sometimes in one place and sometimes in the other. Nothing in the cause of rheumatism explains its effect upon the bones, but this is equally true in regard to its effect upon the fibrous and serous tissues, in which also it produces swelling and pain, and often permanent alterations of structure. Gosselin has described three forms of rheumatic osteitis: (1) rheu- matic osteitis of the long bones without arthritis, (2) osteo-periostitis of the extremities with arthritis, (3) rheumatic osteitis of the flat bones. VIII. Hypertrophy Following General Diseases.—The occur- rence of hypertrophy following certain fevers is comparatively rare, but is seen often enough to make it deserving of study, although the process is rather a physiological curiosity than one inviting or requir- ing medical interference. C. Disorders of Physiological Processes (Diseases). Disorders of physiological processes include all disturbances of bone which are generally known as diseases proper, such as the various forms of periostitis, osteitis, and myelitis, as well as tumors. These are, according to our present views, most accurately classified, not ac- cording to their manifestations, but according to their causes. Thus periostitis is not a disease in itself, but a manifestation of disease. Of diseases of the bones we have those which are occasioned (1) by traumatism, (2) by neuroses, and (3) by infective agents (parasites), together with (4) forms of new growth generally designated as tumors. The articles of Ollier, Vincent, and Poncet, in this Encyclopaedia, have described the processes of the various manifestations of bone disease so thoroughly and so well, that it is not necessary to discuss them again. I. Osteitis due to traumatism is of quite common occurrence. All surgeons who treat large numbers of ambulatory patients must be aware of the frequency with which blows and strains are followed by enlargement and pain of the bones. They also see from time to time interesting cases of deformity caused by increased growth due to oste- itis, occurring especially in adolescents. These deformities are not un- common in connection with fractures, and with strains transferred from the muscles at their points of insertion, in the periosteum and the underlying bone substance. Such traumatisms in the leg bones DISORDERS OF PHYSIOLOGICAL PROCESSES. 449 may result in curvatures and twists upon the long axis of the bone, and may produce a species of deformity, the nature of which is unmis- takable when once it has been seen and properly interpreted. Fractures in which the fracturing violence carries with it some con- tusion of the bones, are in very many cases followed by persistent en- largement at or near the point of fracture, which may be misunder- stood by patients and their friends, or even by surgeons, to such an extent as to lead to unpleasant reflections upon the skill of the surgeon, or even to suits for malpractice. In fractures at the lower end of the radius, it is very common to see what we may call a contused fracture (to coin an expression); and doubtless some cases described as impacted fracture in this position are cases of simple contusion in which, of course, the canals of the spongy tissue at the expanded extremity of the bones are broken. Contusion, in the sense in which it is found in the soft parts, is not possible in an organ made up of rigid walls with soft contents; but in the cases of which I am speaking there is no separation of any part of the bone from the main portion, and there- fore no fracture in the ordinary and common sense of the term. Traumatic osteitis is sometimes observed near the seat of fractures in consequence of irritation applied after the occurrence of the fracture. Such irritation may be the effect of the use of unsuitable apparatus, or of unwise manipulation. The rather widespread impression that so- called traumatic swelling is inevitable in most cases of fracture, certifies to the frequency with which these injuries are treated in a way to in- crease the physiological excitement really inseparable from their oc- currence; and the freedom from swelling and pain which may be secured in most simple fractures testifies to the fact that such swell- ing—and inferentially osteitis—is occasioned either by an unusual de- gree of local traumatism, or by subsequent irritation of the part. In this connection it is probably hardly necessary to speak of the fact that traumatisms of the bones constitute a very common mode of furnishing admission to various infective agents; so that what was originally a simple traumatic osteitis may in a short time become a very serious infective osteitis. II. Neurotic Osteitis.—Disorders of the bones due to pure nerve influence belong properly under disorders of nutrition, and have been referred to in that place. It is doubtful if the processes observed and called osteitis in nervous disorders sought to be spoken of as such, since they are free from inflammatory symptoms. III. Infective Osteitis.—Under this head may be considered the largest number of, and the most interesting, cases of disease of the bones. The history of this subject is comparatively recent; because, whatever suspicions have been entertained in times past in regard to the possible causation of diseases by living parasitic agents, it is only of late that the study of this hypothesis has been conducted with the means and by methods calculated to make it exact and extensive. The principal forms of infective osteitis are infectious osteomy- elitis, tuberculous osteitis, leprosy of the bones, syphilitic osteitis, hy- datids of the bones, and actinomycosis. 450 DISEASES OF BONES. Infectious Osteomyelitis. The nature of infectious osteomyelitis is now quite well understood, es- pecially since the investigations of Liicke, Klebs, Eberth, Schuller, and others. A large number of observations have been followed by a large number of experiments upon lower animals, in which cultures of cer- tain bacteria, especially the staphylococcus pyogenes aureus and albus, have been introduced into bone, with the result of producing typical osteomyelitis. One of the most interesting contributions to the subject was made by Rodet, of Lyons, in 1884.1 In his experiments Rodet made intravenous injections of the pus of infectious osteomyelitis, or of a culture fluid obtained from it; and in eight out of four- teen cases produced juxta-epiphyseal osteomyelitis. In one of his experiments he used a culture of the thirteenth generation and pro- duced osteomyelitis of both femurs, one tibia, and one humerus. The osteitis observed by Rodet was usually of the rarefying sort, but in a few cases it was condensing osteitis. In 1886, Widmark, of Stock- holm, concluded, from experiments made with the streptococcus pyo- genes and the staphylococcus, that the former excited limited inflamma- tion, while the latter caused inflammation of an erysipelatous type. However, many experiments and careful observations by different in- vestigators have apparently clearly established the fact that the cocci found in infectious osteomyelitis are not peculiar to this disease, but are common excitants of suppurative, inflammation, causing abscesses wherever they are operative. The peculiar features of osteomyelitis depend, therefore, not upon the agent by which it is excited, but upon the anatomical and physiological characteristics of the organ in which it occurs. Interesting details on this subject can be found in a number of works on pathology; here I must content myself simply with stating the final result of investigations on this subject, namely, that this form of osteitis is occasioned by the presence in the bones of one or other of the forms of bacteria known as staphylococcus pyogenes aureus, citreus, or albus, and the streptococcus pyogenes; and that there may be found in the inflammatory product the pneumococcus and the bacillus of typhoid fever. These latter have been looked upon as causing osteomyelitis, but this is not clearly demonstrated. The mode of entrance of the infective agent in osteomyelitis may be direct, in consequence of a wound exposing the bone—a very rare mode of infection—or the micro-organisms may reach the bone tissue by the route of the circulation. As in other infective diseases, it is believed that these organisms may lie inactive in, or pass inactive through, the bone, without exciting inflammatory action until something which acts like a traumatism—a real traumatism, or a shock from cold, or the lowering of the power of the tissues by disease—prepares a condition in which the specific micro-organism develops its full activity and sets up an active malady. This is the view entertained largely by German investigators, but Lannelongue asserts that no case of osteomyelitis can be found in which there is not—even though it be not discovered— some excoriation of the skin or mucous membrane by which the germ may effect an entrance to the circulation. For my own part I may 1 Revue de Chirurgie, 1885. INFECTIOUS OSTEOMYELITIS. 451 say, in the first place, that this supposition is merely a surmise, founded upon a priori grounds; and, in the second place, that it ignores the fact that the germs which excite osteomyelitis also excite suppurative inflammation in other parts of the body, and that it is un- likely they should elect the bones at a distance from the point of en- trance, and leave no noticeable trace of their action at this point, or anywhere between it and where the bone disease develops. It has been asserted that these organisms may effect an entrance through the unbroken skin by the route of the hair follicles and seba- ceous gland ducts, as happens in the case of the staphylococcus of fu- runcle and of carbuncle. But this again is 3 matter of surmise. The most probable route of entrance is the mucous membrane of the respi- ratory tract or digestive tract, and probably at some point where there is weakness or lesion of their epithelial lining. Once admitted to the system, cocci may proceed without noticeable manifestations to the bones where—usually in the epiphyses—they find a convenient habitat, in which they multiply, and where they set up the characteristic lesions of infective osteomyelitis. Such outbreaks are in some cases preceded by collections of pus in other parts of the body, in which the staphylococcus may be found. In such collections it has been observed that, the more chronic the process and the less constitu- tional reaction there is accompanying it, the more likely it is that the coccus found will be of a lighter color: that is, the mild forms of the disease are associated with the staphylococcus pyogenes citreus or albus, while the graver and more acute forms of infection are accom- panied by the staphylococcus pyogenes aureus. Lannelongue and Achard, in 1890, reported to the Societe de Biologie a series of experi- ments which seemed to demonstrate the relative degree of virulence just described. Certain conditions are probably necessary to infection with the bac- teria of osteomyelitis: some lowering of the tone or condition of the system, or some excitation like that of adolescence, or some trauma- tism. This may be of so slight a character as to escape particular attention, but it is probably present in every case. In addition to the three forms of staphylococcus referred to, it has already been mentioned that osteomyelitis may be produced by the action of the streptococcus pyogenes; although Ullmann asserts 1 that it has heretofore never been found alone in the pus of osteomyelitis. Unmistakable forms of in- fectious osteomyelitis are occasioned by the bacillus pyocyaneus, as also by the micrococcus tetragenus, and the bacillus prodigiosus. Ullmann, in four attempts to produce osteomyelitis by subcutaneous injection of an emulsion of bacillus prodigiosus, succeeded in every case. The occurrence of inflammatory disease of the bones after typhoid fever is by no means uncommon, and such inflammation has been attributed to the presence of the bacillus of typhoid fever. This bacillus has been found in the pus of osteomyelitis under such circumstances, and in some cases is said to have been found unaccompanied by any other coccus or bacillus. Ullmann reports thirteen experiments—twelve on rabbits and one on a dog—with an emulsion of typhoid bacillus; and in four of the rabbits and in the dog he succeeded in producing the lesions of osteomyelitis. 1 Osteomyelitis Acuta. Wien, 1891. 452 DISEASES OF BOXES. In rare cases, osteomyelitis is produced by the action of the pneumo- coccus ; but the cases so far observed are so very few that there has been little opportunity to study this form of osteomyelitis. Ullmann had no difficulty in producing the disease by injecting pneumococci after preliminary fracture of the bone. Achard reported, in 1890, a case of osteomyelitis caused by pneumococci.1 Petrone and Fournier have described a form of osteomyelitis occurring in gonorrhoea, and at- tributed to the activity of the gonococcus, but Ullmann’s attempts to pro- duce the disease experimentally, failed entirely. The streptococcus of erysipelas is by certain pathologists regarded as identical with the streptococcus pyogenes. Senn2 distinguishes be- tween them, and cites, with apparent approval, Hajeck’s assertion that the streptococcus erysipelatosus is found within lymphatic vessels, while the streptococcus pyogenes penetrates the tissues very deeply, and migrates beyond the lymphatics. The latter also, is found in connec- tion with blood-vessels, the former is not. Senn holds to the view of Fehleisen that these forms of streptococcus are not identical. Ull- mann’s experiments in regard to this subject tend to a different view. He succeeded in producing experimental osteomyelitis with cultures of the coccus of erysipelas; while on the other hand Meierowitsch pro- duced erysipelas with the streptococcus pyogenes. Osteomyelitis has been observed a certain number of times after an attack of smallpox; but its exact nature is not any more clearly under- stood than that of variola itself. Similarly, a few cases have been reported as following measles and scarlet fever, and influenza. The sum of our knowledge in regard to experimental osteomyelitis may be expressed in the language of Ullmann, as follows: “ A disease like osteomyelitis can be produced in animals by introduction into the circulation, or into the bones, of pus-producing organisms, after having injured the bone. This may be done with any form of bacterium which has the property of producing pus. If experiments of this kind are carried out with successful aseptic precautions, the micro-organisms found in the pus are identical with those used in the experiment. In man, the most commonly present micro-organism is the staphylococcus; but other forms of bacteria may undoubtedly produce osteomyelitis. The mode of access of the micro-organism may be through the skin or mucous membrane, probably at some injured point. Osteomyelitis is not a specific disease any more than an abscess is of itself specific. It Is ordinarily produced by micro-organisms, but may be produced exper- imentally without them.” If this statement be accepted, it will be seen that part of our definition of osteomyelitis is set aside; for we have been speaking of “infectious” osteomyelitis; and, of course, osteomyelitis without infection belongs to a different category. Ullmann produced true osteomyelitis by the injection of calomel into the veins of a dog and two rabbits. In these, the symptoms were perfectly typical, including painful swelling and suppuration; and the pus being carefully examined both microscopically and by bacteriological culture methods, showed no bacteria. This re- sult corresponds to the subcutaneous abscesses or diffuse infiltrations of pus produced by Chotzen by subcutaneous injections of calomel. Ull- mann caused osteomyelitis also by injecting turpentine into the inedul- 1 Bulletin Medical, 24 Aout, 1890. 2 Surgical Bacteriology. Philadelphia, 1889. INFECTIOUS OSTEOMYELITIS. 453 lary cavity in two dogs. In these cases also the pus contained no bacteria. Pathological Anatomy of Osteomyelitis.—There are four stages in a typical attack of acute osteomyelitis; the first is that of localiza- tion of the infectious or exciting agent. This is a period not subject to observation, and one about which practically nothing is known. The second stage is that of the local outbreak, consisting in the ordi- nary process of inflammation in the bone, that is, in the medulla of the bone. After this, the inflammatory process passes to the third stage, that of encapsulation of the abscess, and the formation of sequestra. The fourth stage is that of repair, which corresponds precisely to that of other forms of osteitis in which there is dead material to be carried away or extruded from the body, and in which the products of hyper- activity of the tissues are to be disposed of. In the second stage, that of purulent infiltration, there is an inflam- mation of the bone marrow which is not distributed over a large sur- face, but is strung along in multiple foci in which the hypersemia is well-marked; and in addition there are often small extravasations of blood. These are usually in proportion to the severity and extent of the attack. The foci of inflammation break down by the formation of pus, and this process progresses in the direction of the junction of the diaphysis with the epiphysis, and toward the periosteum, which is infil- trated and often elevated by the inflammatory products, forming swell- ings of greater or less size. The extent to which the periosteum is ele- vated usually marks the extent to which the inflammatory process has gone in the interior of the bone. From the periosteum, the products of inflammation may make their way to the surface through the soft parts. The inflammatory process may also proceed to the joint ends of the bone and break down the epiphyseal cartilage. In children the disease often stops short at this cartilage, while in adults it is more likely to pass over into the articular epiphysis and even break into the joint. It is interesting to note that the progress to the joint is always from the medulla, and through the epiphysis, never by means of the perios- teum exclusively. Roser has asserted that the disease may begin as an inflammation of the joint and pass from the joint to the bone. Ullmann does not share this opinion, but believes that careful examina- tion of specimens shows that it is a mistaken one. As osteomyelitis progresses from the diaphysis to the epiphysis it frequently breaks down their junction, so that they are movable, the one upon the other. When the joint is affected, the further progress of the case is like that of other inflammations of the articulation. The third stage of osteomyelitis is that of encapsulation and the formation of sequestra. This is ushered in by the interposition of an inflammatory barrier in the sound tissue, in which the disease does not progress. At this point, the already affected tissue is separated by absorption from the living tissue, and there is formed an abscess cavity containing pus, debris, and sequestra. On section, a bone in this stage of osteomyelitis shows bright red and dark red portions, alternating with yellow and suppurating portions of varying size and form, stretching along the medullary cavity and spongy tissue like beads upon a neck- lace. Toward the end of the bones there are no real abscess cavities, 454 DISEASES OF BONES. but rather suppurative infiltration, the tissues being, in some places, more brittle than in others. In the wall of the bone the diseased por- tion is distinguished from the rest by its dirty yellow color. The amount of destruction of the bone tissue depends upon the extent to which the medulla is affected. Large sequestra are not common, be- cause extensive disease of the medulla is usually accompanied by ex- tensive separation of the periosteum, with accompanying necrosis of the whole thickness of the bone, and no possibility of the formation of a shell to constitute an involucrum. In this stage, the inflammatory products may excavate the bone to such an extent as to leave the sequestrum in a large cavity, or it may be closely in contact with the walls. The pus in osteomyelitis frequently breaks through the surrounding bone and escapes by way of a fistula, which may be broad and straight, or long, narrow, and sinuous. Periosteal, or parosteal, abscesses often communicate by long fistulse with the cavity in the bone. In persons in whom the epiphysis is not solidly united to the diaphy- sis, separation of these two parts is not uncommon. This is possible usually to about the age of twenty years, and in exceptional cases for ten years later. Separation is most common at the upper end of the tibia, or at the lower end of the femur. It occurs so frequently that it has been proposed to call the disease “inflammatory separation of the epiphyses.” The affection in the joint leads to the formation of pus, which is sometimes thin and transparent, or semi-transparent. The synovial membrane is injected, eroded, and ulcerated. The several successive stages of osteomyelitis may be observed in the same bone in consequence of successive infections at different points. The fourth stage of osteomyelitis, or the stage of repair, consists in the separation of the sequestra, and their spontaneous or surgical re- moval. In this stage, the infective process, as such, is at an end, and there remain only the usual phenomena of the extrusion of unfit material, and the filling up of defects by granulation tissue. The de- struction of sequestra is effected by the action of the living tissues— the granulations which surround them and erode them carrying off into the circulation their constituents—and not by any chemical action of pus in these cavities. In the case of cartilage, it seems that pus may dissolve isolated fragments. On the surface of the bones, the process of repair is carried on by the periosteum, in the way in which it is carried on in all forms of osteitis. It is noticeable that the newly formed bone is more adherent to the dead bone than to the peri- osteum itself; so that there is some danger, in removing dead bone, of removing the living bone with it unless this fact is carefully borne in mind. In this stage, the medulla is not in a condition of diffuse sup- puration, though it may contain isolated and encapsulated abscess cav- ities. The degenerated medulla is regenerated with considerable rapid- ity. This regeneration takes place in part from the periphery, and in part from the remains of the medulla occupying the ends of the bone. For the minute details of the various processes of osteomyelitis, the reader may refer to the admirable work on this subject, of Ullmann, cited above. These details may be summarized, however, as follows: The changes in the bone tissue consist in a neoplastic bone formation, with the formation of new vessels and of medullary spaces, on the walls INFECTIOUS OSTEOMYELITIS. 455 of which osteoblasts are to be seen. Below the periosteum, new bone is deposited, and is characterized by having bone corpuscles larger than those of the old bone, and more irregularly arranged. While bone is being formed on one side, on the other, in consequence of in- flammation, lacunae are formed in the old bone, and it contains at cer- tain points, grooves and furrows—the so-called lacunae of Howship— which contain large giant cells with multiple corpuscles (osteoclasts). The investigations of Ullmann in regard to the changes in the medulla indicate that they are the same in every form of infectious osteomyelitis, no matter how it is occasioned. These changes consist in a remarkable multiplication of cells like the white blood corpuscles, and of white cells containing red globules, or pigment granules. With this, there is a diminution of the red cells, and a peculiar change in the giant cells, with an enlargement and multiplication of the connec- tive-tissue cells. The increase in white corpuscles is absolute, as well as relative. Ullmann found them in from four to six times the normal number, and Schede calls attention to the excess of leucocytes, which, in some cases, amounts to an absolute leucaemia. Symptoms of Acute Infectious Osteomyelitis.—The symptoms of an outbreak of acute infectious osteomyelitis are those which mark the outbreak of most infectious diseases. That is, there is a rise of temperature, with the signs of disordered circulation—consisting in this case of suffusion of the face with a rapid and small pulse—a coated tongue, digestive disturbances, and sometimes a foetid diarrhoea. The evidences of general systemic poisoning are seen in these symptoms, and, in more severe cases, in the occurrence of delirium, and even of coma and death. The local symptoms are those of a painful, inflamma- tory process. There is a deeply seated swelling, to be felt along the line of the bone, usually from the neighborhood of the epiphysis to the middle third. A little later, over this swelling, dull redness of the skin may be found, and possibly deeply seated fluctuation. When the joint is involved, the symptoms of pain, swelling, and elevation of temper- ature are often found here also. In some cases, the joint pains are so much more conspicuous than those of the diaphysis, that osteomyelitis has been mistaken for rheumatism. If the swelling caused by osteo- myelitis be incised, pus will be evacuated, characterized by the presence of large fat drops, derived from the medulla. A finger in- troduced detects the bone deprived of its periosteum, and sometimes a separation of the epiphysis from the diaphysis. In osteomyelitis, the infection may be transferred to other parts of the body, and especially to the lungs, at first by infarcts of fat coming from the disorganized bone, and afterward by septic products, causing metastatic abscesses. Such abscesses may occur in the lungs, the kid- neys, the pericardium, or the pleura. This is the history of a severe case of osteomyelitis. But the type may be milder, in varying degrees, until it appears comparatively light. Secondary outbreaks may occur in other bones than the one first af- fected, and, as we have seen before, even the same bone may give evi- dence of secondary infection at a distance from other points of mani- festly earlier infection. These different points of infection may not all 456 DISEASES OF BONES. develop the same degree of severity. Ullmann cites a case of a child who, on one side, had a separation of the epiphysis of the humerus, and in the other only a thickening of the shaft of the corresponding bone. Roser reports a case of similar character. In such cases, there often remains an increase in the length of the bone which has not been affected to the point of suppuration. This increase is precisely that described by Ollier, dependent upon excitation of the physiological activity of the juxta-epiphyseal region. An interesting feature of osteomyelitis, from the clinical standpoint, is the occurrence of recidives—later attacks—apparently due to the re- lease of some infectious material, until then locked up, or to the renewed activity of some such agent until then dormant. These attacks may, of course, be caused by new and unrecognized infections; but many authors hold to the idea of their dependence upon the first attack, rather than upon an obvious predisposition to osteomyelitis of the par- ticular patient. Diagnosis of Acute Infectious Osteomyelitis.—The diagnosis of osteomyelitis is founded upon the symptoms already described; but, as in other diseases, variations from the typical form may obscure a decision; and other diseases may more or less simulate this one. Among those most likely to be confounded with it, is inflammatory rheumatism of the joints. To this osteomyelitis sometimes bears a close resemblance; because the symptoms of joint disease or of inflam- mation at the joint-end of the bone are at times more pronounced than those of the disease in the shaft, and the latter may be inconspicuous while the former are very pronounced. It is important to remember this fact in cases of severe inflammatory conditions in or near a joint, es- pecially if there are marked signs of constitutional disturbance. The possibility of mistaking osteomyelitis for rheumatism is greater when— as sometimes happens—the disease is actually limited to the epiphysis. An error may be avoided if this possibility is borne in mind in every case, and if a careful and thorough examination of the bones is made. In a number of doubtful cases it will be found on examination that there is a spot in the epiphysis where there is localized pain on pressure, and where a skilful touch may discover a diminution of resistance, giving the impression almost of a defect in the bone. Osteomyelitis may be mistaken for typhoid fever; but hardly, if proper attention is given to the state of the bones. Still, it must be remembered that in former days it was proposed to call this disease “typhoid of the limbs.” In this connection it is well also to bear in mind the fact that osteomyelitis may be a complication or sequel of typhoid fever, and that the typhoid bacillus has been found in the pus of osteomyelitis. Osteomyelitis should not be mistaken for primary periostitis, because their courses are not alike, and the appearance of the skin is quite different. In periostitis, the skin is usually more actively hypersemic and reddened. In osteomyelitis, the color is more dull. Further, the change in the skin appears early in periostitis, and late in osteo- myelitis. Suppuration in periostitis is not common, and is a late symp- tom. In osteomyelitis, it almost invariably appears early in the prog- ress of the disease. The swelling in periostitis is more diffuse; in INFECTIOUS OSTEOMYELITIS. 457 osteomyelitis it is more circumscribed. Further, the implication of the joint will settle the diagnosis in favor of osteomyelitis. Confusion of osteomyelitis with tuberculosis is quite possible. Of course, an acute osteomyelitis will not be mistaken for tuberculosis, but the chronic form may prove deceptive. Ullmann records a case in which he amputated above the knee, in a case which was thought to be one of tuberculosis; but on examination of the bones there was found an osteomyelitic abscess in the upper epiphysis of the tibia, in progress toward healing, and communicating with the popliteal space by means of a fistula looking exactly like a tuberculous opening. Albert has called attention to the possibility of confusing osteomyelitis with tuber- culosis in cases in which there is spontaneous luxation of the thigh bone with a firm swelling on the metacarpus, suggesting coxitis and spina ventosa. The confusion of osteomyelitis with pysemia and septicaemia is not remarkable; because both of these conditions not infrequently occur in osteomyelitis, and the mistake consists in a failure to investigate the case sufficiently, and to trace the causes of the various phenomena. Ullmann cites a case from Salomon in which osteomyelitis had the appearance of pernicious intermittent fever. The bones which are by far most frequently the seat of osteomyelitis are the femur and tibia, and after these the humerus. All collections of statistics agree on this point. But even the flat bones may be affected, as was seen in a case under the care of Albert, in which the frontal bone was involved. The symptoms were pain in the forehead, oedema from the root of the nose to the beginning of the hair, and chemosis in both eyes. Upon opening the soft parts and trephining the bone, pus escaped.1 Prognosis of Acute Infectious Osteomyelitis.—The prognosis of osteomyelitis is bad, but not as bad as it was formerly supposed to be; because there was a time when no cases were recognized except the most severe, and those which naturally had the worst outcome. At present the death rate is about 25 per cent. In the majority of cases, after the disease has lasted some weeks, the manifestations of inflam- mation diminish, the general condition of the patient improves, the swelling of the limb lessens, and the disease assumes a rather chronic course, with the occurrence of necrosis and the formation of sequestra, or the development of bone abscesses. Necrosis takes place in about eight out of every nine or ten cases. The part of the bone to die may be the cortical portion, that is, a more or less thick layer of the wall of the bone; or the central portion, the part next to the medullary cavity, may undergo necrosis. There is a form of necrosis intermediate be- tween these two, in which the portion of the bone between the inner and outer layers of the cortical portion dies. Ullmann describes, be- sides these, a form of necrosis called penetrating, in which the bone dies over a certain area, from periosteum to medulla; and a trans- verse necrosis, in which the bone dies over a certain area in its entire thickness. 1 This case is reported by Ullmann, but, notwithstanding the eminence of the operator, the meagreness of detail in the report permits the thought that possibly the case was one of suppuration or inflammation of a frontal sinus. 458 DISEASES OF BONES. The sequestrum of osteomyelitis is enclosed in a cavity, the wall of which is never entirely complete; for the cavity communicates with the soft parts, or even with the exterior, by a fistulous track. The se- questra of osteomyelitis are very seldom absorbed. They are some- times expelled spontaneously, especially when small, and in other cases are removed by the surgeon. The loss by necrosis is sometimes so great that what is left of the bone is liable to fracture upon the slight- est provocation. Indeed, there may occur what are called spontaneous fractures. The discharge of pus after osteomyelitis may continue for a ver}T long time; indeed it may go on through the whole life of the patient. In some cases the discharges are small, and inconvenience the patient but little; in others, the persistence of a fistula is followed by evidence of irritation of the nutritive processes of the soft parts, so that eczema, exuberant granulations, or even carcinoma may develop. In the bone itself, secondary bone abscesses may result from the breaking down of the new-formed tissue in the neighborhood of the original seat of irritation. Osteomyelitis may produce abnormal increase of the length of a bone. This, as has been stated above, is the result of excitation of the nutritive processes in the juxta-epiphyseal region, so admirably de- scribed by Ollier. Treatment of Acute Infectious Osteomyelitis.—The treatment of osteomyelitis is general and local. The general treatment is purely depurative and tonic. In all cases attention must be paid to the condi- tion of the bowels and of the kidneys, and both should be kept gently acting. Care must be taken that the case of the patient is not preju- diced, while he is combating the poison of osteomyelitis, by the forma- tion or retention of toxic materials in the bowels and urinary or- gans. The local treatment consists in rest, both general and local, the latter being absolute. The application of cold by means of a Leiter’s coil, or by the use of ice-bags, is often very comforting to the patient. Ullmann approves the free painting of the part with tincture of iodine, as recommended by Demme and Billroth. The iodine should be painted on with a large brush until the skin is almost blue-black, and the area covered should be larger than that of the affected bone. The painting should be repeated every second day as long as the skin will bear it. Collections of pus must be evacuated, and the cavities must be thoroughly washed out with a disinfectant solution. In the present state of surgical science, any condition like that of osteomye- litis calls for early and thorough removal of any infectious material; therefore early incision should be practised, and thorough disinfection with solutions of carbolic acid, or chloride of zinc, or (according to my experience) tincture of iodine; after which drainage and thorough antiseptic treatment must be continued. Openings of this sort should be washed out again and again until the cavities appear to have lost the characteristics of specific inflammation. If the pus is seated in the sub-periosteal region, it is comparatively easy to evacuate it. If in the bone, the process is more difficult. In the latter case, the bone must be trephined. Kocher practises injection of the bone cavity by means of a perforator and a syringe, or by means of a trephine with INFECTIOUS OSTEOMYELITIS. 459 lateral openings which may be used for the injection. The openings made in the bone in such cases must be numerous. They may be made at distances of about an inch, and the trephine or perforator should be carried forward until it meets no resistance, showing that the medullary cavity has been reached. Ullmann believes that it is better to make these incisions too early than to risk postponing them too long, and prefers this mode of treatment to large and long openings with the chisel. If only the diaphysis is diseased, it may be removed entire. The fear of a subsequent defect in the bone need not deter the operator; because the process of repair is, in many cases, remarkable. When the disease affects the epiphysis, amputation is probably the best treat- ment, because saving the limb without the epiphysis and its connecting cartilage, results in deformity due to interrupted growth, which is as serious as the loss of the member. When osteomyelitis affects the joints, these must be opened and the infective material thoroughly removed by excision, evidement, or resection. In other respects, the treatment of osteomyelitis is what would be suggested by general surgical principles; but I would lay stress upon the importance, in these cases, of considering, besides the purely surgical aspects of the case, the medical conditions presented, and the careful and continuous scru- tiny of all the important organs of the body, with the use of every measure available to maintain the strength and vital force of the patient. In the interesting paper by C. Garre, referred to above,1 he describes what he regards as peculiar forms of acute infectious osteomyelitis. Among these, he includes what is in this work described by Poncet as periostitis albuminosa. This disease is so rare that Garre, examin- ing the literature of the subject, found only 26 cases in all. Schlange, after the study of 15 cases, concluded that it was a form of infectious osteomyelitis, and in one case which he observed, he found the specific micro-organism of that disease. Garre describes two, likewise, in which he found the staphylococcus. In one case the disease was recurrent; in the other it was acute and primary. In both cases the exudate was characteristic of so-called albuminous periostitis. In the first case, cul- tivation produced the characteristic staphylococcus pyogenes aureus; and in the second, this form together with the staphylococcus pyo- genes albus. Garre accounts for the presence of the albuminous fluid in so-called albuminous periostitis upon the supposition that there has previously been a purulent collection which has undergone mucoid de- generation, or that a small quantity of pus is mingled with a rela- tively large quantity of transuded serum or lymph. In addition to the preceding, there is a subacute form of infectious osteomyelitis, which is sometimes difficult to recognize. Garre points out the fact that there may be, at two different points in the same in- dividual, a rapidly progressing osteomyelitis and a chronic subacute variety. In such a case, in a boy 15 years old, the diagnosis depended partly on culture experiments; and their results indicated the careful- ness with which such experiments must be conducted, and the danger of drawing hasty conclusions from them. In this case, the inoculation 1 Einige seltene Erscheinungsformen der akuten infektiosen Osteomyelitis. Festschrift zum 25ten .Jubilaum von Theodor Kocher. Wiesbaden, 1891. 460 DISEASES OF BONES. of a small quantity of pus upon gelatine gave no results. When larger quantities, however, were used, colonies of staphylococci were developed. Garre also describes a chronic sclerosing form of osteomyelitis in which the acute symptoms are typical, and in which the disease pro- ceeds to the stage of swelling, pain, and enlargement of the bones, even with plain infiltration of the soft parts; but in which, instead of the appearance of the expected abscess, the conditions ameliorate, and the patient proceeds to recovery, or at least, to very great improvement. Garre describes three cases of late recurrence (recidive) of osteomyelitis. Tuberculosis of the Bones. The history of tuberculosis of the bones is an exceedingly interesting one, for unmistakable allusions to what is now known by this name are to be found in the writings of those shrewd observers, the most ancient medical writers. For a summary of this history, reference may be made to the classical work of Arloing;1 but no writer of the present time can well avoid mention of the important contributions to our knowledge of tuberculosis of the bones made by Charles Nelaton, Villemin, Cliauveau, Ollier, Konig, Schuller, Krause, Koch, Arloing, and Gangolphe. Various theories in regard to the cause of tuberculosis of the bones, indicated by a variety of names applied to its manifesta- tions, are to be found scattered through the literature of the subject, but the latest conception of the disease dates from the year 1882, when Koch published his investigations in regard to the bacillus tuberculosis, which is now regarded by almost all pathologists as the cause of tuber- culosis wherever it is found. Nevertheless, using the same method of reasoning employed to identify the bacillus of Koch, there can be no doubt that other micro-organisms may give rise to a process having all the clinical features of tuberculosis, and absolutely indistinguishable from it in any other way than by the process of isolating the micro-organism present in the lesions. This is not the place to discuss this matter, which is fully and ably treated of in the admira- ble work of Arloing, who describes four varieties of tuberculosis produced by dif- ferent micro-organisms. The first vari- ety is that which is recognized as due to the bacillus of Koch. The second is what he calls tuberculose zoogloeique, or bacillaire, or strepto-bacillaire. The third is the tuberculose bacillaire of Courmont. The fourth is the tubercu- lose bacillaire of Preisz and Guinard. The evidence upon which Arloing bases his opinions in regard to this subject is given by him in full, and need only be referred to as like that upon which the belief in other forms of parasitic disease rests. A represen- Fig. 1617. Culture of Streptobacillus tuberculosis of Dor. (Arloing.) 1 Lemons sur la tuberculose. Paris, 1892. TUBERCULOSIS OF TnE BONES. 461 tation of the strepto-bacilli of Dor is found in Fig. 1617. The tubercu- losis bacilli of Courmont are seen in Fig. 1618. The classification adopted in this article would lead us to call all forms of tuberculosis unassociated with the bacillus tuberculosis, “pseudo-tuberculosis.” In general, it may be said that the theory that tuberculosis in bone—as elsewhere— is a parasitic disease associated with the presence of the bacillus tubercu- losis of Koch, rests upon a very large mass of clinical and experimental observations; although fairness re- quires the admission that no clinician is so experienced or skilful that he can say with certainty that a given disease of the bones, presenting typi- cal features of what is called tuber- culosis, and clinically entitled to this designation, will, on the most dili- gent search, supply to the bacteri- ologist under the microscope, or on culture media, a single bacillus of Koch. A correct understanding of these cases will doubtless come in time; for the present, it may be said that—as far as the patient is con- cerned^—they are precisely like the cases of tuberculosis with bacilli, and that pathologists who believe in the specific character of tuberculo- sis assume that, in these cases, the bacilli are present in small numbers, or in the spore stage, or have been present at the outset of the disease. Fig. 1618. Culture of Bacillus Tuberculosis of Courmont. (Arloing.) Pathology.—In studying the pathology of tuberculosis of the bones it must always be remembered that many other bacteria besides the bacillus tuberculosis are found mixed with the products of inflam- mation and disintegration of the tissues; also, that the bacilli of tuberculosis are hardly ever found in the old products of inflammation— caseous debris, or the contents of abscess- cavities. Tuberculosis of the bones is peculiarly a disease of the spongy tissue, and it especially affects bones in which this tissue is conspicu- ous, as for example the vertebrse, the tibia, the femur, and the humerus. In contrast to osteomyelitis it attacks the epiphyses rather than the shafts, or the juxta-epiphyseal re- gions. This, it must be remembered, is in general; there are exceptions to the rule. In situation, tubercles may be deposited immediately below the articular cartilage, or immediately below the perichondrium or periosteum, or in the central portion of the epiphysis, or partly in the epiphysis and partly in the diaphysis, as seen in Fig. 1619. Fig. 1619. Latent Circumscribed Tubercle of Epiphysis and Diaphysis, Discov- ered only after Section of the Head and Neck of Femur. (Gangolphe.) 462 DISEASES OF BONES. There are two forms of tuberculosis of the bones: one, in which the process is more or less circumscribed or limited by an area of compara- tively compact tissue—the wall of defense which in many cases nature throws up to prevent further invasion of an inimical force; the second, a diffuse form, characterized by irregularity of distribution, often by multiplicity of foci, and always by the absence of any distinct limiting wall. The analogies between tuberculosis of the lungs and tuberculosis of a tissue entirely shut off from the outer air are interesting and strik- ing. Even in bone, it is found that the first stage of tuberculosis is one of increasing density, due probably to irritation; softening almost in- variably occurs as a secondary manifestation, just as in the breaking down of lung tissue. In the stage of hardening there are sometimes found curious points in which the process has gone on to eburnation, Fig. 1620. Fig. 1621. Eburnated Sequestrum of the Condyles of the Femur. (Ollier.) Section of External Condyle of Preceding. (Ollier.) usually at the articular surfaces of bones. A curious illustration of this is seen in Figs. 1620 and 1621. In tuberculosis of the bones, as in that of the lungs, giant cells are found. In both cases the distribution of the affected parts is such as to suggest the formation of infarcts. Konig and Muller have asserted, and reasonably demonstrated, the occurrence of such infarcts; although their belief that tuberculous deposits are generally conical, with the base directed toward the articulating surface, has not been confirmed by other investigators: in fact, the very opposite condition has-been found. In the hones, as in the lungs, deposits of tubercle may exist for a long time without giving rise to serious symptoms of disease; they may also become encapsulated, or may be carried away and ap- parently cured by natural processes. The large experience gained at the school of Lyons suggested to Gangolphe an investigation of the spontaneous cure of tuberculosis of the bones; but he was able to see only a few specimens in the dis- secting rooms which suggested this occurrence. In twelve years he saw only two cases in which it seemed probable. He quotes Mau- claire, who found only one example in 1600 cases in which he opened the epiphyses of bones in the subjects of dissection. The usual process in the formation of a focus of tuberculosis in bone. TUBERCULOSIS OF THE BOXES. 463 is for some irritant, presumably tubercle bacilli, to provoke an excessive activity of the physiological processes, with the result of the formation, on the one hand, of imperfectly developed tissue, and, on the other hand, of hardening in the surrounding region. This is followed by solu- tion, not only of the first-formed tissue, but also of that which surrounds it. In certain cases the limiting wall soon proves sufficient to restrict the process; in other cases this wall succumbs to the irritation of the disease, and another one is formed beyond it, which in turn gives way to still another. In such cases the originally affected tissue may re- main as a small sequestrum in a comparatively large cavity. There is no good reason for believing that sequestra shut up and bathed in pus are ever dissolved thereby. A section through a typical tuberculous focus includes an outer zone, a middle zone, and a central area. In the first are found engorgement of blood-vessels, proliferation of the cellular elements of the tissue, and some tuberculous follicles. The general color of this zone is red. The middle zone is that in which the tuberculous deposits are most numer- ous. This area is semi-transparent, and but slightly red in color. The interspaces of the tissue are occupied by a gelatinous mass, compared to frog-spawn. In the central zone there is an ulcerated condition, with breaking down of the trabeculae, and often with the presence of small detached pieces of bone—sequestra. With these general statements it may be worth while to repeat that, in diseases of bone, the general characteristics are dependent upon the specific character of the malady; the histological changes which take place are those common to certain well-understood processes. Thus in tuberculous osteitis, there is, first, hypersemia; then the formation of granulation tissue, with condensation on the one hand, or solution and re-infection on the other. The seat of greatest activity is in the middle area, between that re- cently attacked and that which has already borne the onset. In this process the anatomical elements of the bone act in accordance with their physiological properties: osteoblasts contributing to the produc- tion of resistant tissue, and osteoclasts advancing the process of solu- tion. The early death of any considerable portion of the bony tissue leaves this like a foreign body in the centre of a cavity, which fits it closely or loosely according to circumstances, and which in either case makes what Frank 1 has picturesquely called a “ coffin for the se- questrum.” The processes of tuberculosis include caries as well as necrosis, and the cavities in the bone may contain a fine sandy material consisting of very small portions of dead bone-tissue, or nothing but a gelati- nous or puriform fluid. As in all forms of osteitis, tuberculous osteitis may be strictly localized, or it may be scattered over a considerable space. It may be primary, or it may give rise to secondary metastatic infection of the bone, or even of remote organs. The results of tuberculous os- teitis may be destruction of considerable portions of bone, spontaneous fractures due to weakening of the bones, collapse of their articular ends, infection of the joints, or burrowing of pus and the formation of abscess-cavities in the soft parts, as is seen in cases of psoas abscess caused by caries of the vertebrae. Tuberculous osteitis resembles 1 Grundriss der Chirurgie. Stuttgart, 1893. 464 DISEASES OF BOXES. other forms of bone disease in occurring, as Ollier has pointed out, in the great majority of cases in early life, when the process of develop- Fig. 1622. Ossifluent Abscess (Tuberculous) due to Osteitis of Internal Malleolus. (Gangolphe.) ment of bones is most active. Probably one-tliird of all diseases of the bones are found in children under ten years of age, while about one-half occur in persons under twenty years. In connection with tuberculous dis- ease of the bones, there is often present disease of the joints and of the sur- rounding tissues. After a certain length of time the tuberculous process in a bone causes progressive destruction of the overlying structures, until the disease extends to the surface. The communi- cation may take place by means of nar- row and tortuous sinuses, or by such destruction of tissue as causes the for- mation of large abscess-cavities outside of the bone. An illustration is seen in psoas abscess. In some cases the exter- nal manifestations are insignificant as compared with the extent of disease in the bone, as was seen in a case reported by Gangolphe, in which he amputated in the upper third of the leg, in a case of disease of the ankle-joint, because he found a depression in the tibia in- dicating a loss of substance. The wis- dom of the operation was shown when a section was made of the tibia, which was found to be occupied by a very large medullary ossifluent abscess. See Fig. 1622. The communication of tuberculous disease from bone to bone is sometimes particularly noticeable in the spinal col- umn, where the bodies of a number of vertebrae may be affected either at or about the same time. A striking illus- tration of this is seen in a specimen of M. Lannelongue, shown in Fig. 1623. Tuberculosis of the bones occurs most TUBERCULOSIS OF THE BONES. 465 frequently in the spinal column and in the long hollow bones, although it occurs also in the short and the flat bones, like those of the tarsus, carpus, pelvis, and cranium. Diagnosis of Tuberculosis of the Bones.—This is sometimes diffi- cult, especially if we bear in mind the fact, mentioned earlier in this article, that absolute certainty of the presence of the tubercle bacillus of Koch can be secured only by discovering this bacillus in the products of the lesions, or by means of culture experiments. On the whole, it may be said that what is now called tuberculosis is pretty much what used to be called scrofula, and has the symptoms, long ago well known, of that disorder. The special peculiarity of tuberculosis is, that it is a disease which advances slowly and insidi- ously, with little or no suffering, with few or no constitutional symp- toms, and consequently with little or no warning of what is taking place, until pain, deformity, and distention or discoloration of the skin attract attention to the disease at a point removed from that at which it is most active. In this, tuberculosis presents a striking con- trast to other forms of osteitis, which are usually of an acute type. As stated above, there is a chronic form of osteomyelitis in which there is no such pain as occurs in the acute infectious variety; this affects the diaphysis of the bone, is accompanied by the formation of pus, and does not give rise to the formation of fistulous tracks or the production of fungous tissue. Of course the detection of staphylococci would settle the diagnosis. Tumors of the bones, especially sarcomata, might possibly give rise to a suspicion of tuberculosis; but the whole history of tumors and their general appearance usually make them comparatively easy of recogni- tion. When such tumors have undergone fatty degeneration and sup- puration, there may be a question of diagnosis, as stated by Gangolphe. But, as he says, such cases are exceedingly rare. Gummata of the bones are usually situated on the diapbyses, and usually a history of syphilis can be elicited on careful inquiry. Hydatid cysts of the bones are exceedingly rare, but when they occur they present very much the symptoms of tuberculosis. The patients, however, give little evidence of constitutional disease even when the cysts are quite large, and an error of diagnosis may be avoided by considering the impression re- ceived on palpation, that the contents of the sac are very thin and watery. An exploratory puncture, with an examination of the con- tents, would settle the diagnosis. Ollier saw a case in which he found a hydatid cyst in the upper third of the forearm, in a young woman whom he had already treated for tuberculous arthritis of the knee. In most cases of tuberculosis of the bones considerable progress has been made before the patient comes to the surgeon, who finds disor- ganization of the tissues already existing, although the evidences of dis- ease may have but recently come to the surface so as to attract the atten- tion of the patient. In such a case one may be consulted on account of pain attributed to rheumatism, which on examination is found to be caused by an abscess, and on further examination this abscess is found to be of a type called ossifluent. In other cases elevations of the skin first attract the patient’s attention, in others its discoloration. In a case recently under the care of Dr. Willard in the Presbyterian Hos- 466 DISEASES OF BONES. pital, a painless swelling below Poupart’s ligament, in a colored woman, was found to be dependent upon caries of the lumbar portion of the spinal column, and to be the lower part of an abscess cavity which was easily probed from the groin along the inner side of the ilium, to a point above its crest near the spine, where a counter-opening was made for the passage of a large drainage-tube. Such a case illustrates, as every surgeon knows, the great extent to which the lesions of tubercu- lous osteitis may go before surgical advice is taken. In these cases the progress of the disease is very slow, but, on the other hand, it may be very rapid; as was seen in another case, under the care of Dr. O. H. Allis in the same hospital, where a man of seemingly excellent health sustained a violent contusion of the patella, followed by rapid disinte- gration and the formation of ossifluent sinuses, necessitating the re- moval of the entire bone. This case precisely parallels the experimental tuberculosis produced by Schuller by injuring the bone and inoculating the subject with tuberculous matter. Treatment of Tuberculosis of the Bones.—This is partly constitu- tional and partly local. Slow as is the course of the disease in many cases, and slight as are the accompanying constitutional manifestations, it is desirable to treat it by those means which are ordinarily useful in the treatment of tuberculosis elsewhere. This includes the use of cod-liver oil, the hypophosphites, iodoform, creasote, guaiacol, and similar agents, continued for a long time, and with perseverance, as in other forms of tuberculosis. A word should be said in regard to the treatment of tuberculosis of the bones by the tuberculin of Koch. This may now be said to be abandoned. The enthusiasm with which it was at first received has entirely disappeared, and tuberculin, if used at all, must be regarded as a purely experimental agent and not one of demonstrated value. The local treatment of tuberculosis consists usually in the fixation of joints, the prevention of motion, cauterization, the injection of astrin- gent materials, or the removal of the diseased tissue by the knife or by suitable dull or partly sharp instruments. In regard to the former methods, little that is novel has appeared since the previous volumes of this Encyclopaedia were issued. A good deal of attention has been attracted to the plan of injecting curative, irritating, or hardening fluids into the diseased tissue, in cases of joint tuberculosis. Of the curative agents, iodoform is probably the most striking example. This has been used dissolved in ether, or partly dissolved and partly sus- pended in oil or glycerin. Carbolic acid, nitrate of silver, and tincture of iodine, as also perchloride of iron and chloride of zinc, have likewise been employed. There can be no doubt that good results are obtained by any material which will convert a tuberculous focus into a mass of dead but sterilized tissue. A mode of treatment of surgical tuberculo- sis strongly recommended by Max Schuller consists in the combination of medical treatment with surgical, as suggested above. He adminis- ters to tuberculous patients benzoate of sodium, creasote, guaiacol, and cod-liver oil, in a way which has much to recommend it theoreti- cally. Personally I have confidence in the use of creasote and guaiacol, as constitutional remedies in the treatment of surgical tuberculosis, as well as of tuberculosis of the lungs. TUBERCULOSIS OF THE BONES. 467 An important question in regard to the treatment of bone tuberculo- sis is that of the time at which to begin operative interference. In re- gard to this, opinions differ. Collections of tuberculous material need not always be operated on as soon as found. If such collections are limited in area, and can be thoroughly removed, there is no reason to doubt the propriety of treating them actively and by operation; but in some cases too early interference converts a comparatively innocent lesion into one that is very inconvenient to manage. Probably in the great majority of cases which come to a surgeon’s notice, the disease is in such a stage that there can be no question about the desirability of treating it by operation. This operation may be puncture followed by injection, incision, scraping, tunnelling, resection, exsection, or ampu- tation. To describe the cases to which each of these methods is ap- plicable, would require more space than can here be spared, in view of the fact that these procedures are described in every work on sur- gery. In the neighborhood of joints, the treatment resolves itself frequently into a question of excision (arthrectomy) or resection, or in many cases amputation. The last is a method of last resort. The experience of the school at Lyons, of which Ollier is the great head, has relegated amputation to a very subordinate place in the treatment of tubercu- lous diseases of the extremities. Of the two former modes, resection of the bone is not only simpler, but on the whole more practical. In the case of children it is often desirable to save, if possible, the develop- mental cartilage. In the case of adults, the ease with which one can go beyond the area of infection, and the fact that the period for in- crease in length of the bones has passed, combine to make it more de- sirable to practise what are called typical resections, in contrast to atypical resections or arthrectomies. The question sometimes arises, what shall be done in the case of a person affected with tuberculosis of the lungs who presents serious symptoms of bone or joint tuberculosis, or of one with tuberculous bone disease with active febrile development? This question has to be de- cided separately for each case, weighing the advantages of operative treatment with the risks of an unfortunate result. The power of re- cuperation in tuberculous patients is sufficient to justify operation in some cases. A knee, for example, which keeps a man absolutely helpless may be wisely operated upon. In such cases, however, the simplest operation is always to be preferred; and the simplest is ampu- tation. In the treatment of tuberculous inflammation of the hip-joint, which by many orthopaedic surgeons is regarded as the only form of chronic hip-joint disease, and which is usually the result of tuberculous osteitis of the femur, rest and fixation sometimes accomplish a complete cure. Gibney says that they effect a cure in a large proportion of cases, if used early. If suppuration occurs, Gibney aspirates small abscesses, but does not inject them, from three to six aspirations being usually re- quired. If these fail, the abscesses may be opened, curetted, dried, packed with iodoform gauze, and covered with an antiseptic dressing. Such treatment often results in apparent cure; but this may be followed by relapses. 468 DISEASES OF BONES. Leprosy of the Bones. In leprosy, as might be expected, the bones are frequently attacked. Of course they are always attacked in cases of deforming leprosy, in which fingers, for example, are lost. There are two forms of disease of the hones present in leprosy, one of which is of a rapidly destructive character, accompanied by caries and necrosis, and rapid loss of sub- stance; the other is a species of atrophic osteitis. In both conditions, examination reveals the presence of the bacteria of lep- rosy in the bones. Fig. 1624, taken by Gangolphe from Sawtschenko, shows the appearance of a phalanx invaded by several colonies of lepra bacilli. In this disease, as in most diseases of the bones, the point of invasion is usually the epiphysis or the juxta-epiphyseal region. Active resorption or disintegration distinguishes leprosy of the bones, in a manner analogous to what is seen in the soft parts. In some cases osteophytes have been discovered, which are supposed to have been produced by stimulation of the osteoblasts by the pres- ence of lepra bacilli. In the Trinidad Asy- lum for Lepers, Rake finds that operation wounds in general heal kindly, amputation wTounds included. He reports 630 operations of sequestro- tomy with good results. In certain cases he relieved the pain of leprosy, affecting the bones, by very deep incisions. In the foot, these some- times were carried through and through the part. Active interference seems, therefore, to be not only justifiable but also successful in cases of disease of the bones in leprosy. Fig. 1624. Section of First Phalanx of Thumb of a Leper (Sawtschenko.) a, a, a, Nod- ules of leprosy. Syphilis of the Bones. The subject of syphilis of the hones is as extensive and as interesting as that of tuberculosis of the bones. As part of a constitutional dis- ease, it is discussed in treatises on this disorder, and also in all treatises especially devoted to bone diseases. It is a manifestation of what is commonly called the tertiary stage of syphilis, although, as is well known, severe osteocopic pains, usually felt in the shaft of the long hollow bones, and especially in the tibia, occur sometimes within six or eight weeks after the appearance of the initial lesion. At this stage there is at times an obscure form of irritation of the periosteum or of the bone immediately below it, giving rise to pains of more or less severe character which resemble rheumatic pains rather than the pains of osteitis due to a specific virus. They intermit by day, and are often relieved by pressure, instead of being aggravated by it. They are not accompanied by heat or swelling, and they may shift from one part to another. Such pains are not peculiar to syphilis, for they occur in other disorders of the bones; but they are so frequently found in SYPHILIS OF THE BOXES. 469 syphilis, and so infrequently in other disorders of the bones, that their presence leads properly to the suspicion that syphilis is present. True syphilis of the bones, with, distinct lesions, is, as stated above, a manifestation of the later stages of the disease. The lesion character- istic of this form of osteitis is the gumma. Such a lesion, forming under the periosteum, its most common seat, gives rise to an inflam- mation in which the neighboring tissue is involved. There is usually a viscid, serous effusion between the bone and the periosteum, which elevates the latter in a half-fusiform swelling, highest at or near the Fig. 1625. Gummatous (Syphilitic) Osteomyelitis of Tibia. Partial ossification of medulla; rarefaction of new bone tissue. (Gangolphe.) middle, and gradually subsiding toward the ends. This is firmly at- tached to the bone, of course, while over it the skin is at first movable. It is usually tense, but sometimes yields to pressure. This is what is called a node. Such a node may be absorbed and disappear, under ap- propriate treatment, or it may breakdown and ulcerate, giving rise to a syphilitic ulcer. In the substance of the bone, gummata give rise to an irritation in which a large part of the bone or the whole bone may be affected, to- gether with the surrounding tissues. The characteristic of syphilitic os- teitis is that the medullary cavity is often enlarged, and the surrounding bone eburnated or porous, with a total absence of true suppuration or necrosis; a sequestrum may be said almost never to be formed. On sec- tion, a bone showing the characteristic lesions of syphilis presents an eburnated cortical layer, a rarefied or excavated medullary region, with erosions of the walls due to caries—molecular disintegration. (See Fig. Fig. 1626. Gummatous (Syphilitic) Osteomyelitis of Tibia. Extensive erosion of compact layer. 1625 and Fig. 1626.) This is the process usually found in the long bones. In flat bones perforations occur, surrounded often by eburnation, due to condensing osteitis. In the skull, these perforations occur most fre- quently in the frontal bone; and it is a curious fact that the vitreous table resists for a long time the tendency to perforation. Similar per- forations take place in the scapula. In the fingers a form of inflammation occurs which produces a swell- ing like that of tuberculosis, called spina ventosa. 470 DISEASES OF BONES. Pathology.—The pathology of syphilis of the bones is indicated by what has already been said in describing its lesions. It differs from diseases with which it might be confounded in diagnosis, in that it is more painful than sarcoma or tuberculosis of the bones, and of much slower development than acute infectious osteomyelitis. The chronic form of osteomyelitis might perhaps be confounded with syphilitic dis- ease, but a careful study of the history of the case, taken with the mul- tiplicity of lesions common in syphilitic disease of the bones and uncom- mon in osteom}Telitis, and the absence of implication of near superficial lymphatic glands in the case of syphilitic osteitis, would make it unlikely that these two should be mistaken one for the other. Treatment.—The treatment of syphilis of the bones is the treatment of all forms of tertiary syphilis. The various preparations of iodine or of mercury, or both, depending upon circumstances which we need not here consider, and which belong to the general state of the patient rather than to any particular manifestation of the disease which he may pre- sent, are the remedies which are most appropriate to the cure of syph- ilitic disease of the bones. The iodides appear to exercise an es- pecially favorable influence in causing the resorption of gummata. Mercury, in this stage of the disease, is to be used for its tonic effect. Happily, syphilis of the bones is ordinarily quite amenable to treatment, and responds promptly to appropriate medi- cation. Fig. 1627. Hydatid Disease of the Bones. One of the rarest forms of disease of the bones is that caused by the presence of the cysts of the larva of the tsenia echinococcus. This parasite is usually derived from the in- testine of the dog, which is the natural habitat of the fully developed tsenia. The whole tsenia is only one-quarter of an inch long, and consists of but four segments (Fig. 1627). The rings or proglottides of this tsenia when matured are evacuated with the excrement; the ova are then set free by disintegration of the surrounding tissue of the ring, and, on being swallowed, their own surrounding membrane is dis- solved in the gastric juices of their new host, so that the embryos (pro-scolices) are set free. Finding their way through the wall of the intestine, and into the blood cur- rent, they may be conveyed to any part of the body. At the point of arrest, the embryo surrounds itself with a membranous sac, which is filled with a liquid; the whole constituting what is known as a hydatid cyst. The origi- nal cyst is sometimes called the mother-cvst, and may have connected with it a number of smaller ones, called secondary or “daugh- ter” cysts. In. these, are developed immature tsenise (scolices) which need only liberation and transfer to a suitable soil, to develop into the perfect tsenia echinococcus. In whatever tissue a hydatid, single or mul- tiple, is situated, it is surrounded by a wall of connective tissue, formed as result of the irritation of the growing parasite. Within this is the true wall of the cyst, and within this the liquid contents and the scoli- Taenia Echi- nococcus from Dog:. (Payne ) a, Taenia, ma- ture (X 10) ; b, ovum (X 250). 471 HYDATID DISEASE OF THE BOXES. ces, with various substances in solution or suspension. The inner layer of the cyst produces, by a process of budding, the scolices or echino- coccus-heads. These may be developed to an enormous number, or they may be comparatively few. (See Fig. 1628.) The scolices are from one- sixtieth to one hundredth of an inch in length, and are armed with a row of hooks, the shape of which is absolutely characteris- tic. The head of the sco- lex is usually seen in- vaginated within the body, so that the hook- lets' look like internal organs. In some cases the mother-cyst contains a number of so-called daughter-cysts; in other cases the mother - cyst produces on its exterior daughter - cysts, which invade the tissues outside of the original cyst. The more a hydatid tends to be multiple, the less is it likely to produce scolices, and the more likely is it to grow as a collection of barren cysts and vesicles. The tendency of hydatid cysts is always to increase, although slowly, and to produce damage chiefly by their mechanical influence. The most common seat of hydatids is the liver, but any other organ or tissue of the body may be invaded. When hydatids occupy the bones, they are usuall}* unsuspected and undiscovered until they have lasted a long time; because they are of slow development, do not produce deformity, and do not give rise to pain. Their discovery is frequently the result of an accident, such as a so-called spontaneous fracture; after which the diagnosis may be made or not according as the observer is acute and well informed. The location of hydatids of the bones is always in their interior, in the spongy tissue, and usually at the end of the diaphysis, in the juxta- epiphyseal region of the long bones. The bones most usually affected are the tibia, near its head; the femur, near its head; the ilium and the vertebrae. A bone containing hydatids usually presents no sign ex- ternally until its walls have been so thinned by the growth of the para- site that they give way at some point through which the cyst protrudes or bursts, or at which the bone breaks. Inside the bone, the spongy tissue is destroyed in two ways: first, by mechanical pressure, causing resorption; second, by necrosis, caused by ischaemia produced by pres- sure of the cyst upon the blood-vessels. In the first case the cavity in the bone is occupied wholly by hydatid cysts; in the second case there is also a collection of puriform fluid and of small, or even large, se- questra. The puriform fluid is sometimes of a character aptly com- pared to pea-soup. The cavity in a bone caused by hydatids is usu- ally sacculated, or with anfractuosities. The progress of hydatids in a Fig. 1628. Human Echinococci. (Payne.) A, Group of echinococci adher- ing to germinal membrane by their pedicles (X 40); B, echinococ- cus with head invaginated (X 107); C, same compressed, showing suckers and hooklets; D, echinococcus with head protruded; E, crown of hooks—two circles (X 350). 472 DISEASES OF BOXES. bone may be in either direction: first, onward in the bone itself; second, toward a neighboring joint. The annexed illustrations, Figs. 1629-1634, taken from an able paper by Mr. J. H. Targett,1 show the appearance presented in various cases of hydatids of the bones. If the progress is toward a joint, the hydatid does not invade the cartilage, Fig. 1629. Fig. 1630. Human Humerus, Fractured. Cyst Removed from Humerus of an Ox. but sets it loose by destroying the bone with which it is connected, and crosses over to an adjacent bone, passing by its cartilage. The de- struction of a joint, such as the coxo-femoral, may result in a disloca- tion of the head of the femur, through disintegration of the cotyloid cavity, into the pelvis. Connected with a hydatid of the bones there may be invasion of the surrounding tissue, or, by rupture of the cyst, infiltration with the for- mation of sinuses, or of abscesses precisely like the ossifluent abscesses found in other disorders of bones. When hydatids approach the surface—which they do very slowly and without exciting constitutional symptoms—they may be mistaken Fig. 1631. Fig. 1632. Ischium of an Ox. Cyst in Human Tibia. for cold abscesses. If, under these circumstances the surgeon opens them and puts their interior in communication with the air, they im- mediately change their character, and produce violent constitutional disturbance, which may end in death. 1 Guy’s Hospital Reports, vol. 1., 1894. HYDATID DISEASE OF THE BONES. 473 Hydatids of bone probably occur much oftener than statistics would indicate, because they usually receive but passing notice in works on surgery, and are not even men- tioned in some well-known works on pathology. They are chiefly to be distinguished from cancer, syphilis, sarcoma, and tubercu- losis. In cancer there is usually cachexia and often multiple manifestations; cancer of the bones is rarely found without other unmistakable manifesta- tions of cancer. In syphilis of the bones there is usually a dis- tinct history, an obvious involve- ment of the cortical portion of the bones, with, in most cases, pain (osteocopic pains) occurring in the course of the development of the disorder. In sarcoma there is usually a much more rapid develop- ment, and a very distinct tume- faction of the bone, with an absence of fluctuation. These characteristics make the diag- nosis, if once the idea of hydatid is entertained, comparatively easy. Certainty is assured by the examination of the contents of the cysts, which, except when pus is formed, are of a transpa- rent character, often almost col- orless, sometimes straw color, and often containing hooklets which are unmistakable when seen under the microscope. A spontaneous fracture of a bone occurring in an apparently healthy per- son, should always lead to a suspicion that a hydatid may be present. Diagnosis. — The most likely source of error in re- gard to the diagnosis of hydatids of the bones is tuberculosis. The cold ab- scesses of this disease may present a close resemblance to the fluctuating swellings caused by the formation of a hydatid cyst in the soft parts connected with the parent cyst in a bone; and it has even happened to Ollier to see a case in which a hydatid cyst was found in the same pa- tient on whom he had formerly operated for tuberculous disease of a Fig. 1638. Human Tibia. Fig. 1634. Human Femur, Tibia, and Fibula. Fig. 1635. Large Hydatid of Pelvis. (Gangolphe.) 474 DISEASES OF BONES. joint. Such a case as is seen in Fig. 1635, where the pelvis was ex- tensively involved, might prove troublesome in diagnosis. But ordi- narily the general history of the case will help in differentiation. In doubtful cases one important thing must be remembered, namely, that the thought of rare diseases should be in the mind of the surgeon whenever diagnosis is not simple. More cases would probably be rec- ognized if this point were not overlooked, and our knowledge of the subject would undoubtedly be greater. The onty sure test in doubtful cases is to make a puncture—under the strictest aseptic conditions—or even an exploratory incision, and to examine the contents of the cyst. Of course if this contains the characteristic liquid contents of hydatids and they are surrounded by the characteristic wall, the absence of book- lets will not militate against the diagnosis; while the presence of book- lets is absolutely conclusive. Treatment.—The treatment of hydatids of the bones must be of the most radical character. Temporizing or hesitation may be fatal to the patient. It is beyond doubt that many of the deaths reported from this disorder have been due to improperly conducted incisions, which were followed by access of sejitic material to the cavity of the sac, with rapid development of generalized septic infection of the patient. Whenever an exploratory incision is made in a case of suspected hy- datid of a bone, the operator must be prepared to proceed immediately to a radical operation. Hydatids of the bones must be thoroughly eradicated, remembering that they are usually multiple, and that the removal of a single cyst, or even several, is not sufficient, but that every particle of the diseased structure must be removed or destroyed. The exact form of eradication depends upon the situation of the morbid growth. The flat bones must be opened freely and scraped out, and perhaps treated with an application of the hot iron. Even the spinal column may be operated upon, in order to put an end to pressure upon the cord. After any operation of this kind, thorough washing out of the cavity and drainage with large drainage-tubes must be employed. In certain cases* as after spontaneous fractures of the long bones, the necessity for amputation may arise. Experience indicates that little reliance can be placed upon resection of the bones, and when joints are involved, or large parts of the bones of the limbs, it is usually necessary to amputate at some distance from the seat of disease. Actinomycosis of the Bones. The subject of actinomycosis of the bones is treated of very briefly in Vol. III. of this Encyclopaedia, and something may be added to what is there stated in regard to the manifestations of this very rare disorder. It is almost unknown except in Germany and in the northern part of Europe, although von Jaksch says that it is a dis- ease of very wide distribution, and that it is probably the cause of what is known as angina Ludovici. The first accurate description of actino- mycosis, as a parasitic disease in animals, was given by Bollinger, and Ponfick first gave a scientific description of its occurrence in man, although he classed with this disorder two cases reported by Israel; ACTINOMYCOSIS OF THE BONES. 475 while, with the knowledge of these, Langenbeck concluded that a case which he had observed thirty years before at Kiel was of the same character. In recent years numerous publications on the subject have appeared, and the disease is now fairly well understood. It is a curious fact that actinomycosis in man does not present manifestations like those seen in neat cat- tle. In oxen, the disease is known as “lumpy-jaw,” because it is marked by swelling of the lower jaw- bone. In man, no enlarge- ment of the bones occurs in actinomycosis, which has been observed in the jaw- bone, the vertebra, the ribs, the clavicle, and the pelvis. The parasite is a peculiar fungus, consisting of a sort of stalk, with club-shaped, radiating buds. Its general appearance is seen in Fig. 1636. The progress of the disease is always from the soft parts to the bones. In the former there is a sort of abscess cavity, in appearance not unlike the ordinary ossifluent abscess, which on reaching the periosteum de- stroys this, and proceeds to attack the bone, which it invades by a process of erosion and caries. An illustration of the action of ac- tinomycosis upon the bodies of the vertebra is seen in Fig. 1637. In the case here illus- trated, the bones were saturated with pus, so that it could be squeezed out of them as if from a sponge. Actinomycosis may suc- cessively invade one part after another of a bone, and pass from one bone to another through a joint. It is a characteristic of this disorder that its progress does not ex- cite the reaction of irritation. Nowhere does the bone oppose its progress by the formation of a wall of inflammatory new tissue; on the contrary, the bone shows progressive rare- faction and caries, but never sclerosis or the formation of osteophytes. The lesion of actinomycosis is a species of abscess or cyst, containing usually a sero- purulent fluid, and bearing upon its wall, or containing in its cavity, certain granules of a yellowish color looking something like mustard seeds. These consist of an aggre- gation of small spherical masses, made up of pear-shaped agglomera tions arranged radially about a centre. The general appearance of Fig. 1636 Actinomyees—Unstained. (von Jaksch.j Fig. 1637. Actinomycosis of Vertebrae. (Gan- golphe.) 476 DISEASES OF BONES. such a granule under a low power of the microscope is seen in Fig. 1638. To examine such a granule, it is sometimes necessary only to press it out under a cover-glass, while at times the surrounding viscid fluid must be dissolved with a little liquor potassse. The contents of the actinomycosis cyst or cavity are sometimes viscid and serous, sometimes sero - purulent, and sometimes exclusively purulent. In the latter case it has been found that the detritus shows evidence of mixed infection, and the presence of staphylococci and streptococci of different varieties. The usual mode of entrance of actinomycosis is by way of an in- jury within the mouth, caused sometimes by rough teeth, or, in cattle, by the lacerations produced by hard and sharp-edged food. It is stated that actinomycosis has been communicated from an ani- mal to man, as reported by Hart- mann and by one or two other observers cited by Gangolphe. Gangolphe failed in attempts to inoculate animals with actinomycosis, using the products of the lesions for the inoculation. Fig. 1638. Actinomycosis Granule, (von Jakscli.) Diagnosis.—The abscesses connected with actinomycosis resemble in many respects those of tuberculosis, being of an indolent character, of slow development, and unmarked by signs of constitutional reaction. In this respect they are not unlike the forms of hydatid of the bones in which the soft parts are invaded. The diagnosis is likely to rest upon the history of the case and the presence of some injury connected with the mouth, together with the appearances found in the sac when this comes to be opened. Prognosis.—The prognosis of actinomycosis varies according to the situation of the lesions. The tendency of the disease to progress is decided, but this tendency can be overcome by means of radical operations. Treatment.—The treatment of actinomycosis is very much the same as that of hydatids, namely, free removal of all the diseased tissile. This must be followed up in all its anfractuosities, and the eradication practised must be of the most thorough sort. This may require the re- moval of a considerable portion of the soft tissues or of the bone, and should be followed up, in many cases, by an application of caustic liquids, such as a solution of chloride of zinc, or even by the application of the hot iron. The latter, besides being a most potent disinfectant, serves also to excite an irritation of the surrounding bone, which may cause the formation of an inflammatory barrier of new tissue against ALBUMINOUS OSTEO-PERIOSTITIS. 477 further infection, and may provoke reparative action to supply the tissue which has alredy been sacrificed. Disease of the Bones due to Disease of the Lung. It is a curious fact that diseases of the lungs are sometimes followed by a peculiar disease of the bones. Attention was first called formally to this by Marie, in 1890, who described a peculiar kind of deformity following diseases of the lung or pleura, accompanied by the production of pus. The characteristic of this disease is a singular enlargement of the bones, especially in the extremities. In many cases the appearance of a patient with this disorder is quite like that of patients suffering with acromegaly. Marie calls this disease “ osteo-arthropathie hyper- trophiante pneumique.” The pathology of the disease is entirely un- known, and its treatment consists in that appropriate to the conditions which give rise to it. Albuminous Osteo-Periostitis. This form of disease of the bones was described in 1874 by Poncet and Ollier as a distinct affection; but observations made by many differ- ent surgeons since then indicate unmistakably that it does not deserve this distinction. Its lesions are not new or peculiar; they consist princi- pally in the pouring out, under the periosteum or near it in a bone, of a peculiar, viscid exudate, like synovial fluid, albuminous in character and containing a comparatively small quantity of phosphates. This description of albuminous periostitis fits perfectly well conditions in which the exciting causes are very unlike. Such effusions are seen, for example, after accidental traumatisms or amputations, and in the course of infectious or tuberculous osteo-myelitis. In many cases it has been found that the fluid has contained staphylococci. This form of effusion has also been found in traumatisms of the soft parts, the bone being entirely uninjured. In various disorders and injuries of the bones, the presence of an albuminous fluid is of some consequence as indicating a comparatively benign condition; but it is purely a con- comitant and not an independent disease. INJURIES OF JOINTS. BY EDMUND ANDREWS, M.D., LL.D., PROFESSOR OF CLINICAL SURGERY IN THE CHICAGO MEDICAL COLLEGE; SURGEON-IN-CHIEF OF MERCY HOSPITAL, CHICAGO. Dislocations. The treatment of dislocations has in recent years been modified by the introduction of bolder operative measures. The weight of author- ity now is on the side of arthrotomy, or free section of the soft tissues, in all cases where from any cause the reduction cannot otherwise be ac- complished. Under antiseptic management the knee and other large joint cavities are now cut down upon, subperiosteal detachment of mus- cles and ligaments effected, and various plastic and reparative operations done without fear of injury to joint function. Arthrotomy, as a con- servative substitute for excision in old dislocations, is rapidly gaining ground. In the case of congenital dislocations of the hip the special operations of Lorenz and Hoffa seem destined to supplant all other forms of treatment, effecting, as the}T do, nearly complete cure. It is only within half a decade that much attention has been directed to the subject of arthrotomy, although theoretically the possibility of curing old dislocations by such means has been recognized since the ad- vent of antiseptic surgery. The chief credit for the perfection of arthrot- omy as opposed to arthrectomy must be given to the German surgeons, whose work has been the basis of the modern practice of English and American operators. Special Dislocations. Vertebra.—Luxation of the cervical vertebrae can undoubtedly occur without fracture. In the dorsal and lumbar spine this is proba- bly impossible. Walton reports five cases with only one death, and one followed by permanent paralysis. In the remainder there was slight loss of power of rotation. A case is reported by Feranchomme in which the sixth and seventh cervical vertebrae were displaced laterally, and the atlas forward, with paraplegia. Autopsy showed also hemorrhage in the spinal canal. La Place, in an old dislocation of the fourth cervical vertebra, recently performed a successful arthrotomy, cutting the soft parts down to the laminae and forcing the displaced bone into position. This, the first case of its kind, was followed by recovery. No disability remained after three months. 479 480 INJURIES OF JOINTS. Great difficulty will be experienced in determining the presence of fracture in these cases. Probably more of them should be cut down upon, as in fracture the operation is even more strongly indicated than in simple dislocation. Ribs.—At least one case of dislocation of a rib from its corresponding vertebra has been reported (Quint). This confirms the statement of earlier writers. Late authors have doubted the existence of this dis- placement except by fracture of the costal neck. In Quint’s case an autopsy was made and the diagnosis verified. The first rib wTas separ- ated by the passage of a wagon-wheel across the body. Costo-chondral dislocations are not always reducible. Bradley reports a case of dis- placement of five ribs backward from their cartilages in which replace- ment could not be effected. Although dyspnoea existed at first, com- plete recovery followed, though with deformity. Other similar cases have recently been published (Stoner, Stimson). A free incision of the skin and muscle, care being taken to avoid the pleura, would give an opportunity to grasp the rib by forceps, but no such operation has as yet been reported. Sternum.—The injuries caused by railway accidents include not in- frequently displacements of the bones of the sternum. The accident is far more common than formerly. In several cases seen by myself, the cause has been the same, viz., crushing of the chest between mov- ing cars in the occupation of switching or coupling them together. Usuall}T such cases have a fatal ending from other injuries. In one case of backward dislocation of the manubrium I was unable to effect reduction, and as the patient declined operative interference the deform- ity remained. There was, however, no dyspnoea or apparent disability after a few weeks. Clavicle.—The treatment of dislocation of the sternal end is often disappointing. The deformity which remains has recently been treated by periarticular injections of alcohol. Stimson reports success in re- storing normal position by this measure. Double dislocation of the sternal ends was successfully treated by Carraher, pressure being ap- plied by a figure-of-eight bandage crossing over the heads of the bones. The difficulty in these cases is not the reduction, but the retaining in position. Shoulder.—Ory reports a case of dislocation of the shoulder from muscular action in striking out with the fist. This accident has also occurred in swimming. Sir J. Lister reports two cases of double dislo- cation, one of which was caused by lifting a man from the water by the hands. A dislocation of the shoulder has recently been reported in a child two years old, said to have been the youngest patient in whom this injury has been noted. Autopsies made by Berthat would seem to show that a portion of the tuberosity of the humerus is commonly torn off in dislocations. Stimson found in an irreducible dislocation of the shoulder that the tendon of the subscapularis crossed the head of the bone. After this had been divided, reduction was easy. Arthrotomy is much to be preferred to manipulation or excision in SPECIAL DISLOCATIONS. 481 old dislocations of the shoulder. Rupture of the axillary artery is a danger not to be overlooked in efforts at reduction by manipulation. Forty-four cases of this accident, with a large percentage of fatal end- ings, had been reported up to 1885.1 In the treatment of this accident ligature of the subclavian has given the best result:— In 7 cases with double axillary ligature all died. “ 14 “ “ subclavian “ 9 “ “ 19 “ without operation 13 “ “ 4 “ with amputation at shoulder 3 “ Kbrte, of Berlin, claims that in many cases the rupture of the artery occurred at the time of dislocation, the bleeding being prevented by pressure of the head of the bone until relieved by reduction, but this view does not seem to be supported by the history of most of the cases. The application of pressure should always be tried, and will cure a small portion of these cases. If it fail and the resulting traumatic aneurism be large, either ligature of the subclavian or amputation will give bet- ter results than cutting down and placing a double ligature on the axillary. Arthrotomy is preferable to excision as giving a more useful limb and being an operation of less severity. Sir Joseph Lister makes an incision from the coracoid process a little outward and downward. All the muscles are detached from the tuberosity of the humerus by a chisel or periosteotome, and reduction is then usually easy. If not, then the head of the humerus is turned out of the wound and the rotators de- tached, which allows the bone to go into place. Four cases treated by this method were all successful. Robson, McLaren, Stimson, and Mor- ton report numerous successful cases of arthrotomy of the shoulder to assist reduction. The last writer makes an incision through the deltoid instead of that employed by Lister. Elbow.—After dislocations of the elbow extensive deposits of bone sometimes occur behind the external condyle, causing limitation of mo- tion, as in fracture. Several cases have recently been reported of this result without fracture having been present. The pathology of the ob- scure injury known as subluxation of the head of the radius has been cleared up by a careful analysis of 100 cases made by Van Arsdale. In many of these cases there is really a fracture of the neck of the bone. The only case on record of inward dislocation of the ulna at its upper end is reported by Loison. The bone remained luxated, and there was some limitation of motion. Arthrotomy for old dislocation is to be recommended in this as in other joints. Ssokolow reports four successful cases and advises against excision. Ollier reports a case of successful arthrotomy after 54 days. He declares that “the section of all structures holding the joint in ab- normal relation is preferable to excision.” The incision should be in the posterior line. The chisel may be used to separate the attachment of the triceps. After the “toilet” of the joint this may be replaced by nailing or wiring. In some cases a tem- porary suture of the joint has been used to prevent reluxation. Maydl has reported six cases, and Nicoladoni nine cases of this operation, all successful. 1 Annals of Surgery, November, 1885. 482 INJURIES OF JOINTS. Thumb.—Great difficulty is often experienced in reducing dislocations of the proximal phalanx. An important step in the procedure is rota- tion in both directions, in order to clear the bone from the two heads of the short flexors. Subcutaneous section of the glenoid ligament, or open dissection, should always be resorted to if necessary. Guermon- prez makes prolonged traction followed by rotation. Palmer advises the making of a small buttonhole in the palmar surface, and the intro- duction of a lever to pry the head into position. I am disposed to think highly of this expedient. Hip.—Recent autopsies seem to show that in many cases the pyri- formis, obturator interims, and gemelli muscles are torn in dislocation of the hip. The acetabulum is commonly fractured at its margin, and fragments of the head of the femur are often broken off. Thorndyke reports a case of backward dislocation reduced after eleven months by manipulation alone. A case of compound dislocation in a girl of 8 years is reported at the Boston Children’s Hospital. Infection and sup- puration were not avoided, but recovery finally was secured with bony anchylosis. Parkes reduced two cases of ancient dislocation of the hip by cutting the muscles very widely and using manipulation. Cliiene, Nelaton, Yolkmann, Quenu, Severeano, Sydney Jones, Paci, Nico- ladoni, Marguary, ATecelli (twice), Yilleneuve, Hughes, Gerster, Harris, and Robson also report such cases. Kinn has collected reports of 19 cases of arthrotomy of the hip for old dislocation, with 3 deaths. Since 1890 the operation has received much attention. Nelaton and the early operators favored an incision over the displaced head of the femur, that is, posterior to the trochanter in dorsal dislocations. While this readily uncovers the head itself, it renders it difficult to get access to the acetabulum and ligaments. There is still a muscular and ligamentous resistance which prevents reduction, and which requires free sub-periosteal section for its removal. A long, free, anterior inci- sion will usually lead more directly to the acetabulum. This must be carried along the great trochanter far enough to allow free dissection from it of all the shortened and resisting muscles and their tendons. The acetabulum and capsule are, after fourteen days, liable to be filled with new deposit. Yolkmann has shown by experiments on dogs, that, up to twelve days, this is soft granulation tissue easily pressed or wiped out by the returning head. After this time it may be found firm. An essential part of the operation consists in clearing out the acetabulum with a sharp spoon, prior to reducing the bone. Excellent functional results follow this operation when technically well done and not complicated by septic accidents. The very important operation of Lorenz and Hoffa for congenital dis- location of the hip marks an era in the treatment of that deformity. It is appropriately discussed in the section on orthopaedic surgery. Knee.—Considerable interest has been shown of late in dislocations of the semilunar cartilages, cases having been reported by Craft, Ailing- ham, Davies-Colley, and Annandale. Annandale operates by a circular incision, exposing the joint in front and laterally, and then drawing out and securing the cartilage by sutures. Congenital dislocations of the knee are reported by Joachimsthal, and GUNSHOT WOUNDS OF JOINTS. 483 at a meeting of the New York Academy of Medicine six cases were re- ferred to, of which three were double. Patella.—If necessary in the reduction of old dislocations of the patella, the vastus externus may be cut. In order to retain the bone in position Lucas-Championniere cut a groove with a chisel, and placed the bone in the groove. Eoux sewed the capsule to assist in holding the bone, and nailed the patella to the tibia. Fig. 1639, Fig. 1640. Gunshot Wounds of Joints. Two causes have greatly modified military surgery. One is the use of the new army rifles, which deliver bullets of very small diameter at the enormous velocity of over 2000 feet in a second, and the other is the more systematic use of antiseptics on the field of battle. Nearly all the great military nations have changed their guns, especially Germany, France, England, and Austria, and the United States of America. The new Springfield rifle has a cali- bre of only thirty one-liundredths of an inch, and the guns of the other principal nations are of nearly the same size. The bullet consists of lead, or lead and antimony, wedged into an elongated thimble of German silver, which gives the projectile a hard surface, and prevents it from being knocked out of shape or cut to pieces when striking a bone. It is consider- ably longer than the old bullet. These peculiar projectiles with their high velocity often perforate a bone in a remarkable manner, causing but little shattering, especially if the per- foration is in cancellated tissue. Figs. 1639 and 1640 show a bone perforated by a modern bullet fired at a medium distance, at which it has a singular power of making clean per- forations. At short distances, however, the modern ball acts differently. When striking the brittle surface of the middle of a long bone, the shaft is smitten into numerous small pieces as shown in Fig. 1641. The bullet going at 2000 feet a second drives these pieces before it, causing them Perforation of Bone by Modern Bullet. Fig. 1641. Comminution of Bone by Modern Bui 484 INJURIES OF JOINTS. to spread out in the form of a cone, and to act as if the bone had act- ually exploded. The bullet and the fragments rush out of the limb in a cluster, tearing the tissues wide open, as in Fig. 1642, making fright- ful wounds, with everted edges. The fragments of bone and bits of flesh are often driven 20 or 30 yards beyond the patient. This pseudo-explosive action, however, is not peculiar to the new rifle, as some writers seem to suppose. It was often seen in the War of the Rebellion, when the old Minie bullets struck the shaft of the femur or of the tibia. The tearing, semi-ex- plosive action caused great surgical shock, which was frequently fatal. When the new bullets strike joints at a medium distance from the gun, they often make clean perforations, which admit of being searched and disinfected, and they will allow of saving in many cases a useful articulation, when the old bullets would have shattered the joint, permitting nothing short of am- putation or excision. At long distances the new projectiles produce wounds much like those of the old kind when moving at corresponding velocities. Another difference between the new wounds and the old is due to the struc- ture of the bullet. The simple bullets of soft lead, whether round or conical, used to spread out, on striking the bone, into very singular forms, and in multi- tudes of cases were cut to pieces by the bony edges, producing fragments the smaller of which lodged in the injured parts, while the larger often flew on as separate projectiles. The remarkable tendency of soft lead bullets to be torn to pieces on striking a bone developed a singular theory as to its cause. It was seriously argued by some authors that on striking a bone the sudden arrest of velocity in the bullet caused its motion to be converted into heat, suddenly melt- ing the lead, and causing it to be dashed about in the tissues as a spray of liquid metal. To one intimately acquainted with the phenomena in question this theory is absurd. After carefully studying a great number of these fragments of lead, I assert without fear of contradiction that they are always chips and raspings, showing clearly the striae where the rough bone has scratched the surfaces. Neither in battle nor in my numerous cadaver experiments have I ever found a single piece of lead, large or small, showing any of the forms peculiar to the molten condition; nor any cauterized surfaces of tissue such as molten lead would produce. Mr. Victor Windett, a distinguished engineer, has shown by careful cal- Fig. 1642. Laceration of Soft Parts in Gun-shot Fracture by Modern Bullet. GUNSHOT WOUNDS OF JOINTS. 485 dilations that if the whole onward motion of a bullet weighing half an ounce and moving at 2000 feet a second were instantly arrested, and converted into heat, it would only raise the temperature to 351° F., which is 284° below the melting-point of lead. It is evident, therefore, that the deforming and comminution of the old projectile on striking a bone were purely mechanical. The new bul- lets are neither cut nor rasped to pieces. Being swedged into a slen- der but pretty strong thimble of German silver, the hard casing pre- vents both the spreading of the end on striking a bone, and the cutting and rasping of the metal as it goes through, so that in gunshot wounds of joints we now have in many instances a comparatively smooth per- foration, with only a few radiating cracks around it. This is in strik- ing contrast with what we found in the wars of past times, where we had to operate on joints literally reduced to a handful of bony gravel, interspersed with chips of lead. The simpler modern wounds admit in many cases of complete disin- fection, and consequently of successful treatment without amputation or resection. Field surgery has not yet fully tested the effects of the new guns, but we are safe in drawing the following practical conclusions:— 1. When a joint is wounded, whether by a bullet, a piece of shell, a splinter, a knife, or a bayonet—in short, by anything not known to be perfectly aseptic—no conclusion should be drawn from mere outside in- spection. The soldier should be anaesthetized, and the surface scrubbed with a solution of bichloride of mercury of the strength of one part to 2000 of water, or if, in the exigencies of battle, the bichloride is not at hand, then with tincture of iodine, alcohol, or any other antiseptic. 2. Still proceeding antiseptically, the surgeon should examine the wound. Synovial effusion, or the depth and direction of the wound as shown by a probe, often settles the question at once whether the capsule of the joint is perforated. If he is not clear as to this point, the surgeon should slit up the track of the ball to any extent necessary to allow a complete search for an opening in the capsule. If none is found, then the treatment is simply antiseptic. 3. If the bullet has merely grazed the capsule, making a slight rent, free from any evidence of dirt, bits of clothing, etc., and has not fractured the bone, and if also the wound is examined immediately after the in- jury, then the interior of the capsule will probably not be infected. The track of the bullet can be scraped or shaved with the scalpel, thor- oughly disinfected, and closed up antiseptically, with a prospect of success. 4. If the bullet has gone deeper, passing through the joint, or even gouging its bony edges, the wound must be considered as infected. In the Russo-Turkish war, Reyher advocated dissecting around the orifices of entrance and exit, and sealing up the wounds. He had a certain moderate amount of success, as things went in that pre-anti- septic time, but his method will not answer in future battles. In the cases under consideration it must be remembered that the sol- dier’s clothing is very foul with sweat, dust, and mud. His skin is in the same condition. There is nothing clean from head to foot about a soldier in battle. The track of the bullet which has traversed his clothing, or even the skin alone, is infected from end to end. It is 486 INJURIES OF JOINTS. therefore necessary to lay the joint widely open, inspect its interior, re- move fragments of bone or cartilage, cleanse the whole with antiseptic solutions in the most thorough manner, and then, if the joint surfaces are not shattered, close up the wound antiseptically, using drainage if the parts are much injured. If, however, the joint is badly comminuted, resection may be neces- sary, and if the shattering extends too far from the joint, or if the prin- cipal nerves and vessels are destroyed, amputation is usually required. The deadly experience of former wars firmly settled for that time the rule that excisions of the knee joint for gunshot wounds were not or- dinarily justifiable, the mortality being too great, but the advent of antiseptics has again brought up the question. We have had no great wars yet with a full trial of antiseptic exci- sions of the knee, and, beyond doubt, it will be very difficult in the exi- gencies of rapid marching and fighting to excise a soldier’s knee, and put it up in such a secure way that he can be hauled a hundred miles in an ambulance, and come out all right. In light marching, the sur- geon cannot have several barrels of plaster-of-Paris for dressings, yet binder’s board or thin elm splints might be furnished, and would serve for short trips to general or steamer hospitals. Where long ambulance hauling is not required, there seems no reason why military resections of the knee should not have a reasonable success under antiseptic con- ditions, and the question will therefore come up again, and will have to be decided by the experience of future wars. As to the shoulder, elbow, and wrist, exsections succeeded admir- ably in former campaigns, and will no doubt do still better in those of the future. The question of excision or amputation is to be decided in the superior extremity much as it is in civil practice, that is to say, excision is preferable to amputation unless the circulation is so far de- stroyed that mortification is inevitable, for even a slightly useful hand is far preferable to none at all. The articulations of the cranium, being firm sutures, with no syno- vial membranes, scarcely require special consideration. The new weapon has, however, introduced a form of injury little known before. In many cases the bullet in entering gives such a sudden expansion or out-fling to the substance of the brain as actually to burst and shatter the bony walls of the cranium. This is probably explicable by the law of hy- draulics, that fluids—and the living brain is a semifluid substance— transmit force equalty in all directions, and there is an experiment which gives analogous results. If a bullet be fired from one of the new guns through an empty tin flask, it merely perforates it, but if the flask be filled with water and the stopper put in, the bullet will not only pierce the tin, but shatter the whole flask. As far as practical management is concerned, gunshot wounds affect- ing the articulations of the cranium must be treated precisely like fractures of the skull in general. Punctured, Incised, and Lacerated Wounds of Joints. Punctured wounds of joints, as well as incised, contused, and lacer- ated wounds, are to be treated much like gunshot wounds which have PUNCTURED, INCISED, AND LACERATED WOUNDS OF JOINTS. 487 not fractured the bones. That is to say, the wound should be carefully explored, the orifice being freely enlarged when necessary, and if the interior of the capsule is likely to have been infected with septic mate- rial, it should be laid open, thoroughly disinfected, and closed antisepti- cally, drainage being provided if the interior is materially injured, or is believed to be decidedly infected with septic material. DISEASES OF THE JOINTS. BY ROBERT W. LOVETT, M.D., ASSISTANT SURGEON TO THE CHILDREN’S HOSPITAL, OUT-PATIENT SURGEON TO THE BOSTON CITY HOSPITAL, AND SURGEON TO THE INFANTS’ HOSPITAL, BOSTON. Probably no department of Surgical Pathology has experienced a more radical change in the last ten years than that relating to diseases of the joints. Not that new diseases or new conditions have been dis- covered ; simply that old and well-known pathological conditions have been differently interpreted. Tuberculosis, which occupied a compara- tively minor place in the old system, has come forward to take the chief place in the joint pathology of to-day. Perhaps we attribute too much to it and allow it more scope than it deserves, for the pathology of bone and joint disease is a department of much uncertainty. It is indeed a transition time in these matters: no classification worthy of the name exists, and there is no authority in the matter weighty enough to establish a classification which would be accepted by all. Syphilis and rheumatism are unknown factors to a large extent, and their pathological and clin- ical manifestations are often confused with those of tuberculosis. The chief duty, then, of one who would record the progress of the last ten years must be to state briefly on what grounds the various affec- tions have been accepted as tuberculous, and what influence this must have upon their treatment. Synovitis and articular osteitis will be con- sidered from this general point of view, and then attention will be paid to the diseases of the individual joints with especial regard to the more recent methods of treatment. Synovitis. Simple Acute Synovitis.—Simple serous synovitis deserves no es- pecial mention, as no modification of note has taken place in the views held by surgeons with regard to it, except in the general direction which has already been indicated. More cases are recognized as in- stances of tuberculosis than formerly. Especially is this true in chil- dren, where it is urged that a diagnosis of acute synovitis should be made with very great circumspection, and only after recovery has taken place. As hip disease, for example, has been studied, it has been seen that many a case remains latent until some fall calls into being the active symptoms. These follow immediately upon the traumatism and are naturally enough attributed to it, whereas a chronic osteitis was 489 490 DISEASES OF THE JOINTS. already present. These cases are so common as to be every-day matters in large orthopaedic clinics. Again, simple acute synovitis in children often passes directly into a chronic tuberculous synovitis. This is to be particularly noted in the knee, when the progress of the affection can be watched. These cases begin in the common way, and show no signs by which they may be recognized in advance. Hence it seems merely a precaution of common wisdom to urge that all cases of acute synovitis in children should be regarded as suspicious until permanent recovery lias taken place. Simple acute synovitis is not a common affection in young children, while joint tuberculosis is. Treatment.—The treatment of simple acute synovitis is for the most part unchanged. The use of cold, heat, and pressure, in connection with rest, is still the treatment of the best authorities. Best is the es- sential, and such experiments as those of Phelps 1 show how little is the danger of anchylosis from joint fixation. It has been shown plainly enough that fixation perse does not produce anchylosis in healthy joints. A question in the "treatment of simple synovitis which has assumed a semi-scientific aspect, is the immediate application of passive move- ment and massage. Such books as those of Mansell-Moullin 2 bring the matter before the profession and entitle the treatment to consideration from a critical standpoint. A quotation will show the tendency of the book: “As a rule, passive movement may be commenced from the second day with the certainty of preventing adhesions and without the least fear. . . . Supposing the case of a sprained ankle of moderate severity in a healthy person a few hours after the accident; the liga- ments are strained, perhaps even slightly torn; the synovial cavity is distended with fluid, etc. ...” In this case Moullin recommends massage. This will serve to show the extent to which the advocates of this theory would push it. They recognize no limitations as a rule, and an article may be found recommending even the immediate treatment of intra-articular fractures by massage and manipulation, and quoting successful cases3 treated in this way. With regard to the immediate treatment of synovitis by massage, it can only be said that it is not sanctioned by general surgical authority. That with a few exceptions those most used to the treatment of joint injuries advise immediate and complete rest, to be followed by massage when heat and active signs of inflammation have wholly or partly sub- sided. In slight sprains massage answers admirably, in severe sprains it is occasionally tried with signal success, but most surgeons will call to mind cases where the results have been most unfortunate. So that it may be said that, in simple acute synovitis, he who advises immediate massage recommends a treatment which is not generally sanctioned by the best surgeons, and which is attended with a risk of increasing instead of controlling the disease. Acute Purulent Synovitis.—The chief point in regard to acute suppurative synovitis which the researches of late years have developed, is the recognition of germs in the joint fluid in acute infectious diseases. 1 New York Medical Journal, May 17, 1890. 2 Mansell-Moullin, Spraius. London, 1887. 3 Lyou Medical, t. lvii., p. 12. TUBERCULOSIS OF BONES ANI) JOINTS. 491 The gonococcus has been found in the joints in the synovitis of gonor- rhoea, the pneumococcus in the joint disease occasionally occurring in pneumonia- These serve only to establish more fully the fact that these joint affections are distinctive, and are an integral part of the general disease in such cases. The treatment of acute suppurative synovitis is more vigorous than in former days. Early free incision of the joint, thorough antiseptic irrigation, and drainage if necessary, are the accepted methods. Early aspiration of the pus, with washing out of the joint through the aspi- rating tube until the fluid returns clear, is advocated by such men as Mayo Robson, and in the early stages yields good results. If it fails, incision of course is required. Prolonged rest to the affected joint is necessary after operation, especially in the case of children. Tuberculosis of Bones and Joints. The names of strumous and scrofulous joint disease are best omitted in the present connection, and the affections formerly called by these names are to be classed as tuberculous. The situation is fairly well stated by Dr. Peters,1 who says that those who do not recognize the identity of scrofula and tuberculosis are “such surgeons at home and abroad as do not perhaps enjoy the privilege of closely following the rapid advance of pathological investigation.” It can be stated very briefly upon what evidence these diseases are classed as tuberculous, and it is the more necessary to do so because Mr. Barwell was unwilling to accept the evidence of ten years ago; but the last years have been so fruitful in investigation in this direction, and the investigations so convincing, that to-day the question must be con- sidered as to a large extent settled. The Presence of Bacilli.—In the first place, tubercle bacilli are found in the affected structures. When they were first looked for, the results of investigation were unsatisfactory and imperfect; Kanzler, for example, found bacilli in only 8 out of 15 cases examined; this, how- ever, was in 1884.2 But with the perfection of the methods for their detection, the investigator of to-day is reasonably sure of finding the bacilli in the tissues affected by “ strumous” joint disease. Castro Soffia, in 1885,3 never failed to demonstrate the existence of bacilli, nor did Schuchardt and Krause in examining 40 cases of surgical tuberculosis from the clinics at Halle and Breslau.4 The bacilli are generally very few in number, and persistent search may he needed for their detection, and even expert observers are occasionally obliged to give up the search.5 In the pus they are even harder to find than in the joint tissues. Mog- ling6 was able to find them in all of 53 cases that he examined, but Schlegtendal,7 in 520 specimens of pus from tubercular abscesses, only 1 Canadian Practitioner, 1890; see also, Treves, Manual of Surgery; Howard Marsh, Dis- eases of Joints, p. 7; Hueter, Gelenkkrankheiten; Id., Arcliiv f. Cliirurgie, 1879, Bd. xi. 4 Berliner klinische Wochensclirift, 2 Jan., 1884. 3 These de Paris, 1885. 4 Fortscliritte der Medicin, Mai, 1883. 6 Muller, Centralblatt f. Chirurgie, 1884, No. 3. 6 Die Chirurg. Tuberculosen. Tubingen, 1884. 1 Fortscliritte der Medicin, Bd. i., S. 537. 492 DISEASES OF THE JOINTS. found the bacillus of tubercle in about To per cent. Experiments have, however, repeatedly shown that pus in which no bacilli can be detected is capable, when inoculated, of producing tuberculosis, so that in the 25 per cent, of cases in which the bacilli could not be identified they were undoubtedly present, as indeed Schlegtendal admits. Inoculation Experiments.—Another and most important link in the chain of evidence that strumous joint disease is really tuberculous, lies in the fact that inoculation with the diseased joint tissue produces general tuberculosis in animals. Tavel, for instance, has used this as a means of diagnosis. On inoculating material from so-called strumous joints he found that in Guinea pigs it invariably produced diffuse tuber- culosis and death in from five to six weeks.1 The experiments of Scliuel- ler have become classical. After rendering the animals tuberculous by the injection into their lungs of tubercular tissue, the knee-joints on the right side were damaged and were found afterward to develop a form of fungous joint-disease similar to “ tumor albus. ” Mr. Barwell was the chief objector to these experiments, which he did not consider conclusive; but in the light of further experimentation it must be ad- mitted that they established at least as much as Schueller claimed.2 Another most conclusive point is the fact that injection of pure cul- tures of tubercle bacillus into the joints causes a fungous joint-disease of the type known formerly as strumous or scrofulous. Pawlowskv3 found that an intra-articular injection of a pure culture of tubercle bacilli produced a tuberculous synovitis in animals in four days. At the end of three weeks the process had advanced to the stage of gran- ulation tissue and suppuration, and microscopical examination showed the tissues thoroughly infected with the bacilli. The injection of in- organic material into the joints does not cause tuberculosis. The most convincing experiments of all were those of Muller,4 who produced a typical tuberculosis of bone by the injection of tubercular material into the artery supplying the tibia. The experiments were made chiefly upon young goats, and the resulting bone lesions were identical with tubercular bone lesions as found in man. In one case where the animal was killed thirteen months after the injection, a typical fungous disease of the knee-joint was found, and bacilli were constantly found in the diseased structures. Cheyne 6 produced a typi- cal synovial tuberculosis which afterward went on to arthritis, in a rabbit, by the injection of tuberculous sputum diluted with distilled water; and tubercular pus put into the femoral artery of a rabbit pro- duced a cheesy mass in the upper part of the tibia, near the epiphysis. The injection of an emulsion of a pure culture of tubercle bacilli into the knee-joints of several rabbits produced in every instance a typical tuberculosis of the joints. Krause in the same way produced tubercu- losis of joints in rabbits by the injection of pure cultures of tubercle bacilli. These experiments show plainly enough that tubercle bacilli are capable of causing typical joint disease of the type that we recognize as tuberculous. 1 Senn, Tuberculosis of Bones and Joints, 1892, p. 13. • 2 Hueter, P., Archiv f. Chirurgie, 1879, Bd. xi., S. 317. 3 Annals of Surgery, vol. x., p. 225. 4 Centralblatt f. Chirurgie, 1886, S. 233. 6 British Medical Journal, April 11, 1891. TUBERCULOSIS of bones and joints. 493 Generalization of Tuberculosis.—Another evidence of the tuber- cular character of these joint lesions lies in the fact that so many of the patients ultimately die of generalized tuberculosis. Cheyne states that of 386 patients who had bone or joint tuberculosis, 10 per cent, died of phthisis, or some other form of tuberculous disease, within a period of three years after the end of treatment. Of 2106 cases of tubercular dis- ease of the bones and joints, Billroth and Menzel found that more than half were complicated with tuberculosis of the internal organs. Koenig believed that in only about 20 per cent, of cases of joint tuberculosis was the disease confined to the joint affected. Neumeister collected 438 cases of tubercular joint disease, and found that 10 per cent, of the patients had died of generalized tuberculosis. Presence of Tubercle Structures.—In addition to this, there is the evidence afforded by the microscope of the existence of tubercle in the diseased tissues. This evidence is, of course, less convincing to the general mind than the direct production of this form of joint disease by experiment, but it nevertheless points in the same direction. These experiments and investigations would seem to show that the type of chronic joint disease known by the various names of strumous, scrofulous, and fungous, is in reality a local form of tuberculosis, and that this statement rests upon the soundest pathological and scientific basis. The matter has been entered upon at length because the posi- tion here taken is the outgrowth of the work of the last ten years, and must needs be recognized by all who have to deal with the treat- ment of chronic joint disease. * Local Treatment of Tuberculous Joint Disease by Tubercu- lin.—It was hoped that with the introduction of Koch’s method for the treatment of tuberculosis a new era had begun in the treatment of tuberculous disease of the joints. The history and the failure of the tuberculin treatment are matters of medical history, and the reader will have no difficulty in finding exact directions for the use of the remedy as it was advocated by the originator. The idea of Koch was that the remedy did not kill the bacilli, but attacked the tubercular tissue and not the healthy structures, which gave clearly a limit to the inflammation that attended its use; and the action of the remedy cer- tainly was an increase of irritation in cases of surgical tuberculosis. When the fluid was injected into the subcutaneous tissue of the hack, tubercular joints became swollen, red, and irritated. It was hoped that not only would tuberculin serve as a remedy in surgical tubercu- losis, but that it might he utilized as a diagnostic sign in cases of tuber- cular disease. Neither of these anticipations has been realized. Its first use in affections of the joints was made by Bergmann, and from the 16 cases analyzed by him he was led to anticipate that in cer- tain cases its employment would be attended by brilliant results. Hahn 1 reported 59 cases of surgical tuberculosis treated by Koch’s method, and reported that 16 were considerably and 12 noticeably benefited. In tubercular joint disease the results were better when sinuses existed 1 Deutsche med. Wochen'schrift, 1 Jan., 1891. 494 DISEASES OF THE JOINTS. than when there was no outlet. Socin 1 tried the method in 20 cases with unsatisfactory results. Verneuil2 claimed that an authentic and permanent cure of surgical tuberculosis by the use of Koch's lymph had not been recorded at the time of his writing in 1891. Among the papers written by surgeons who have obtained favorable results from this treatment are those referred to in the foot-note.3 An attack upon this method of treatment was made at the Second Congress of Tuberculosis, July 27, 1891. It was demonstrated by Ar- loing, Rodet, and Courmont that the curative effect of tuberculin in cases of bird, bovine, and human tuberculosis occurring in animals, was practically nothing, and finally the assertion of Koch that the Guinea pig was given immunity against tuberculosis by treatment with tuber- culin, was disproved. It was stated, indeed, that in many cases animals thus treated developed more confluent tubercular lesions, and with greater tendency toward speedy degeneration. Dr. Senn4 gives the history of 53 cases of tuberculosis, 43 being cases of pulmonary phthisis, and 10 cases of surgical tuberculosis, and as his conclusion from this experience speaks as follows: “ I ltave given Koch's lymph a fair trial, and have carefully observed its results, and have become firmly convinced both of the danger which attends its use and of its utter inutility in curing any form of tuberculosis.” He protests, moreover, “earnestly against further experimentation with this myste- rious and dangerous fluid.” A purified preparation of Koch’s lymph, called by its advocate, Professor Klebs of Zurich, Tuberculocidin, has been advocated on the ground that the toxic substances which produced the unfavorable fea- tures in Koch’s lymph have been done away with, and that the thera- peutic value of the preparation is ecpial to that of tuberculin, but so great was the distrust engendered by the failure of Koch's tuberculin treat- ment, that Klebs’s newer remedy has aroused but little interest. Treatment by Injection.—Within the last few years the treatment of tuberculosis of the joints by the direct injection of some remedy has been advocated. The proceeding has not as a rule found favor so much with orthopaedic surgeons as with general surgeons in certain parts of this country and in Germany. I have had personally little or no experi- ence in the use of these parenchymatous injections, but have depended largety upon the admirable account given of the method by Professor Senn in his “Tuberculosis of Bones and Joints.” Tincture of iodine, arsenious acid,5 carbolic acid,6 corrosive sublimate,7 phosphate of lime,8 1 Correspondenzblatt f. Sclnveizer Aerzte, 1891, H. 1, S. 91. 2 L’Union Medical, 22 Janv., 1891, p. 24. 3 Bericlit uber die Anwendung des Koch’schen Heihnittels bei Kranken; von Esmarch, Deutsche med. Wochenschrift, H. 8, S. 4, 1891. Mittlieilungen uber das Koch’sclie Heilver- fahren; H. von Burkhardt. Med. Corresp.-Blatt des Wiirt. iirzt. Landesvereins, 18 Dec. 1890. Das Koch’sche Heilverfaliren combinirt mit chir. Eiugriffen ; Sonnenburg, Deutsche med. Wochenschrift, H. 1, 1891. Mittlieilungen liber das Koch’sche Heilverfaliren aus dem Kaiser Franz Josef Kinderspital in Prag ; Ganghofer und Bayer, Prager med. Wochenschrift, No. 84. 1891. Das Koch’sche Heilverfaliren in Spital Munsterlingen; Kappeler, Corresp. f. Schweizer Aerzte. 1891. 4 Chicago Medical Becorder, June, 1891. 5 Cavagnis, Etudes de la Tuberculose, p. 462. 6 Die Wirkungcn der parencliymatosen Carbolinjectionen bei Entzliudungen der Gelenke und Knoclien. Deutsche Zeitsclirift f. Chirurgie, Bd. iv., S. 526; Bd. v., 8. 120. 1 Ibid. 8 Korlisclier, Ein neues Heilver. bei lokalisirten tuberculosen Processen. Wiener med. Presse, Bd. xxviii., H. 22, 1887. Ibid., Bd. xxviii., II. 24, 1887. Ibid., Bd. xxvii., H. 29. Centralblatt f. Chirurgie, H. 15, 1888. TUBERCULOSIS OF BOXES AXTD JOIXTS. 495 chloride of zinc,1 balsam of Peru,2 and camphorated naphthol3 have all found their advocates for this use. The treatment cannot be called strictly a new one, because several of these substances have been in use for many years—as, for instance, tincture of iodine as introduced by Brainard, of Chicago—in chronic inflammation of the joints; but the persistent and extensive use of irritating and germicidal substances into the diseased tissue is strictly the outcome of late years. These various substances have found their respective advocates, as will be seen from the references given, but the majority of surgeons prefer the use of iodoform to that of cany other drug.4 Although it has been shown in the laboratory that iodoform may not be a germicide, its anti-tubercular action is thoroughly recognized from a clinical standpoint, and experimentally it has been clearly proved that a pro- longed use of this article by subcutaneous injection in animals, pre- vents or at least retards the extension of tuberculosis. However that may be, the treatment of chronic tuberculosis of the bones and joints by the use of iodoform is a matter of very great importance, because it is not only supported by a great weight of surgical authority, but offers a reasonable ground for hoping that it may take the place under cer- tain restrictions of more radical operative measures. The iodoform is generally injected in sterilized glycerin or olive oil. A 10-per-cent, preparation is used, and it is said that not more than half a drachm of iodoform should be injected the first time, and in children less than this. It is stated by Senn that after its use in this manner the risk of iodoform intoxication is very slight, not a single case having been observed in 108 cases thus treated in the Tubingen Clinic and at Halle. The treatment has been very extensively used, as for instance by Bruns,5 who says6 that, in the last five years, of 100 cases of tubercular abscesses treated at his Clinic, 80 per cent, have been cured, and that in the last four years 50 cases of joint tuberculosis have also been cured. A 10 to 20 per cent, mixture of iodoform is used in pure glycerin or olive oil, prepared fresh and thoroughly sterilized. No pain or in- flammation follows the injection, although the temperature rises for a 1 Lannelongue. 2 Munch, med. Woch., H. 40, 1888. Wiener med. Presse, Bd. xxx., H. 17-20, 1889. Centralblatt f. klin. Medicin, Bd. x., 1889. 3 Etudes exper. et clin. sur la Tuberculose, Paris, 1888-90, p. 608. 4 Berliner klin. Wochenschrift, 1881. Arch. f. klin. Chirurgie, Bd. xvii., S. 3, 1882. Wiener med. Blatter, Bd. viii., H. 10-12, 1885. Berliner klin. Wochenschrift, H. 41, 1886; Ibid., H. 20, 1891. Supplement to British Medical Journal, July 8, 1891. Etudes sur la Tuberculose, 1 Juillet, 1887. De la Tuberculose Chirurgical, etc., Paris, 1890, p. 485. Anato- mie Pathologique Generate. t. x., p. 616. Archives Generates de Medecine, 1829, t. v. These de Paris, Archives de Physiologic, 1878. Clinique Chirurgicale des Maladies Chroniques, 1877. Etudes sur la Tuberculose, fasc. ii., p. 416. Revue de Chirurgie, 1885, p. 428 et seq. Ibid., 1886, pp. 476-502. Gazette des Hopitaux, No. 146, 1887. CongrSs de la Tuberculose, p. 586. Gazette Hebdomadaire, 1887. Revue de Chirurgie, Fevrier, 1890. Etude experimentale de I’action de quelques agents chimiques sur le Deve- loppement du Bacille de la Tuberculose, 1888. Archives de Medecine et de Pharmacie, t. xvi., No. 8, 1890. Verb, der Deutschen Gesellsch. f. Chirurgie, 1887. Beitr. zur klin. Chirurgie, Bd. vi., II. 3, S. 639, 1890. Centralblatt f. Chirurgie, II. 38, 1889. Bruns, Beitr. z. klin. Chirurgie, Bd. ii., 1887. Ueber die Behandlung kalter Abscesse in tuberculoser Caries mit Jodoform-Emulsion, Berl. klin. Wochenschrift, No. 49, 1890; Bond. Med. Recox-der, 1889; Centralblatt f. die gesammte Therapie, 1887; Deutsche med. Wochensclmft, 1887; Cen- tralblatt f. Chirurgie, 18 Mai, 1889; Berl. klin. Wochenschrift, 5 Oct., 1891; Beitr. z. klin. Chir., Bd. iii., Tubingen, 1887, 5 Verh. d. Deutschen Gesellsch. f. Chirurgie, 1887. 6 Beitr. z. klin. Cliii-urgie, Bd. 6, H. 3, S. 639, 1890. 496 DISEASES OF THE JOINTS. day or two from one to two degrees. Bruns says that he has never met with cases of iodoform intoxication from these injections. In connection with this I am tempted to speak of a case under my own observation, in which a sinus communicates with a diseased hip-joint of many years’ standing. The patient is a physician of unusual intelli- gence. Iodoform bougies of three grains each were prescribed, one to be put into the sinus every night. The patient finds invariably that after the use of these bougies for a few days, an irritating coryza be- gins, and continues until their use is discontinued. After he stops using them the coryza immediately stops, only to return again after they are resumed. This case may perhaps serve as a contrast to those reported by the enthusiastic advocates of the use of large amounts of iodoform in closed cavities. For two years Krause treated tubercular affections of the joints by intra-articular injections of iodoform, as follows:— Cases treated. Cases cured. Knee joint, .... . 36 15 Hip joint, .... . 13 4 Ankle joint, . 6 1 Wrist joint, . 5 3 Trendelenburg treated 135 cases by the injection method, and re- ported that in 68 per cent, there were favorable results. Comparatively few instances of serious poisoning have been reported in connection with this mode of treatment, though toxic effects have been noticed after an injection of only one decigramme of iodoform. The use of this remedy dissolved in ether is objectionable on account of the vaporization of the latter at the temperature of the body, which causes so much distention that it may even lead to gangrene in extreme cases. It is said 1 that tubercular abscesses, treated by iodoform injections and examined at different intervals subsequently, show disappearance of the bacilli, and that ultimately the tubercles themselves disappear by fatty degeneration of the cells and liquefaction of the cellular detritus. With regard to the treatment by iodoform injection, Senn says that its curative power has so far been most manifest in the treatment of what have been heretofore most hopeless cases of surgical tubercu- losis—tubercular abscesses in connection with inaccessible osseous foci. In the successful cases not only abscesses but the primary bone lesions are also cured. This mode of treatment deserves consideration, as has been said, on account of the weight of authority in its favor; but at the same time it is evidently advocated by enthusiasts, and its real value must be regarded as something to be proven by careful and scien- tific experiment. It must manifestly be unsafe to inject large quantities of iodoform into closed cavities in every instance, especially in the case of delicate children, and few surgeons who have used iodoform freely have been so fortunate as to escape without some annoying or alarming symp- toms of iodoform intoxication. References have been given so that the reader may be able to judge for himself of the merits and the claims of this plan of treatment. If it be decided to adopt it, the joint or ab- scess cavity should be irrigated with a solution of boric acid, carbolic acid, or corrosive sublimate, until the fluid returns clear, and then 1 Beitr. z. klin. Cliirurgie, Tubingen, 1887. LOOSE BODIES IN JOINTS—ACUTE ARTHRITIS OF YOUNG CHILDREN. 497 a 10-per-cent, mixture of iodoform in glycerin should be thrown not only into the joint but into the thickened fungous capsule with an ordinary hypodermic syringe. The procedure should be repeated at intervals of a week, and each time at a new place in the joint contour. The ethereal solution should never be used, and the best method of using the iodoform is in the glycerin mixture. Senn says that from three fluidrachms to one fluid-ounce is the average dose. The strictest antiseptic precautions should be used, and the injections should be persisted in until the indications point to a cessation of tubercular inflammation, or until the result has shown the inefficacy of the treat- ment and the necessity of operative interference. However these injections are used they cannot be regarded as a substitute for mechani- cal measures, but should be employed in connection with the best ortho- paedic treatment obtainable. Loose Bodies in Joints. The only change that has occurred in the views held as to the forma- tion of these bodies, lies in the recognition of the tubercular character of many of them which were formerly supposed to be due to other causes. The larger loose bodies are generally of some other origin, either occur- ring in cases of rheumatoid arthritis or being traumatic,1 but the smaller loose bodies have of late been recognized as most often the product of tubercular inflammation. Although the bacilli of tuberculosis have not yet been found in them, they are capable of producing tuberculosis when inoculated.2 They were at first thought by Konig3 to consist purely of fibrin, the result of the tuberculous inflammation, but Schu- chardt 4 and others6 advocate the view that they are rather the result of proliferation of the synovial membrane, by which papillomatous growths are pedunculated and cast loose into the joint. The modern treatment is removal by simple incision.6 Acute Arthritis of Young Children. This affection of the joints, originally brought to the attention of the medical public by Mr. T. Smith 7 under the name of the acute arthritis of infants, is an acute osteomyelitis of the articular ends of the bones form- ing the joint. Researches of later years have merely served to show that the affection cannot be regarded as due to traumatism alone,8 but that it is a septic process resembling pyaemia in most instances. Culti- vations made from the cocci of acute osteomyelitis, when injected into 1 Marsh, British Medical Journal, April 14, 1888. Shattock, Trans. Path. Soc. Lond., vol. xv., p. 206. Hueter, Cf. St. George’s Hosp. Reports, 1867. Virchow, Die krankhaften Gesehwiilste, Berlin, 1863. Klein, Virchow’s Archiv, Bd. xxix., S. 190. Kragelund, Cen- tralblatt f. Chirurgie, 1887, S. 412. 2 Wallich, La Sernaine Medicale, 21 Nov., 1888. Senn, op. cit., p. 147. 3 Konig, Centralblatt f. Chirurgie, Bd. xiii., S. 25. 4 Schuchardt, Virchow’s Archiv, Bd. cxiv., Heft 1, S. 186. 5 Tillmanns, Archiv f. mikr. Anatomie. 1874, Bd. x., S. 425. 6 Woodward, Boston Med. and Surg. Journal, April 25, 1889. 1 St. Bartholomew’s Hospital Reports, 1874, vol. x. 8 Rosenbach, Centralblatt f. Chirurgie, 1884, No. 5, 1877, S. 289. Krause, Fortschr. der Medicin, 1884, Nos. 7 und 8. 498 DISEASES OF THE JOINTS. joints, cause a violent purulent arthritis,1 and Rosenbach has found the same coccus in furuncles, empyema, and pyaemia, so that we must infer that an acute septic process lies at the bottom of these cases. This form of joint disease at times occurs after the exanthemata,2 and in other in- stances a source of purulent infection may be found in a suppurating umbilicus, an empyema, or the like. In many cases, however, we must adopt the suggestion of Roswell Park, and assume “that the infection may occur through the ears, eyes, nose, mouth, pharynx, respiratory passages, mucosa of the alimentary canal, or skin; . . . furthermore from any subcutaneous phlegmon however small.”3 No form of coccus has yet been discovered in the acute arthritis of infants which is different from the cocci of acute osteomyelitis, so that, as stated by Park, the conclusions are that “ (1) there is no specific microbe for the production of acute infectious processes in bone; (2) most of the staphylococci can cause them, and exceptionally the strep- tococci; (3) the staphylococcus aureus is the most pernicious of all forms.” In short, this acute joint infection is to be regarded as a form of pyiemia; ten years ago it was conjectured that such was the case, but to-day the statement rests upon excellent pathological evidence. It is probable, however; although not definitively established, that cer- tain forms of this acute arthritis are merely manifestations of joint tuberculosis of exceptional rapidity and virulence, qualities which are apt to characterize surgical tuberculosis in very young children. Diseases of the Special Joints. Hip-Joint Disease.—The treatment of Hip Disease has been the subject of much discussion of late years. Attempts have been made to formulate the results of practice, and ambulatory treatment has been both denounced and most warmly advocated. The many manifesta- tions of tuberculous disease of the hip have been in part to blame for the varying conclusions, and 14 have elsewhere attempted to classify for clinical purposes these variations in the disease, distinguishing four types or forms. These are:— (a) The Destructive Form, where the disease is rapid, severe, and but little influenced by ordinary treatment; extensive infiltration of the soft parts takes place, and in most instances the disease passes on to a fatal issue. (b) The Painful Form, where pain is a prominent symptom, and exacerbations are common. (c) The Quiet or Painless Form, where pain is an unimportant factor or is entirely absent. (d) The Transient or Ephemeral Form,6 where the symptoms are mild and the course of the disease is run in a few months. It may be said that in general American orthopiedic surgeons believe 1 Id., Mikro-Organismen bei d. Wundinfections-Krankbeiten, Wiesbaden, 1894. 2 Holmes, Surgical Treatment of Children’s Diseases. McLeod, Indian Med. Gazette, 1883, p. 232. Ancell, Archives of Medicine, 1830, vol. iv., p. 49. Asbhy and Wright, Diseases of Children. 3 American Journ. of Med. Sciences. July, 1889. 4 Boston Med. and Surg. Journal, Oct. 13, 1892. 6 Ibid., Aug. 18, 1892. DISEASES OF THE SPECIAL JOINTS. 499 in and practise ambulatory treatment with a long traction splint, vari- ously described as the Davis, Taylor, or Sayre splint. That the results by.this method are so good that early resection is not practised by the representative men, but is regarded as a measure to be adopted when mechanical treatment has failed and the general condition of the patient is becoming bad. In these cases it is rather to be regarded as a life- saving measure than as an operation likely to yield brilliant results. English surgeons, however, incline much more to early resection,1 and do not regard the “American method,” as the traction method is called, with favor. In place of the long traction splint, cases are treated by bed extension, and when the time for going about has arrived, by the Thomas fixation splint. It is hard to arrive at any correct idea of the comparative value of the two methods by any comparison of sets of figures. One can only conclude that in view of the serious nature of the disease the results by either method are surprisingly good. In suppurative cases, Shaffer and Lovett2 reported 26 which had been investigated from four to ten years after the cessation of treatment by traction: 2 patients had re- covered with perfect motion, 3 with 90° of motion, 5 with from 10° to 45°., 4 with slight motion, and 12 with anchylosis. Howard Marsh analyzed 37 suppurative cases one year after discharge. These cases had been treated by rest in bed with extension, and afterwards the Thomas splint. In the 37 cases he found one with perfect joint motion, free movement in 10 cases, slight movement in 7 cases, and anchylosis in 18 cases. It would seem on general principles that cases treated without con- tinuous traction should show a greater elevation of the trochanter than would cases treated by traction, and that traction must exercise a quieting influence on the joint which cases treated by fixation alone can never obtain. By a combination of traction and fixation, a method which will presently be described, it would seem that the ad- vantages of both plans might be secured. With regard to the merits of excision as compared with mechanical treatment, there are two factors to be considered: (1) the mortality rate in the two methods; and (2) the functional results to be obtained. (1) The Mortality Rate in the Tivo Methods.—Mr. Wrright,3 in an- alyzing 2461 cases of hip excision done with and without antisepsis, found a mortality percentage of 34 per cent., the older groups, such as Leisrink’s,4 giving 63.6 per cent., and Culbertson’s 41.6 per cent, in 418 cases. Bradford and Lovett give a table of results of excision under modern conditions as follows:— Mortality per cent. Volkmann, 48 cases, . . 25.30 Korff, 88 “ . 48.5 Grosch, 166 “ . . 36.7 Alexander, 36 “ . 30.6 That is to say, the immediate mortality of excision, not counting the remote results, is not less than 30 per cent. The operation has 1 Barker, British Med. Journal, June 9, 1888. 2 New York Med. Journal, May 21, 1887. 3 G. A. Wright, Hip Disease in Childhood. 4 Arch. f. klin. Chirurgie, Bd. xii., S. 177. 500 DISEASES OF TIIE JOINTS. been advocated as a means of preventing the generalization of tubercu- losis, but that this result is not obtained is shown by such figures as those of Koenig,1 who reported that in 21 cases of hip excision, 47.6 per cent, of the patients died of tuberculosis inside of four years. In 837 cases of resection analyzed by Wartmann, it was found that 10 per cent, of all deaths were the result of rapid miliary tuberculosis, and Mr. Barker, a warm advocate of early excision, says that in 10 per cent, of all deaths following the operation “rapid miliary tuberculosis came on in such a way as to suggest strongly, if not to prove, that the surgical interference was the cause of the generalization of the disease.” (2) The Functional Results to be Obtained.—In 100 cases analyzed by Mr. Wright, another warm advocate of excision, the results were as follows:— Soundly healed, ... ..... 17 Unhealed, .......... 57 Dead or dying, . 18 In bad condition, 3 Amputated, 4 Recent case, doing well, 1 Total, 100 In analyzing this table it appears that about 20 per cent, of the cases may be classed as unsatisfactory. As 30 cases had been in pro- gress only nine months or less when excision was done, they represent the most favorable class for operation, and we should look here for the best results. If compared with the results given above as obtained by mechanical treatment, it is easy to see that they are manifestly inferior; indeed this might be anticipated, because removal of part of the bone necessitates shortening, while destruction of the joint capsule and of the ligaments must necessarily leave a less efficient joint than can be obtained by any process less destructive in its character. The London Clinical Society’s Committee2 investigating the ques- tion of hip excision, report “ that the limb after treatment by rest and extension, though frequently more or less fixed, is more firm and useful for purposes of progression.” Grosch3 declared as the result of an extensive analysis of cases of hip excision, that the results were no better than they had been before the daj's of antisepsis. In reviewing these figures, which have been presented very briefly, it does not seem that the case for excision is a very strong one. Evi- dently the mortality rate is high, and if one considers the remote deaths following excision, it is much higher than by conservative treatment. The operation does not prevent systemic infection, as has been claimed for it, and its functional results are not so good as after mechanical measures. It is difficult, therefore, for an American surgeon to under- stand on what ground Mr. Barker, for instance, can advocate excision of the hip joint “as soon as it is suspected that caseation is advancing in it,” until Mr. Barker explains that he regards “tubercle in the light of a malignant growth,” and of course would deal with it by most radical means. Of course, if one believes as Mr. Barker does, the position of such extremists as Mr. Wright and himself can be under- 1 Arch. f. klin. Chirurgie, Bd. xxvi., S. 822. 2 Transactions of Clinical Society, vol. xiv., p. 234. 3 Centralblatt f. Chirurgie, 1882. DISEASES OF THE SPECIAL JOINTS. 501 stood; but the remarks of Mr. Howard Marsh 1 furnish a fair statement of the position of the matter as it appears to most surgeons: “ It is im- possible, however, to shut one’s eyes to the fact that this is an estimate of tuberculosis which the great majority of burgeons would not for a minute entertain. The estimate formed by Brodie, indorsed by Paget and Hilton, and accepted by a very large majority of those who have studied the subject from a clinical point of view, is that, though often intractable and destructive in its later stages, tuberculosis on a general survey wears the aspect of simply an obstinate, inflammatory process, the whole course and progress of which are widely divergent from those of malignant disease.” Yet in a very extensive experience Mr. Wright has reached no more temperate conclusion than “ that treatment short of excision, when once suppuration occurs, is useful only as a palliative, or means of tem- porizing.” It may be said again, therefore, with regard to the comparative merits of mechanical treatment and excision of the hip-joint, that modern American opinion inclines toward a thorough trial of mechanical treat- ment, and that excision is to be regarded as a last resort, done as a life- saving measure, when mechanical treatment has failed, or as an inferior substitute for mechanical treatment in the case of the children of poor and destitute parents, who are out of the reach of hospitals, and for whom mechanical treatment cannot by any possibility be obtained. Treatment by Recumbency.—The mechanical management of hip dis- ease is conducted either by extension during recumbency or by ambula- tory treatment. Extension during recumbency is to be preferred to am- bulatory treatment when the disease is so acute that the hip is sensitive to jar, when night cries are present to any extent, and when attempts at going about with suitable apparatus cause pain and irritability of the joint. It is also to be adopted when deformity of the leg due to muscular spasm is present; when the child should rest in bed and trac- tion should be made in the line of the deformity. In short, irritability of the joint and deformity are the two indications for bed extension. Extension in bed is most simply applied if the child is placed flat upon the back and prevented from moving and turning in bed. This is Fig. 1648. Bradford’s Bed-Frame. almost an essential to the success of the treatment. The most simple appliance for securing this rest during recumbency is an oblong gas- pipe frame invented by Dr. E. H. Bradford, of Boston. This frame is covered with a stout cotton cloth, and is laced or buckled on the under side to keep it tight and unwrinkled. The cover to the frame is made in two pieces, leaving an open space under the pelvis so that the child need not be taken from the frame at any time, but that a bed-pan may be placed under the opening. (Fig. 1643.) 1 British Medical Journal, July 20, 1889, p. 121. 502 DISEASES OF THE JOINTS. This frame should be a little longer and a little wider than the child, who is secured to it by two straps crossing over the chest and passing under the frame. A towel is passed around the frame and the pelvis, securing fixation there. Extension is then made in the usual way by weight and pulley from the foot of the bed. (Fig. 1644.) This does away with the necessity of the long splint and the various appliances de- scribed to secure fixation. It forms a part of the routine treatment of hip disease in the Children’s Hospital in Boston, and is gradually being Fig. 1644. Weight and Pulley Apparatus for Bed-Traction. adopted elsewhere as the most useful aid to the treatment of hip disease by recumbency. If deformity is present, the same frame is used, and the leg should then be pulled upon in the line of deformity, and supported in the de- formed position by an inclined plane. (Fig. 1615.) Traction during recumbency may also he effected by applying a long traction splint to the limb. (Fig. 1646.) Treatment by recumbency is in my judgment not to be advocated as a routine, long-continued method in hip disease; but simply as a temporary measure to meet the indications which have been noted. As a rule some ambulatory treatment is to be preferably adopted, making it possible for the tuberculous child to obtain exercise and air within the limits of safety to the joint. The place which recumbency should DISEASES OF THE SPECIAL JOINTS. 503 occupy in treatment by ambulatory methods will be spoken of under the latter heading. Treatment by Ambulatory Means.—Treatment by fixation after the method of Mr. Thomas has been discussed in full by Mr. Barwell1 and Fig. 1645. Bed-traction in a Case of Flexion and Abduction. needs no further elucidation here. As has been said, it meets with much more favor in England than in America, and is to be considered as a method furnishing a fixation as complete as is possible by any simple apparatus, although far from being complete in reality. The method of ambulatory treatment by traction 2 was based upon the fallacious idea of permitting motion at the hip-joint without friction. Later investigation has shown that this cannot possibly occur, and that treatment by traction de- pends for its efficiency upon the fact that it induces Fig. 1646. Traction Splint Applied During Recumbency. a modification of intra-articular pressure, even separating the head of the femur from the socket. Much experimentation has been done with a view of determining the question whether traction really separates the joint-surfaces or not. References are appended 3 to articles showing the sort of experiments 1 See Yol. III. 2 Argument with the Censor at St. Luke’s Hospital, New York; London. 1889. Ridlou, Medical Record, Sept. 15, 1888. Shaffer, Transactions of the American Orthopaedic Associ- ation, vol. ii. Judson, Medical Record, July 7, 1883. Lancet, Dec. 2, 1888. 3 Transactions of American Orthopaedic Association, vol. ii., p. 207. Bull, et Mem. de la 504 DISEASES OF THE JOINTS. which have been made and the variety of conclusions which have been arrived at. Some recent experiments 1 upon the living subject, with and without hip-disease, have demonstrated that separation of the joint- surfaces may be produced by bearable and practicable amounts of traction. The conclusions which may be drawn seem to be the following: That traction of ten pounds in children before puberty as a rule produces lengthening of the leg in hip disease, and that this lengthening is due to separation of the joint surfaces; that the amount of this separation varies in different instances, being in general less in older children than in young ones, and also varying in individual cases under apparently the same conditions, perhaps on account of some anatomical peculiarity; that twenty pounds of traction, as a rule, produces more separation than ten pounds. It is probable that in the later cases of hip disease, where cicatrization of the capsular tissue may be supposed to have taken place, distraction is not as readily made. It cannot be supposed that the best results can be obtained by the application of inefficient traction. A sufficient amount of traction, constantly applied during the stage of muscular spasm, is needed. It is, of course, not the only therapeutic measure which is required; fixa- tion and protection are also needed at the various stages. If traction is not applied properly, or is applied at the wrong time, or is insufficient in extent, it is no more efficient than a drug injudiciously or wrongly used or administered at the wrong time. Judgment is required in the use of this measure as of any other, and a great deal of care and atten- tion to detail not only on the part of the surgeon, but on the part of the nurses and assistants, is necessary to insure the constant application of from eight to ten or fifteen pounds’ traction uninterruptedly for two or three or six months. It is owing to a defect in this respect that in many cases treatment by traction is ineffectual, and that the results obtained are not so satisfactory as desired. This leads to an unjust condemnation of the methods of traction-treatment by those who have tried this plan, and, having met with unsuccessful results, have blamed not their own mode of application, but the method in general; which is as irrational as if any one who should administer a drug in an insuf- cient dose should lay the failure to the drug, when it was properly due to its faulty administration. The thorough use of traction—that is, to the point of distraction— requires on the part of the surgeon not only a familiarity with the me- chanical details of apparatus, and the proper application, adaptation, and fitting of appliances suitable in each case, but the ability to arrange for such co-operation and assistance on the part of nurses or attendants as shall insure the continuance of the necessary amount of traction at all times. If, through the neglect of a nurse, a hip which needs con- tinued traction of ten to fifteen pounds for protection against blows from muscular spasm, is left during an acute stage for a time with a traction of only two pounds, the joint may be seriously damaged. Soc. de Chirurgie, 1886. t. xii., p. 31. Deutscli. Zeitschrift f. Chirurgie, 1873, Bd. iii., S. 256. Boston Med. and Surg. Journal, 1880, vol. ciii., p. 465; Ibid., August 30, 1888. Transactions of American Orthopaedic Association, vol. i., p. 193. 1 Bradford and Lovett, New York Med. Journal, Aug. 4, 1894. DISEASES OF THE SPECIAL JOINTS. 505 If a number of pathological specimens of pronounced hip-joint disease are examined, it will be seen that the head of the femur has been crowded upward and backward. This in typical cases continues until the head of the femur is partially absorbed and the acetabulum en- larged, and finally a subluxation takes place, and the exaggerated pres- sure of the femur upon the acetabulum is diminished. After a while, in successful cases, cicatrization of bone follows, and ossification with resulting deformity—the deformity consisting of a shortened and ad- ducted limb with subluxation, as indicated by the fact that the tro- chanter is higher than the Nelaton line. The change from carious destruction is most marked in the upper portion of the acetabulum, and in the lower portion of the acetabulum there is evidence of repair in some of the specimens where there was no pressure. From specimens examined it is clear that in hip disease the head of the femur is crowded against the acetabulum in a direction upward and backward, and that the process of repair is more advanced where the pressure is removed. It is a well-known fact that in hip disease, in the acute or sub- acute stage, a reflex spasm of the muscles about the hip exists, this spasm being in proportion to the amount of inflammation of the joint. The muscular pressure thus caused in disease is very much greater than is ordinarily supposed. Physiologists estimate the force of a muscle fully contracted at from six to ten kilogrammes to every square centimetre of muscular surface on cross section. In an adult, at the hip joint, the muscles connecting the femur with the ilium may repre- sent from ten to fifteen square centimetres, and although these muscles are rarely contracted to their full extent, it is evident that the amount of force which they exert even when slightly contracted is by no means inconsiderable; and during an acute spasm, when the muscles are firmly contracted, the pressure driving the head of the femur upon the acetabulum must be very great even in a child. It is well known that tiie muscular spasm at its acute stage is both a tonic spasm and also an acutely exaggerated spasm on any jar or violence to the hip, or even on the apprehension of any jar or violence. This spasmodic stage subsides after a while, if the hip is kept absolutely free from motion, but it is a matter of experience that the spasm may persist for months, reappearing upon locomotion until the morbid process is entirely cor- rected and the inflamed bone has become solid. It is also known that fixation of the hip joint is a difficult matter, and that complete fixation (that is, the prevention of even the slightest motion) is impossible. The femur can be fixed, but the ilium can not. This is true for the reason that neither the thorax nor the abdomen can be compressed to the point of firm fixation, and that the lumbar spine is capable of more or less motion. Furthermore, no amount of fixation can draw the head of the femur away from the acetabulum—that is, distract it—and pathological evi- dence would show that where pressure is entirely removed the process of repair is promoted. It would appear, therefore, that if a pulling force can be applied which will not only counteract the spasmodic muscular force, but actu- 506 DISEASES OF THE JOINTS. ally produce distraction, it will be desirable to employ it, this being entirely independent of any attempt to limit the motion of the hip joint. The specimens represented by the annexed cuts (Figs. 1647, 1648) speak most emphatically for the thorough use of this method. Fig. 1647. Fig. 1648. Head and Neck of Femur Without Traction. Head and Neck of Femur after Employment of Traction. The specimen shown in Fig. 1648 is of the head and neck of the femur where excision was done after two or three years of efficient treatment by traction, but where the reparative process was not sufficient to establish a cure; the patient’s general condition failed, and excision was resorted to. It is to be noticed that there is very little alteration in the shape of the head of the excised femur. ’ This, compared with the specimen shown in Fig. 1647, an excision in a patient with hip disease of similar severity and duration where no traction had been applied, would appear fairly to show the effect of traction in saving the head of the femur from destruction. If an indication for surgical treatment is ever clearly written in pathological specimens, certainly that of distraction should never be overlooked. It should always be remembered that in treating hip disease at a certain stage, the ob- ject should not be simply rest, or fixa- tion, or protection from jar, but actual distraction, and that traction short of this is inefficient. Traction while the patient is going about can be most easily produced by the long traction splint known as the Davis, Sayre, or Taylor splint. The especial form and construction of this splint are matters of very slight con- sequence provided that its aim be kept Fig. 1650. Fig. 1649. Splint with Curved Pel vie Band. Splint with Straight Pelvic Band. DISEASES OF THE SPECIAL JOINTS. 507 Fig. 1651. in mind. The object is to provide a rigid pelvic band which shall serve as a basis for counter exten- sion, made through a perineal band, with a foot-piece placed at the bottom of a shaft running down the leg. To the leg is ap- plied an adhesive-plaster extension apparatus, such as would be used in the Buck bed extension, and this is fastened to a windlass on the foot-piece of the splint. When this windlass is wound up traction is made upon the leg, and if the pelvic band is provided with stout perineal straps, traction comes di- rectly upon the hip joint. The splint is one which can be made by any blacksmith, and de- mands no nicety of construction. The forms most commonly used are shown in the annexed illustra- tions (Figs. 1649 to 1654). The pelvic band should fit tightly to the pelvis, and the upright of the splint may be somewhat curved to conform to the outline of the leg. The perineal bands should pass under the tuberosity of the ischi- um, and are most conveniently made of leather, or of webbing covered with canton flannel. I have de- scribed a cheap hip splint made of gas-pipe,1 which can be construct- ed for one or two dol- lars, and in which trac- tion is made by leather straps attached to the flat foot-piece instead of by the windlass; the splint is fairly efficient, although inferior to any splint in which the windlass is employed. (Fig. 1655.) It need hardly be added that the efficiency of the apparatus de- pends upon the nicety of its adjustment, 1 Boston Med. and Surg. Journ., March 12, 1891. Fig. 1652. Splint with Straight Pel- vic Band. Splint with Open Space over Trochanter. Fig. 1658 Fig. 1654. Curved Two-Band Hip-Splint Applied. Straight Two-Band Hip-Splint Applied. 508 DISEASES OF THE JOINTS. and upon the care which it receives at the home of the wearer. It is not an apparatus which can be applied and left to the discretion of hospital patients. It must be seen to and adjusted constantly. It should be worn continuously, and the traction should be kept up by constantly winding the wind- lass as fast as it gets loose. (Fig. 1656.) The pa- tient will experience from this a sense of comfort not to be obtained in any other way, and will be the best judge of the amount of traction to be ex- erted. In general, however, as much traction as is bearable should be kept up. The splint does not furnish complete fixation, but is to a certain extent a fixation appliance, and pos- sesses the merit of exerting traction, which to the mind of most American orthopaedic surgeons is essential in certain stages of hip disease. The long splint cannot be so adjusted that a patient can walk upon it without modifying the traction at each step, thus producing a jar upon the sensitive joint; consequently it is advisable, if the best results are to be obtained, that the patient should be provided with a high sole upon the well foot, and should walk upon crutches so as to allow the diseased leg .to swing, without having even the bottom of the splint touch the ground. It is also essential as a part of the treatment that the patient should during a part of the day be quiet, preferably upon his back. No diseased hip-joint can be so perfectly protected that the patient can go about with entire impunity, and it is desirable that he should be in bed certainly more than half the time. Modifications of this splint have been made which exert less traction, such as the perineal crutch of Dr. Judson, which aims at effecting only very slight trac- tion, if any, and is so balanced that the centre of grav- ity is higher than in the ordinary splint, and walking is easy. (Fig. 1657.) The splint in a modified form is manufactured very cheaply, and is spoken of as the New York Polyclinic splint. To my mind it is defi- cient, inasmuch as it exerts practically no traction, and should be regarded only as a protection splint. The splint of Dr. Phelps is perhaps one of the most important modifications of the long traction splint. (Figs. 1658, 1659.) This aims not only at securing bet- ter fixation than the common splint, by an arm encir- cling the thorax, but it also provides theoretically a cer- tain amount of lateral traction in addition to that Fig. 1655. Fig. 1656. Diagram of Cheap Gas-pipe Hip-Splint. Fig. 1657. Windlass and Exten- sion as used in Long Traction Splint. Judson’s Perineal Crutch. DISEASES OF THE SPECIAL JOINTS, 509 made in the length of the limb. It is doubt- ful, however, if the splint really exerts much lateral traction, and it probably owes its chief efficiency to the fact that it pro- vides better fixation than the simple Davis- Taylor splint. The question of the value of lateral traction is one which is still un- settled. Dr. Phelps attaches very much importance to it, and uses it as a routine mode of treatment. It has not as yet been largely adopted, and it remains for the fu- ture to decide whether it shall form part of Fig. 1658. Fig. 1659. Fig. 1660. Phelps’s Hip Splint. Fig. 1658 represents the perineal crutch with the abduction bar (1) adjustable by means of the key (6). for the pur- pose of making lateral extension. The steel bar (2)'is adjusted to the steel ring (3), which makes a firm crutch, the pressure coming on the tuberosity of the ischium. Adhesive straps extending to near the body from the ankle, furnish means of extension by tightly buckling them to the straps (7, 7), the ring (3J furnishing counter-extension. The rod (5) ending in the upper ring prevents flexion and extension of the legs. The whole splint is intended to prevent every motion at the hip- joint, and at the same time apply extension in a line with the neck of the bone. Fig. 1659 shows the crutch and splint adjusted, the patient using crutches, and standing on a high shoe upon the well leg. the habitual treatment of hip disease or not. The chief point at stake seems to be the em- ployment of strong and persistent traction to separate the joint-surfaces. Another modification of the long traction splint, with the purpose of furnishing better fixation, is that shown in Fig. 1660, in which I have made an attempt to combine the Thomas and the Taylor splint, and which has as its ob- ject to furnish better fixation to the diseased joint while still exerting traction. It is suit- able for use chiefly in hospital practice, in the case of unruly children who cannot be controlled by their parents. Certain more elaborate modi- fications of the long traction splint have been made, but have not secured general acceptance. Lovett’s Long Splint. 510 DISEASES OF THE JOINTS. In Germany no one method of treatment meets with general adop- tion. Fixation splints have been employed by some surgeons, but the tendency in the last few years has been strongly in the direction of the adoption of some form of traction treatment. Another important modification, described by Dr. Phelps, is a fixation bed, made partly of plaster-of-Paris, being practically a modification of Fig. 1662. Fig. 1663. Phelps’s Fixation Bed. DISEASES OF THE SPECIAL JOINTS. 511 the wire cuirass to which the addition of traction has been made. It provides complete fixation for the patient, who can be carried about, as on a frame, without any jar to the hip; and it is easy to see that the apparatus in spite of its clumsiness may serve a very useful purpose in many cases. (Figs. 1661-1663.) Where traction treatment is to be adopted, it should in most cases be con- tinued over a period of some years. Traction and rest to the joint should be secured until a time has been reached when muscular spasm and articular pain have been absent for many weeks or months, and then the joint should be further protected for at least two years in ordinary cases. The danger of a re- lapse is an important one, and is always to be guarded against. The splint spoken of in American text- books as the Dowse splint, is the long traction splint merely fastened to the shoe instead of projecting below the foot. It is of such a length that it acts as a perineal crutch, and lifts the heel out of the boot, prevent- ing thereby the impact of the foot in walking. The theory of the splint has been very carefully worked out by Dr. Brackett,1 who has demonstrated that the foot, and conse- quently the hip, are protected by it from pressure except at the last part of the step, when the foot is in the act of leaving the ground, and when the least pressure is required. This splint serves to receive the weight of the body in walking, serving as perineal crutch. In a this way the jar does not come upon the convalescing joint, but upon the splint. (Figs. 1664-1666.) The frequency and danger of relapse make it advisable that the use of this splint should form a regular part of the traction treatment of hip disease, and that the dis- eased joint should be thus protected for at least one or two years after the cessation of active symptoms. Abscesses in Hip Disease.—In spite of much discussion and a certain amount of dissension on the part of men whose opinion carries much weight, such as Shaffer and Judson, it is generally accepted that the proper treatment for the abscesses of hip disease consists in early incision and evacu- ation of the contents. It is permissible to Fig. 1664. Fig. 1665. Convalescent Splint. Fig. 1666. 1 Boston Med. and Surg. Journal, Oct. 6, 1887. Convalescent Splint Applied. 512 DISEASES OF THE JOINTS. sew these abscesses up after a thorough clearing out, without drainage, and in a certain number of cases primary union may be secured.1 A large proportion of abscesses treated in this way ultimately break down again, but some of them remain permanently healed. On the whole, however, it seems better to pack the wound or close it loosely, allowing the cavity to drain, and the spontaneous closure of the sinus is one of the most favorable of prognostic signs. It is important, in operating upon a hip abscess, to lay open, as far as practicable, the whole extent of the cavity. If possible, the joint should be explored, as its capsule must necessarily have burst, and if a sequestrum is found it should be removed. The Prevention of Hip Abscesses.—This is a still more important question than that of the treatment of hip abscesses, because it has received very little attention. Mr. Howard Marsh said, in speaking of his cases: “My own estimate, from what I have seen in the hospital and elsewhere, is that the formation of an abscess may be averted in at least 80 per cent, of the total number of cases.” In the earlier series of cases reported, however, 60 or 70 per cent, developed abscesses. (Gibney, and London Clinical Society.) In contrast to these cases a series reported from the Boston Children’s Hospital is of much interest; in 320 cases under ambulatory treat- ment only 23 per cent, developed abscesses. In a later series of cases from the same institution, only 18.7 per cent, developed abscesses in 574 new cases treated by ambulatory measures. The reason for this small percentage is probably the fact that patients under ambulatory treatment are at once admitted to the hospital whenever sensitiveness or deformity of the joint occurs, and are treated by recumbency. Treat- ment by aspiration and the injection of iodoform, and the like, is in general unsatisfactory, in comparison with free incision. Malum Coxje Senile.—The form of disease of the hip occurring in elderly persons has generally been regarded as an intractable form of rheumatoid arthritis. The extension of mechanical methods of treat- ment in all departments of joint surgery, has served to show that much may be accomplished by mechanical support when pain and irritability are present in this condition. H. L. Taylor,2 in an admirable paper, has related several cases where rest to the joint was afforded by recum- bency and traction. After a period of such treatment, a splint similar to that used in convalescence from hip disease was applied, and after a rather long period of such treatment extremely favorable results were obtained. The irritability in these joints seems to yield as readily to rest and traction as do similar symptoms in tubercular disease of the hip. Congenital Dislocation of the Hip.—Any article on diseases of the joints would be incomplete without some mention of the recent ad- vances made in the treatment of that most serious affection of the hip joint, congenital dislocation. Information upon its etiology and pathology can be found elsewdiere, but the advance in treatment within late years is so promising that the importance of the subject demands a description of the newer methods. 1 Boston Med. and Surg. Journal, Sept. 18, 1890. 2 New York Med. Journal, Dec. 15, 1888. DISEASES OF THE SPECIAL JOINTS. 513 Treatment by Traction.—The early methods of treatment by continu- ous extension, either in bed or by means of apparatus worn while the patient was walking about, had been practically abandoned until the case reported by Buckminster Brown,1 of Boston, in 1885. In this case a girl four years old with double congenital dislocation of the hip had very loose joints, the walk was bad, and no trace of an acetabulum could be found by manipulation. The patient was put to bed, and con- tinuous traction was made by weights to stretch the contracted tissues, and to bring the femur into its proper position. After some weeks, passive movements were made by changing the position of the pulleys. The child was kept recumbent for thirteen months, and after two years and three months of treatment, either in bed or by going about in a wheel-crutch, the heads of the femora were found in place on Nelaton’s line, and the patient was allowed to begin walking about. At the time of Dr. Brown’s report the walk was normal, and she was able to play and run about like other children. It has since been reported that a relapse finally occurred. Only under the most exceptional circum- stances, and with parents of exceptional intelligence and interest, could any such treatment be pursued satisfactorily. Other methods of treatment by traction have not as a rule yielded good results, though Myers quotes from Schede four complete cures ef- fected by means of a splint which held the leg constantly abducted; and the large number of corsets and pelvic bands which have been advocated to retain the head of the femur in its proper position are for the most part worthless, or of very little use,2 so that on the whole it may be said that the results of mechanical treatment for congenital dislocation of the hip have been of an unsatisfactory character. Operative treatment was employed very early, even in the time of Guerin, who practised tenotomy of the peri-trochanteric muscles with comparatively little relief. Subcutaneous operations, with or without extension, were performed by Bouvier, Pravaz, Corridge, and Brodhurst. Barwell revived the old operation of Guerin, and reported good results. Koenig and Hueter attempted elaborate operations for covering the head of the femur with periosteum detached from the ilium, but no one operation met with any extended acceptance. The results of excision have not on the whole been satisfactory. In the first place a stiff joint is likely to result from the procedure; in the second place a certain amount of shortening is necessitated. It is not worth while to enter upon the details of these operations, which have not realized the expectations which had been formed of them.3 Of 27 cases which I have analyzed of reported resection for congenital dislocation of the hip, 17 were unilateral, 7 were bilateral, and in 3 this point was not mentioned. In the 7 cases of double dislocation 3 patients walked badly after operation; 4 walked passably, requiring the use of a cane, while in 3 cases it was noted that displacement of the femur during walking persisted. In the 17 unilateral cases operated 1 Boston Med. and Surg. Journal, 1885, No. 23. 2 Lehrbuch d. spec. Chirurgie, 188?, Bd. iii., S. 287. Arcliiv f. klin. Chirurgie, 1885, Bd. xxxii., S. 516. 3 Jules Guerin, Reclierclies sur les Luxations Congenitales, 1841. Le9ons Cliniques sur les Maladies de 1’Apparatus Locomoteur, Paris, 1885. Giraldes, L’Union Med., 1869. Lec- ture on Orthopaedic Surgery, London, 1876. Lancet, 1885, vol. i., p. 271. A. Mayer, Dasneue Heilverl'ahr. bei Fotalluxationen durcli Osteotomie, Wurzburg, 1885. Brit. Med. Journal, May 28, 1887. 514 DISEASES OF THE JOINTS. upon, 1 patient was able to walk all day without fatigue; 2 could walk for an hour or two; 5 walked better than before the operation; 2 were obliged to use crutches; 6 limped; while 1 walked worse than before, and 1 was not reported upon. These might be classed as 3 good results, 5 moderate results, and 8 bad results. It, therefore, seems safe to say with regard to resection of the femur as a curative measure in con- genital dislocation of the hip, that its results are unsatisfactory.1 Hoffa’s Operation.—A possibility for the relief of this condition is held out by the operation of Hoffa, which bids fair to yield better re- sults than any other method of treatment. The operation aims to replace the head of the femur in a socket artificially made by scooping out a hollow in the bone. A free incision is made as if for excision of the hip by the posterior curved line; the cut is carried down until the posterior aspect of the joint is exposed; the capsule is extirpated as far as it offers any resistance; the soft parts and ligaments which prevent the femur from being pulled down are cut, and with a heavy Volkmann spoon the acetabulum is made at the proper place by hollowing out a receptacle in the ilium. The head of the femur is placed in this hol- low, and the wound is closed. The operation is most suitably performed upon young children, under six. In older children the contraction of the parts about the hip is so great that it is difficult in many instances to reduce the dislocation. In some instances Hoffa performed tenotomj" of the hamstring tendons and of the fascia about the ilium. He advises against the operation in children over ten years of age. Of 75 patients operated on by Hoffa all who recovered were “greatly improved by the operation.” If sup- puration occurs, or if the acetabulum is not made sufficiently broad and deep, anchylosis is apt to take place. The first dressing should be kept on for three or four weeks, but after five weeks the child is allowed to walk in apparatus which allows motion at the hip, and which, in unilateral cases, should be worn for several weeks or even months. Lorenz’s modification of Hoffa’s operation requires an anterior inci- sion, made below the anterior superior iliac spine. The capsule is very easily reached in this way, and the contraction is more effectively attacked from the front, because the chief obstacle to reduction seems, as demonstrated by Bradford,2 to lie in the ilio-femoral bands of the cap- sule. The attachment of the Y ligament should be thoroughly divided near the inter-trochanteric line of the femur. It is possible that by this operation older patients may be operated on and with better suc- cess than by the original method of Hoffa. Lorenz 3 has further modified his operation by making a transverse incision directly outward from the longitudinal incision, in order to afford still easier access to the acetabulum. 1 Klinik der Gelenkkrankbeiten, 1870. Lehrbuch d. spec. Cliirurgie, 1889, Bd. iii. Centralblatt f. Cliirurgie, 1887, S. 386. Quoted by Kronleiu (Deutsche Cliirurgie). Central- blatt f. Cliirurgie, 1884, No. 14. Arcliivio di Ortopedia, Anno i., fasc. 5, 6. Arcliiv f. klin. Cliirurgie, Bd. xxx., S. 666. Centralblatt f. Cliirurgie, 1884, No. 45. Berliner klin. Wochenschrift, 1887, No. xiv., S. 398. Quoted by Teufel. Deutsche Zeitscli. f. Clii- rurgie, Bd. xxix., S. 343. Giornale della R. Aecad. di Med. di Torino, fasc. 6, 7, 1885. Arcliivio di Ortopedia, t. ii., Nos. 3, 4. 5. Quoted by Hoffa, Revue d’Orthopedie, Mars, 1891. p. 101. Centralblatt f. Cliirurgie, 1887, S. 336. 'Quoted by Porto, Les Luxations Con- genitales de la Handle, etc.. Paris, 1887. Quoted by Holla, loc. cit. Ogston, Annals of Surgery, vol. viii., p. 1. Brit. Med. Journal, 1885. 2 Trans. Am. Orthopaedic Association, vol. vii., p. 95. 3 Ibid., p. 112. DISEASES OF THE SPECIAL JOINTS. 515 Myers1 reports 177 cases of Hoffa’s operation and its modifications, among which are 6 of death which may have been due directly to the operation, making a mortality of 3.3 per cent. Up to the end of August, 1894, Lorenz had operated upon 99 cases of congenital dislocation of the hip-joint without a single failure. At the 66th Assembly of German Naturalists and Physicians, in Vienna, he presented no less than 34 children upon whom he had operated. He says: “Scarcely a trace of limping was noticeable, and the patients walked gracefully and exhibited excellent form of body. The children marched erect and with an almost military step, amidst the outbursts of applause on the part of the illustrious assembly of surgeons.”2 The experience of American surgeons has not been so favorable as that of Lorenz and Hoffa. Many of the operations have been unsuc- cessful, although done with care and by skilful operators. It has often been found difficult to reduce the dislocation; stiff joints and relapses have at times occurred; and in general the attitude among American orthopaedic surgeons is one to a certain extent of indecision. A very fair statement of the feeling is made by Myers, who agrees with the conclusions of Redard, that after the bloody reposition the number of perfect cures is very small; the number of cases improved is large; the results in double dislocation are not so favorable as those in single; and the limp almost always persists in some degree. In general, the present feeling in regard to the treatment of congeni- tal dislocation of the hip may, I believe, be stated as follows: That traction treatment has been to a large extent a failure; that methods of operation by excision, etc., have not yielded good results; and lastly, that Hoffa's operation or some modification of it offers the best chance of relief. In these cases the success of the operation will depend largely upon the age of the child and the anatomical conditions peculiar to the individual case. The parents of the child cannot be assured that the operation will be a success, but they may be told that it is not likely to make the child any worse, and that it is attended by very slight risk to life. Diseases of the Knee-Joint.—The affection known as tumor albus and formerly classed as strumous, scrofulous, or fungous synovitis is the most frequent of all diseases of the knee-joint. It is now recog- nized as a tuberculous affection, sometimes beginning in the bone and sometimes in the synovial membrane. The following table, from Wille- mer, shows the frequency with which each structure is attacked:3 Under 10 years, From 10 to 20 “ Primarily synovial. . 39 Primarily osseous. 61 . 49 51 Above 20 “ . . 33 65 Konig reached similar results in analyzing 114 museum specimens, 69 being osseous in origin, 33 synovial, and 12 doubtful. It seems probable from these statistics and others4 that in youth the disease begins in the synovial membrane in about half of the cases, while the others are of osseous origin—whereas later in life the osseous forms predominate much in frequency. ! Transactions Am. Orthopaedic Association., vol. vii. 3 Willemer, Deutsch. Zeits. f. Chirurgie, Bd. xxii., S. 268. 4 Clieyne, Brit. Med. Journal, April 4, 1891. 2 Ibid., p. 104. 516 DISEASES OF THE JOINTS. In practice one can generally dis- tinguish between the two forms, for in the one case a synovial distention passes slowly or rapidly into a fun- gous enlargement, whereas in the cases of bony origin enlargement of the bone, pain, and muscular spasm precede any synovial effusion. No- where can the traumatic origin of tubercular joint disease be more clearly demonstrated than in these cases of beginning tumor albus. Treatment.—The treatment of tu- mor albus originated by Thomas and advocated by Barwell, is the one in most common use in American or- thopaedic practice. Partial fixation can be obtained by means of plaster- of-Paris, leather, silicate, or dextrin bandages applied to the leg, and these are the meth- ods in use in most general hospitals (Fig. 1667). But they are not suitable for continued use, as they loosen and become dirty, and they furnish in- complete fixation, no matter how care- fully they may be applied. Dr. Judson says with regard to them: ‘‘ It may be an exaggeration, but it conveys the idea, to say that a plaster-of-Paris or silicate splint, applied to the leg and thigh, con- tains a mass of jelly in which the femur is but little restrained from motion.” In addition to this, unless the patient has a high sole upon the other boot and uses crutches for an indefinite period, the joint is not protected from weight-bear- ing in walking, and this is a matter of prime importance in tumor albus. So that if the stiff bandage is adopted it must be for an indefinitely long time, and the patient should not bear his weight upon the limb. The Thomas knee-splint (Fig. 1668) is a ring of iron fastened at an angle of 15 degrees to two uprights which project below the foot. This ring of iron is padded and fits closely the upper part of the thigh, so that in walking the patient receives perineal support, practically sit- ting in this ring and bearing no weight Fig. 1667. Plaster-of-Paris Bandage Ap- plied to Knee. Fig. 1668. Thomas Knee-Splint. DISEASES OF THE SPECIAL JOIXTS, 517 upon the knee. As used at the Bos- ton Children’s Hospital this splint is slightly modified, as shown in Fig. 1669. It is provided with accurately fitting leather lacings for the thigh and the calf of the leg, furnishing excellent fixation, and in addition to this a bar is provided at the bottom of the splint around which a sticking- plaster extension band may be buck- led so as to make traction upon the knee in cases attended by much irri- tation. A high shoe is placed upon the other foot, and the patient is able to go about during the whole course of the disease unless this is too acute or unless the knee is flexed. If there is much flexion from mus- cular spasm the Thomas splint be- comes unwieldy, because it is difficult to fix the flexed leg by a straight ap- paratus, and because traction cannot be made in the line of the deformity, while if made otherwise it becomes painful and irritates the knee. Un- der these circumstances various plans may be adopted:— (1) The knee may be straightened while the patient is under the effect of ether by the use of more or less force, and a fixed dress- ing, as of plaster-of-Paris, may be applied while the limb is in the straight position. This plan is only to be used in cases of moderately long stand- ing, because, of course, if anchylosis has oc- curred some more radical operation is required. (2) By a succession of plaster bandages, applied at intervals of a week or ten days to the flexed limb in its deformed position, the irritation may be quieted, and at each applica- tion the knee will be found in a straighter position, without the use of force; this method is to be pursued until the leg is straight. (3) In cases where fibrous anchylosis has occurred in a flexed position the apparatus of Goldtliwait1 (Fig. 1670) is of much use for forcible correction. It is always employed with the patient under ether. After the ad- Fig. 1669. Fig. 1670. Modified Thomas Knee-Splint. Goldthwait’s Apparatus for Forc- ibly Straightening the Knee. 1 Boston Med. and Surg. Journal, Sept. 7, 1890, and Dec. 1. 1892. 518 DISEASES OF THE JOINTS. hesions have been broken up as much as possible with the hands, the apparatus is applied with the leg flexed. The posterior band (d) is then screwed forward, and the leg straightened intermittently, by the use of the long lever. A dressing of plaster-of-Paris is afterward applied. This apparatus not only straightens the leg, but tends to correct the subluxation of the tibia as well. (-1) An apparatus known as the Billroth splint is used at the Hospital for the Ruptured and Crippled, in New York, to straighten these limbs by gradual and gentle force, without the use of ether. A plaster bandage is applied to the limb, and in this bandage are incorporated two hinges attached to broad curved iron plates. These hinges are placed over the lateral aspects of the joint, allowing anterior-posterior motion. The bandage is allowed to harden, and then a circular division of the plaster is made at the level of the knee, and the front of the bandage over the knee is cut away. Into the transverse slit at the back of the knee are inserted wedges of increasing size, until the limb is straight. The splint exercises considerable pressure. (Fig. 1671.) The Thomas knee-splint has been advocated as a means of straightening the knee by fixing the thigh and pulling the leg forward by bandages passing behind the calf. In my own hands it has proved more often a source of irritation to the knee than a means of cure. (5) Correction of flexion during the acute stage by traction made in the line of deformity is by far the most satisfactory method,' as well as the safest; and the splint which is used for this purpose is, to my mind, by far the best apparatus for routine employ- ment in tumor albus. It provides three things—protection from weight- bearing, fixation of the diseased joint, and traction in any desired line. In principle it is practically like the long traction splint jointed at the knee. From Fig. 1672 it can be seen to consist of a pelvic band, an outside upright jointed at the knee,'and a traction foot-piece; an inside upright reaches from the foot- piece nearly to the adductor tendons, but is not es- sential, and is used merely to steady and strengthen the apparatus. The disc at the knee-joint in the outer upright is perforated with screw-holes, so that the splint may form any desired fixed angle at the knee. Leather lacings fix the thigh and calf of the leg. Sticking- plaster extension bands, attached below the knee, pull downward by winding the windlass, while plas- Fig. 1671. Fig. 1672 Billroth’s Knee-Splint. Traction Splint for Dis- ease of the Knee-Joint. DISEASES OF THE SPECIAL JOINTS. 519 ter counter-extension bands, attached' to the thigh, pull upward and are buckled to the outside and inside uprights, the straps passing through the thigh lacing. In addition to this extending plaster pulling upward on the thigh, counter-extension to the downward pull is fur- nished by the perineal band in the groin, which also protects the leg from weight-bearing in walking, being, just as the hip splint is, a peri- neal crutch. The splint is applied, adjusted at any angle that suits the diseased limb, and the perineal band is then strapped and the upward thigh extension buckled. Then the straps from the calf extension plas- ter are passed around the windlass and tightened. This pulls directly upon the knee-joint, tending to distract the joint surfaces. Then the leather lacings are tightened, serving to prevent motion at the knee, which is being pulled upon in the line of deformity, and all the time, except in the severest cases, the patient may go about freely walking upon the bottom of the splint. The splint is rather complex, and therefore expensive, but it can be made by almost any machinist if the surgeon knows just what is wanted, and is in every way the best and most useful splint for the purpose. Excision of the knee is to be regarded as a mode of treatment in- ferior to the mechanical methods just mentioned, or as a treatment to be adopted when mechanical measures have failed, or are not likely to be of use on account of the advanced stage of the disease. The operation necessarily entails a loss of bony substance, and short- ening, and in the case of young children the injury to the epiphysis may be a very important matter in causing serious injury to the growth of the limb.1 Mechanical treatment on the other hand in suit- able cases produces excellent results, in the milder cases often restor- ing perfect motion. In most cases which are under control and not ad- vanced when the treatment is begun, mechanical measures suffice to cure the disease. This remark of coarse applies chiefly to children, for in the case of adults tuberculous disease of bone offers a less favor- able outlook than in childhood. Considering then excision as a mode of treatment to be adopted only in advanced cases, and where mechanical treatment has failed, the question of the mortality rate of the operation becomes of the first importance. The advent of antiseptic surgery has produced a most striking change in this matter. Ollier’s2 mortality fell from 80 to II per cent, after antiseptic precautions were adopted. Meusing3 found in 80 cases that:— 1. Before antiseptic surgery the mortality was 33 per cent. 2. After antiseptic surgery was introduced the mortality was 8.5 per cent. 3. After the introduction of permanent dressings the mortality was 2 per cent. Phelps gives the mortality in 329 cases treated antiseptically as 9.12 per cent.4 The latest statistics with regard to resection of the knee may perhaps be quoted from Lossen.5 Of 586 patients who had had resection of the 1 Hoffa, Archiv f. klin. Chirurgie, Bd. xxxii., S. 4. 2 Revue de Chirurgie, 1884, p. 157. 3 Centralblatt f. Chirurgie, 1883, No. 49. 4 Phelps, Trans. N. Y. State Med. Society, 1886, p. 586. 5 Deutsche Chirurgie. Lief. 29, b. 520 DISEASES OF THE JOINTS. knee for tuberculosis and its results, observed during hospital treat- ment only— 439 or 74.9 per cent were healed. 59 “ 10.1 “ “ “ unhealed. 50 “ 8.5 “ “ “ amputated. 38' “ 6.5 “ “ “ dead. Of 384 patients observed from one to fourteen years after resection— 274 or 71.3 per cent were permanently healed. 46 “ 12 “ “ showed sinuses. 18 “ 4.7 “ “ were unhealed. 10 “ 2.6 “ “ “ amputated. 36 “ 9.4 “ “ “ dead. It seems hardly worth while to quote in full the very large number of statistics given on this subject, and the more recent references therefore only are given.1 It is evident that the mortality rate is a low one (3-10 per cent.), that the results of the operation are more satisfactory than in the hip, and that it is a proceeding to he undertaken without hesita- tion when necessary. Excision of the knee is, I believe, indicated (a) when the disease is advanced to a stage when sinuses of long standing are present, and the joint is thickened, hot, and tender; (b) when in spite of careful mechanical treatment the disease has progressed unfavorably, and flexion and sensitiveness of the joint cannot be controlled; (c) in cases of moderate severity when mechan- ical treatment cannot be obtained; and (d) in cases of cured disease where anchylosis in a position of right-angled flexion is present. In the acute stages of the disease the operation is much less likely to be of use in the case of adults, and amputation is often to be preferred; but this is a matter which must be decided in the individual case rather than by rule, and belongs to the domain of general surgery. Arthrectomy or erasion of the knee-joint has been advocated as a sub- stitute for excision by many surgeons of distinction. Artlirotomy is a term used to describe the same procedure, but the former name is the correct one. Synovectomy is another name occasionally employed. The operation consists in opening the joint freely by a semilunar in- cision, as if for a resection. The joint capsule is cut away in front of the joint, and all pulpy granulation tissue is removed by the scissors and forceps, or by the curette; diseased foci in the bone are gouged out. and in doing this, especially at the back of the joint, much care is necessary. The infiltrated capsule and semilunar cartilages are removed, and every effort must be used to leave none but sound tissue. In accomplishing this the application of the Paquelin cautery is often useful. Various modifications in the operative technique have been suggested, but the essentials of the procedure are as above given. The operation, it is easy to see, is not suited to advanced cases, and is most likely to be of use in those of primary s}rnovial tuberculosis, which are not as common as the osseous. If the surgeon believes, as I do, that mechanical treat- ment is sufficient to cure most cases, and should be persisted in until it is manifestly inadequate, he will see that it will then commonly be 1 Ollier, Sur la Resection du Genou, Bull, de l’Acad. de Medecine, No. 20, 1889. Hitzegrad, Mitt, aus der cliirurg. Klinik zu Kiel, Bd. iv. Zoege-Manteuffel, Deutsche Zeitschrift f. Chirurgie, Bd. xxix., 8. 113. Neugebauer (101 resections of Liicke’s), ibid., Bd. xxix., S. 4. Boeckel (140 cases), La Semaine Medicale, 12 Avril, 1892. Cristovitch. Bull, gen. de Tlierapeutique, Paris, 15 Avril, 1892. DISEASES OF THE SPECIAL JOINTS. 521 too late to perform arthrectomy, and that excision will be the only operation to consider. Arthrectomy then will find a place chiefly with those who favor early operative treatment,1 either because they have not apparatus at their command, or because they prefer operative to slower measures. If arthrectomy be done early, perfect motion may be obtained in the affected joint, and the results of the operation are in general reported as satisfactory: the wound closes early, the mortality rate is low, and there is not the shortening which is likely to accompany complete resection. Senn analyzes TO cases of arthrectomy for knee-joint disease collected from various sources. Of these 7 proved fatal, the causes of death being as follows: pulmonary tuberculosis 2, iodoform poisoning 1, chloro- form 1, general tuberculosis 1, tubercular meningitis 1, and tubercular peritonitis 1. Nineteen times the operation was a failure, and was fol- lowed by return of the disease. Forty-four times the operation was suc- cessful, and in none of these cases did any shortening of the limb occur. A movable joint was noted in 8 cases, and a fixed joint in 32; in no case did a flail joint occur. Contraction of the joint into a flexed position occurs in certain cases when the splints are removed too early. With regard to amputation for knee-joint disease, it only remains to be said that it is a measure occasionally necessitated in children by a relapse after excision or arthrectomy, and that in adults it is frequently to be considered as a primary measure in cases of extensive disease, inas- much as excision is in these cases often unsatisfactory. Ankle-Joint Disease.—Tubercular disease of the ankle and tarsus is an affection fairly common in childhood, but fortunately more rare in later life. The location of the disease is most frequent in those bones which seem to transmit the body weight, viz., the os calcis and the astragalus. It is believed by most authors that the disease is generally of primarily synovial origin. Munch, for example, found in 28 cases that the disease was primarily synovial in 23, while in the other 5 cases the focus was once situated in the tibia and four times in the astragalus. Erasmus, however, differed from the general opinion in finding that of 11 cases only 2 were primarily synovial. As to the individual bones affected, Czerny found that in 52 cases the astragalus was affected 15 times, the os calcis 13 times, the cuboid 16 times, and the scaphoid.and cuneiform 8 times. Often the lower end of the tibia is affected while there is a focus in the head of the astra- galus, but the colnplex arrangement of the synovial membrane at the ankle makes extension of the disease very easy to other bones and other parts of the articulation from that originally affected, and the same condition renders complete removal of the diseased tissues very difficult. The symptoms of disease of the ankle-joint, in addition to the swelling, have been very slightly alluded to, and are of much importance in connection with the diagnosis. A persistent swelling about either malleolus is exceedingly suspicious; any thickening over the front of the ankle-joint points to an inflammation of the synovial membrane; while swelling and tenderness over the os calcis indicate probable dis- 1 Volkmanu, Centralblatt f. Chirurgie, 1885, No. 9. Mandry, Beitr. zur blin. Chirurgie (Bruns), Bd. iii , H. 2, 1887. Israel, Berliner klin. Wochenschrift, 1889, No. 5. Zesas, Centralblatt f. Chirurgie, 1886, No. 28. Duncan, Amer. Journ. Med. Sciences, April, 1889, p. 869. 522 DISEASES OF TIIE JOIXTS. ease of that hone. Along with the swelling and the inflammation of the joint is associated stiffness of the joint movements. This is apt to he deceptive, because at times the medio-tarsal joint becomes more than normally flexible, and executes a certain amount of the movement or- dinarily accomplished at the ankle-joint itself. This tends, unless the surgeon is carefully on the watch, to mask the rigidity of that articu- lation. There are two malpositions which are not commonly found in cases of ankle-joint disease and which have been but slightly alluded to. One is a distinct talipes equinus with the foot held rigidly in that position. In connection with this there is generally swelling of the ankle, to show that it is not an ordinary talipes equinus. The same may be said of talipes calcaneus, which occasionally, although more rarely, ex- ists in connection with ankle-joint disease. The foot is sharply flexed and held in that position by muscular spasm. Pain is generally a prominent factor, but is not always noticeably present, so that the significance of these two malpositions may be overlooked. They are evidences of muscular irritation, and are of the same class of symptoms as the malposition of the hip in early joint disease, and the flexion of the knee in early tumor albus. To speak for a moment of tarsal and metatarsal disease, it is dis- tinguished chiefly from ankle-joint disease by the fact that in the former the ankle-joint is movable, and that the swelling is chiefly localized to the tarsal region, or to some especial metatarsal bone. Swelling of the metatarsus involves ankle-joint movement if it goes on to any marked degree, although it is never severe enough to cause the malposition spoken of in connection with ankle-joint disease proper. It is in young children chiefly that metatarsal disease occurs, and the bone most frequently affected is the first metatarsal. The process seems more like a periostitis than a true osteomyelitis, and very fre- quently on incising these swellings a partial necrosis is found. With regard to the treatment of ankle-joint disease, I incline very strongly toward the expectant method, not only in children but also in mild cases in adults. In pursuing this treatment the error is very often made, just as it is in disease of the knee-joint, of fixing the diseased joint in plaster of Paris, and allowing the patient to walk about, without perhaps even the use of crutches. This, of course, furnishes fixation to the joint as far as hinge motion goes, but it af- fords no protection whatever against the jar of the body weight in walking, and consequently is very incomplete, and insufficient to pro- tect the joint from becoming worse. Fixation, even if enough to pre- vent motion, is only half the treatment, and should be joined to protec- tion against weight-bearing in all cases severe enough to require any treatment at all. The method to be pursued in these cases is a very simple one, and has yielded the most satisfactory results. The child’s foot is done up in a small and light plaster-of-Paris bandage reaching from the toes to just below the knee, or in severe cases even above the knee. This bandage is ordinarily left on for some weeks, although it may be cut down the front and furnished with lacings to be removed just as is a plaster jacket. It is preferable, however, for it to be left on for some weeks at a time, unless in exceptional cases. This fixation splint is DISEASES OF THE SPECIAL JOIXTS. 523 worn in connection with the Thomas knee-splint which has been de- scribed. In speaking of diseases of the knee-joint it was shown that this Thomas knee-splint furnished fixation to the knee, and prevented the child from bearing weight upon the foot in walking. The combination of fixation and protection enables the ankle to be absolutely protected against traumatism, and, except for the unfortunate dependent position of the ankle, it is placed as favorably as possible for recovery. Instead of the plaster-of-Paris fixation bandage, a more comfortable and fully as satisfactory an apparatus is obtained in a small, light fixation shoe, which is practically a skeleton bandage furnishing fixation to the foot by leather lacings. The apparatus consists of a light steel sole-plate fitting the sole of the foot, and two uprights connected with it fitted to the leg, and running to the upper part of the calf, where they are connected posteriorly by a flat curved band. The foot and the leg pieces are furnished with leather lacings, which afford as complete fixation as does a plaster bandage, and the apparatus is cooler and may readily be removed. It also is worn in connection with the Thomas knee-splint. The patients are allowed to go about freely until some months after the swelling and tenderness, and the muscular irrita- bility, have disappeared. Then the use of the splint is gradually discon- tinued. Dr. Gibney has made some investigations as to the results in cases of ankle-joint disease treated conservatively.1 Observations were made upon thirty cases, the average duration of which was three years and. three months, with a minimum duration of one year and a maximum of six years. In nineteen cases suppuration was very ex- tensive, while in only five cases of the whole number was it entirely absent, this showing that a severe class of cases was under considera- tion. When these cases were investigated the limbs were slightly shortened, and the calf was atrophied. Twenty of the patients did not limp at all, and seven only slightly. The remarkable results ob- tained from this series of cases show that tubercular disease of the ankle belongs to a more benignant class of affections than similar disease of the knee or hip joints; in fact, the results from proper conservative treatment are generally extremely satisfactory, and operative measures are not indicated until mechanical treatment has manifestly failed. If the conservative method fails to give a satisfactory result after a proper trial has been made, three measures remain for consideration. The simplest is curetting the sinuses or removing whatever diseased bone is within reach of the curette. The second operation is a formal ex- cision of the diseased bones, and the third is amputation of the foot or leg, which is occasionally necessary. With regard to curetting the diseased bone without the performance of a formal excision, the complex nature of the ankle-joint, already alluded to, makes adequate removal of the diseased tissue very difficult. The work is done in the dark, without a knowledge of the situation or extent of the disease, and must necessarily be done blindly, often leaving large masses of unhealthy tissue behind. In certain cases this plan of treatment may affect the disease favorably, but in the majority re- lapse occurs and requires a more formal and extensive operation. 1 Med. Record, Aug. 21, 1880, p. 197. 524 DISEASES OE THE JOINTS. With regard to excision, it may be said that in general the results are extremely satisfactory in young children, and less so in adults. In eighteen cases analyzed by Dr. C. L. Scudder,1 six patients died, five from tubercular meningitis and one from shock. The end results in all cases were good when investigation was made years after opera- tion. Most of these cases were at first treated conservatively, and an operation was only employed when it became necessary, so that they represent a trial of conservative methods and of late rather than of early excision. In all but one case the disease was ended by opera- tion. Dr. Scudder thought that the degree of flexion and extension of the ankle-joint was slightly greater in cases successfully treated by ex- cision than in those treated expectantly. No serious deformity occurred in any instance. Of 108 cases reported by Conner in which excision was resorted to, he found that in 10 J per cent, there was failure. In six per cent, the pa- tients could walk with only a cane, and the remainder were classed as good or perfect results. These figures are sufficient to show that after a carefully performed excision the result is likely to be excellent, and that the death-rate is a very low one; but none the less I would advocate very strongly the adoption of the conservative plan of treatment, which is capable in most cases of yielding excellent results, and which only occasionally fails to prevent the necessity of excision. Shoulder-Joint Disease.—Chronic sprain of the shoulder is an affection which has received very little attention, but which is exceed- ingly frequent, especially in hospital clinics, and which is much bene- fited by suitable treatment. How often the lesion should be classed as a chronic synovitis cannot be determined: in many cases it seems only a muscular contusion, persisting as a stiffness and irritability of the muscles involved in moving the shoulder joint; in other cases it is clearly a bursitis, or a teno-synovitis of the tendon of the biceps or of some neighboring muscle; at other times it is a simple chronic synovitis of the joint, sometimes made worse by the fact that the patient is the subject of chronic rheumatism. In either of these conditions the history is that after a blow or a fall upon the arm or shoulder, the pain does not sub- side, but persists for weeks or months. Tenderness is often present over the anterior surface of the joint. Motion is limited, especially in the direction of deltoid movements. Pain may be present, and stiffness to a greater or less degree is uniformly prominent. These may be the symptoms of chronic osteitis, of rheumatoid arthritis, or simply of chronic sprain, and the diagnosis must of course be made with care, although the treatment about to be described is not unsuitable to any one of these conditions. Assuming then, as is evident from the symptoms, that the condition of the joint is one of irritability, the problem is first to quiet the irrita- tion and then to restore motion to the part. The shoulders should at first be fixed so that motion may be impossible. This is most easily done by the application to the arm of a sling long enough to sup- port the elbow, with a broad swathe embracing both arm and chest to prevent lifting the arm from the side. This combination of the sling 1 Transactions of American Orthopaedic Association, vol. ii. DISEASES of the special joints. 525 and the swathe is a firm and efficient bandage. The clothes are put on without disturbing the arm, and counter-irritation is applied to the joint by iodine, blisters, or preferably light scoring with the Paquelin cautery. This is likely to cause the sensitiveness to diminish rapidly. After some days, or two or three weeks, of such fixation, the bandage is removed daily for a few minutes of massage and passive manipulation, and is then at once reapplied. Gradually the time of passive motion is increased, and active motion is substituted, always remembering that the chief danger is of going too fast rather than too slowly, and not allowing rough or painful manipulation. In my hands this plan has yielded the most satisfactory results, much more so than electricity, forcible manipulation, or rough massage. Tubercular Disease of the shoulder is fortunately not very common, and occurs most often in children. It is not practicable to apply traction satisfactorily on account of the impossibility of obtaining counter- extension in the axilla, because of the vessels and nerves there. For- tunately the weight of the arm in itself furnishes a mild form of traction, and with such fixation as can be furnished by a plaster band- age enveloping the arm, chest, and shoulder, satisfactory results are generally attainable. Excision is to be undertaken when the disease is progressing in spite of a fair trial of expectant measures. Disease of the Elbow-Joint.—Little need be said that has not already been mentioned in speaking of other joints. Disease is made evident by swelling of the synovial sac with pain and muscular limita- tion, along with wasting of the arm and forearm. Flexion and perhaps rotation are painful; the arm is held stiffly by the muscles, perhaps at a right angle, but more commonly, and especially in severe cases, somewhat extended. The indications are, just as in similar conditions in the shoulder or the hip, to rest the affected joint, and dis- traction of the joint surfaces would be desirable could it be obtained. But the apparatus invented for that purpose is so cumbersome as to be useless, and the best substitute is plaster of Paris, or a leather splint, simply preventing motion. Continued fixation by a tin internal angular splint is objectionable on account of the necessity of using sticking-plaster, the irritation attendant upon which is an annoyance. Fixation must be persisted in until joint irritability has ceased, as tested by the subsidence of pain, heat, swelling, and muscular irrita- bility. As in the other joints, fixation may be gradually removed when this condition has become permanent. Excision is to be deferred in the case of children as long as possible, for often the most surprisingly bad cases will recover under expectant treatment, and the results of elbow-joint excision done in children for tubercular disease are not encouraging. Fortunately the disease is chiefly confined to young adults, where the results of resection are more favorable. Disease of the Wrist-Joint and Carpus.—This offers no especial features of interest. The joint is easy to fix, traction is not needed, and a plaster-of-Paris, a leather, or a tin splint is sufficient to fulfil all in - dications. Excision is necessary in persistent or had cases. NOTE. For permission to use in the preceding Article Figs. 1643, 1644, 1645, 1649, 1650, 1651, 1652, 1653, 1654, 1655, 1656, 1657, 1664, 1665, and 1666, the Author is indebted to the Trustees of the Fiske Prize Fund. EXCISIONS AND RESECTIONS. BY JOHN ASHHURST, Jr., M.D., BARTON PROFESSOR OF SURGERY AND PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE PENNSYLVANIA HOSPITAL, PHILADELPHIA. Since the publication of the article on excisions in the third volume of this work, my personal experience in this particular class of opera- tions has been more than trebled, and I have been led to modify some- what the conclusions then expressed. Thus as regards the contra-in- dications to excision, I have been encouraged to apply this conservative operation to cases of an acute character in which I formerly thought amputation preferable, and I have ventured, in the case of the knee at least, to extend the benefits of this procedure to patients of consider- ably more advanced age than I did in the earlier period of my practice. On the other hand, by the introduction of “ arthrectomy,” or “erasion,” as a mode of treating knee-joint disease, I have found that in selected cases a better limb can be secured than by resection, while by the adop- tion of Billroth’s suggestion to practise intra-articular and interstitial injections of iodoform suspended in glycerine (one part to ten), I have in a few instances, in which I should have formerly thought excision necessary, succeeded in obtaining a cure without resorting to any cut- ting operation whatever. Observance of the precautions of antiseptic surgery has diminished the immediate risks of excision, and has has- tened the healing of the external wound, but on the other hand has, I am satisfied, in some cases delayed bony union (which is wished for after knee-excisions), and has thus compelled the use after recovery of prosthetic apparatus, which otherwise would not have been required. I have in the following pages endeavored to summarize in tabular form the results of my increased experience with excision and resection in the several regions of the body, and venture to hope that the exposition will be of interest to the reader. Upper Jaw.—-To the six cases of complete excision of the upper jaw referred to in the original article, I have added three more, the nine cases having given three deaths, only two of which, however, can be directly attributed to the operation. But besides these three deaths, it will be observed that in an equal number of cases recurrence of the disease for which the operation was performed took place within three months, so that the ultimate results of the procedure are not very encouraging. In view, however, of the hopeless character of the affections for which excision of the upper jaw 527 528 EXCISIONS AND RESECTIONS. is usually resorted to, and considering the excessive pain and discom- fort which they cause, the operation must be considered a justifiable one, even for the temporary relief afforded. Table of Nine Cases of Excision of the Upper Maxilla. No. Sex, age, and date. Nature of affection for which operation was required. Result. Remarks. 1 Male, 10 Naso-pharyngeal tumor Died • Episcopal Hospital. Death from shock. Jaw excised as preliminary to removal of growth. 2 Male, 25, 1879 Osteoma of upper jaw clo. University Hospital. Death from secondary hemor- rhage. 3 Female, 50, 1879 Sarcoma of upper jaw Recovered University Hospital. 4 Female, 71, 1880 Carcinoma of upper jaw do. do. 5 Male, 8, 1886 Sarcoma of upper jaw do. do. 6 Male, adult, 1887 do. do. Do. Recurrence in 2 months. 7 Female, 50, 1887 do. Died Do. Death from renal dis- ease on 12th day. 8 Male, 63, 1889 do. Recovered Do. Recurrence in 3 months. 9 Male, 65, 1892 do. do. Do. Recurrence in 3 months. Lower Jaw.—In addition to the cases referred to in Yol. III., I have since successfully excised the middle portion of the lower jaw with a part of the tongue, for epithelioma, and I have twice removed wedge-shaped portions of the bone for contraction of the jaw, according to Esmarch’s method. Both cases afforded good results, but in the first the patient suffered much after the operation from pain in the course of the inferior dental nerve, apparently from irritation caused by the saw with which the bone was resected; hence in the second case I took the precaution to expose the nerve first with a trephine and ex- cise a portion, and I would recommend this as a useful modification of the ordinary procedure. Sternum.—-Linoli’s case of excision of a displaced ensiform cartilage after laparotomy for uncontrollable vomiting, is mentioned in Yol. III., and the operation has since been repeated by Rinonapoli. Annandale relieved the vomiting in a similar case b}T replacing without excising the bone, after abdominal section. I have successfully excised the en- siform cartilage without opening the peritoneum in a case of intracta- ble neuralgia, for which, from its analogies with the similar condition met with in the coccyx, I would suggest, when the pain is localized in this part, the name xiphodunia; the external surface of the peritoneum is necessarily exposed in this operation, but by keeping the knife close to the bone, and exercising great care, it is possible to avoid wounding the serous membrane. Graves has successfully excised the gladiolus for sarcoma. Ribs.—I have in four cases had occasion to employ excision ot one or more ribs—in one case for syphilitic necrosis involving hut a single rib, and in three cases for empyema (Estlander’s operation), in one instance removing portions of three, and, in the other two, portions of four ribs. PELVIS—CLAVICLE—SCAPULA. 529 The result in all lias been satisfactory, though in one of the cases of empyema the patient is tuberculous, and entire recovery is therefore not to be expected. Contrarily to the ordinarily received view, I have found very little trouble from hemorrhage in excisions of the ribs, the intercostal arteries being commonly occluded as the result of the pre- viously existing disease. Pelvis.—C. Velaton records a case in which he removed the whole ilium, the patient recovering and preserving the power of walking; partial resection—cutting out a wedge from the crista ilii—has, in my hands, proved of value in the treatment of iliac abscesses, and is, I think, upon the whole preferable to trephining the ilium as advised by Fischer, Kiedel, and Gangolphe. Partial excision of the sacrum is re- commended by Kraske as a means of facilitating operations on the rec- tum, a purpose accomplished by Heinecke, Rydygier, and Gussenbauer, by means of temporary resection of the same bone. Clavicle.—I have twice had occasion to excise the entire clavicle, once for necrosis and once for tumor—an ossifying encliondroma—and in a third case I removed the inner two-thirds of the bone for a large osteosarcoma, the last-mentioned operation having been the most diffi- cult of the three. In the case of necrosis, the bone was readily peeled out from its periosteal sheath, and quick reproduction took place, the patient regaining the use of his arm in not much longer time than is required for the repair of a fracture of the bone concerned. In all the three cases the patients recovered satisfactority from the operation, but in the case of sarcoma the growth recurred after some months and led to a fatal result. To the 28 cases of total excision of the clavicle tab- ulated in Vol. III., page 580, I am now able to add 9 more, viz., the successful cases of Jessett, Kronlein, Sloan, Tansini, Wheeler, and two of my own, the fatal case of Segond, and one of uncertain result in the hands of Despres; the whole 37 cases gave 29 known recoveries, one undetermined, and but 7 deaths, a mortality of only 19.4 per cent. Additional successful cases of partial excision of the clavicle reduce the death-rate of that operation to only 14 per cent. I have once excised the sterno-clavicular articulation in a case of un- reduced dislocation with marked deformity, suturing the resected bones together, and obtaining a satisfactory result. Scapula.—Total excision of the scapula, the arm being preserved, appears to have been now practised in 59 cases, the additional success- ful operations, since the publication of the table in Vol. III., page 583, having been those of Ceci, Maclean, Phelps, Putti (two cases), Shutz, Simons, Southam, Symonds, and Walder, ten in all; the fatal opera- tions, those of Brinton, Ceci, Cheever, and Poinsot, four in number; and the undetermined cases those of Bull, Dysart, and Weir. Wood’s case, marked undetermined in the table, was a success. The whole 59 cases therefore have given 43 recoveries, 12 deaths, and 4 uncertain results—a mortality of determined cases of 21.8 per cent. Extirpation of the scapula subsequent to amputation at the shoulder lias been prac- tised in six cases additional to those tabulated in Vol. III., page 584, there having been two successful operations, by Conant and Lange; two 530 EXCISIONS AND RESECTIONS. fatal, by Swaine and Wood; and two undetermined, by Blair and Jes- sett. The whole 20 cases have therefore given 13 recoveries, 5 deaths, and 2 uncertain results, a death-rate for determined cases of 27.7 per cent. Shoulder-Joint.—My personal experience with shoulder joint exci- sion now embraces nine cases, as shown in the annexed table, all the patients having recovered from the operation, though one, who was affected with general tuberculosis, died of phthisis three months afterward. The functional results have likewise been satisfactory, and, upon the whole, removal of the head of the humerus, though less fre- quently demanded in civil than in military practice, must be considered a valuable resource in cases of destructive disease of this articulation. Table of Nine Cases of Excision of the Shoulder. No. Sex, age, and date. Nature of affection for which operation was required. Result. Remarks. 1 Male, 30, 1882 Suppurative arthritis Recovered Useful arm. University Hospital. See Yol. iii., page 587. 2 Male, adult, 1884 Caries do. Useful arm. University Hospital. 3 Female, adult, 1884 Necrosis of humerus do. Remainder of humerus subsequently removed. Useful arm. University Hospital. 4 Female, old, 1887 Caries do. Sinuses persisted. Uni- versity Hospital. 5 Male, adult, 1888 Suppurative arthritis do. Useful arm. University Hospital. 6 Male, 12, 1888 Necrosis of humerus do. Sinuses persisted. Chil- dren’s Hospital. 7 Male, adult, 1889 Caries do. Useful arm. University Hospital. 8 Male, adult, 1891 Caries do. General tuberculosis. Uni- versity Hospital. 9 Male, adult, 1895 Caries do. Under treatment. Uni- versity Hospital. Shaft of Humerus.—In a case of acute necrosis of the humerus, occurring in a woman, I removed the head and upper portion of the bone, and some weeks afterward, the disease recurring in the remainder, excised the lower portion, the two operations taking away the whole length of the bone, from shoulder to elbow. The muscles of the upper arm became markedly shortened, and the power of raising the arm was to a great extent lost, but the use of the hand and forearm was preserved, and the patient was able to pursue her occupation as a sempstress. I have also resected the humerus in several additional cases of ununited fracture, with a fair measure of success. Elbow-Joint.—To the ten cases of elbow-joint excision tabulated in Vol. III., page 596, I can now add eighteen, with only two deaths— one from tuberculosis subsequent to consecutive amputation, and one from traumatic gangrene; in this case, as in two successful operations for necrosis, partial excision was resorted to. In a third case, the pa- tient died after recovery, from abscess of the brain following middle- RADIUS AND ULNA. 531 ear disease. In nine cases, it is known that a useful arm was pre- served by the operation; recurrence took place in three syphilitic cases; and the ultimate functional result in three was not determined. Of my whole number of 28 cases, six proved fatal (21.4 per cent.), but in only two of these was the unfavorable result directly attributable to the operation, death in both instances being due to gangrene. Table of Eighteen Additional Cases of Excision of the Elbow. No. Sex, age, and date. Nature of affection for which operation was required. Result. Remarks. 11 Male, 30, 1884 Gelatinous arthritis. Recovered Useful arm. University Hospital. 12 Male, adult, 1884 do. do. 13 Male, 5, 1885 Syphilitic necrosis and caries (hereditary) do. Partial excision. Chil- dren’s Hospital. 14 Male, adult, 1886 Chronic arthritis do. Useful arm. University Hospital. 15 Male, youth, 1886 Tuberculous arthritis Died Arm amputated. Univer- sity Hospital. Children’s Hospital. 16 Male, 6, 1886 Syphilitic disease of joint (hereditary) Recovered 17 Male, 26, 1886 Compound fracture of elbow- joint Died Partial excision. Death on 5th day from gan- grene. University Hos- pital. 18 Male, child, 1888 Necrosis of humerus Recovered Partial excision. Penn- sylvania Hospital. 19 Male, adult, 1888 Compound dislocation of el- bow do. Useful arm. Pennsyl- vania Hospital. 20 Male, 30, 1888 Syphilitic caries do. Sinuses persisted. Uni- versity Hospital. 21 Female, child, 1888 Chronic arthritis do. Death subsequently from intracranial abscess fol- lowing disease of middle ear. Children’s Hos- pital. 22 Male, 16, 1889 Syphilitic arthritis and ne- crosis do. Disease recurred. Penn- sylvania Hospital. 23 Male, 15, 1889 Suppurative arthritis do. Useful arm. University Hospital. 24 Male, adult, 1891 Caries do. do. 25 Male, adult, 1891 Syphilitic arthritis do. Disease recurred. Penn- sylvania Hospital. 26 Male, adult, 1893 Chronic arthritis do. Useful arm. University Hospital. 27 Male, 10, 1893 Unreduced dislocation of el- bow and fracture of inner condyle do. do. 28 Male, 10, 1893 Unreduced dislocation of elbow and fracture of outer condyle do. do. Radius and Ulna.—I have thrice had occasion to resect portions of both bones of the forearm—twice for ununited fracture, and once for deformity following a badly treated fracture—and in all three cases with success. I have also resected the radius alone in two cases addi- tional to those referred to in Vol. III., one. being a case of ununited fracture with marked displacement, and the other a case of rachitic •curvature; the result in both instances was satisfactory. Three times I have resected portions of the ulna alone; once successfully, for com- pound fracture from the bite of a mule; and twice unsuccessfully—in 532 EXCISIONS AND RESECTIONS. one case for syphilitic necrosis, the patient dying some time afterward from visceral disease of the same character, and in the other case for sarcoma of the ulna, the disease promptly recurring, as it did again after amputation, and the patient dying from secondary growths in the thorax. Wrist-Joint and Carpus.—I have not had occasion to resort to complete excision of the carpus and wrist-joint, and my judgment as to this operation remains the same as that expressed in Vol. III., viz., that it is seldom required, most cases of wrist-disease which call for any operation being better adapted to amputation than to excision. I have, however, in one case removed the first row of the carpus with the articulating extremities of the radius and ulna, and in another case the second row of the carpus, both patients recovering from the opera- tions, but sinuses persisting when they passed from my observation, so that I cannot speak of the ultimate result as regards functional utility. Hip-Joint.—My personal experience with excision of this articula- tion now embraces fifty-eight cases, one of which was a re-excision for recurrent disease. Table of Thirty-Seven Additional Cases of Excision of the Hip. No. Sex, age. and date. Nature of affection for which operation was required. Result. Remarks. 22 Male, 25, 1884 Bony anchylosis with caries and sinuses Recovered Femur divided in situ, and head of bone removed with gouge. University Hospital. 28 Male, child, 1884 Hip-disease in suppurative stage do. Children’s Hospital. 24 Male, 11, 1884 do. do. do. 25 Male, 10, 1884 do. do. University Hospital. Children’s Hospital. 26 Female, 11, 1884 do. do. 27 Male, 15, 1884 do. do. Useful limb. University Hospital. 28 Male, 26, 1885 Recurrent caries after exci- sion Died Death from suppurative osteo-myelitis of femur and septic peritonitis. University Hospital. Same patient as No. 22. Children’s Hospital. 29 Female, child, 1886 Hip-disease in suppurative stage do. Recovered 30 Female, child, 1886 do. do. 31 Female, 3, 1886 do. do. do. 32 Male, 8, 1886 do. do. do. 33 Male, 8, 1886 do. do. do. 34 Male, 9, 1887 do. do. Case of double hip-dis- ease. Excision of right hip. University Hospi- tal. Same patient as No. 34. Excision of left hip. Uni- versity Hospital. 35 Male, 9, 1887 do. ' do. 36 Male, youth, 1887 Necrosis. General tuber- culosis Died Death from phthisis. Uni- versity Hospital. 37 Female, 10, 1887 Hip-disease in suppurative stage Recovered Children’s Hospital. 38 Male, 24, 1888 Caries and anchylosis Died Death on 8tli day. Uni- versity Hospital. 39 Female, 16, 1888 Hip-disease in suppurative stage do. Death on 3d day. Penn- sylvania Hospital. HIP-JOINT. 533 Table of Thirty-Seven Additional Cases of Excision of the Hip.— Continued. No. Sex, age, and date. Nature of affection for which operation was required. Result. Remarks. 40 Male, 35, 1888 Caries Died Death after 1 year. Uni- versity Hospital. 41 Female, child, 1888 Acute necrosis Recovered Children’s Hospital. 42 Male, child, 1888 Caries do. do. 43 Male, 11, 1889 Necrosis and perforation of of acetabulum. Suppura- tive osteitis of femur Undeter- mined Phthisis 4 months after operation. University Hospital. Children’s Hospital. 44 Male, 6, 1889 Hip-disease in suppurative stage Recovered 45 Male, child, 1889 do. do. do. 46 Male, 11, 1890 do. do. Pennsylvania Hospital. 47 Male, 17, 1890 Anchylosis and caries do. Femur divided in situ; head of bone removed with gouge. University Hospital 48 Male, 11, 1890 Anchylosis with extreme deformity do. Bone removed with gouge and forceps. University Hospital. Children’s Hospital. 49 Male, 9, 1891 Caries do. 50 Female, 8, 1892 Hip-disease in suppurative stage do. Pennsylvania Hospital. 51 Male, child, 1892 do. do. do. 52 Male. 34, 1892 do. do. Children’s Hospital. 53 Female, 17, 1893 do. do. University Hospital. Children’s Hospital. 54 Male, 6, 1893 do. do. 55 Male, 4, 1893 do. do. do. 56 Female, 6, 1893 do. do. do. 57 Female, 21, 1894 do. do. Disease had lasted 15 years ; head of bone sep- arated and bone in aceta- bulum. Pennsylvania Hospital. 58 Male, 12, 1894 do. do. Pennsylvania Hospital. Of the two patients still under treatment when the table in Vol. III., page 612, was printed, one recovered and the other died, while of the 37 additional cases now tabulated 5 proved fatal and the result of one is undetermined; the whole 58 operations, therefore, have given 45 known recoveries and 12 deaths, a mortality in determined cases of 21 per cent. This small general mortality is still further reduced if the cases occurring in children only are considered, 51 operations in persons less than 20 years old having given 42 recoveries, 1 undetermined, and only 8 deaths (16 per cent.), and is strikingly contrasted with the death-rate which attends the operation in adults, 7 cases in persons more than 20 years of age having given only 3 recoveries and 4 deaths, over 57 per cent. Indeed, excision of the hip is such a grave proced- ure in adult life, that it should not be recommended, under these cir- cumstances, unless in very exceptional cases. I have in one case, in a girl of 17, resorted to amputation at the hip- joint subsequent to excision, caries having recurred some months after the latter operation, which had been performed with temporary benefit by my colleague Dr. Packard. The patient has recovered and im- proved much in health, though a few sinuses still persist. Amputa- tion subsequent to excision has been practised in 37 cases to which I have references, 22 ending in recovery, with 10 deaths and 5 undeter- mined, while primary amputation for hip disease appears to have been 534 excisions and resections. employed in 55 cases, with 42 recoveries, 11 deaths, and 2 undeter- mined ; so that, apart from the mutilation necessarily entailed by this procedure, its death-rate is but fractionally less than that of excision, which will therefore properly be preferred in all suitable cases. Femur.—I have in one instance resected a small portion of the femoral shaft in a case of badly united fracture, fixing the fragments with a buried silver splint as advised by Dr. Halsted, of Baltimore. The patient made a good recovery, with a useful limb, the silver splint remaining in situ without causing any disturbance. Knee-Joint.—In the article on Excisions, in Yol. III., page 632, I tabulated 26 cases in which I had excised the knee-joint, and I now Table of Fifty-Eight Additional Cases of Excision of the Knee. No. Sex, age, and date. Nature of affection for which operation was required. Result. Remarks. 27 Male, 25, 1884 Gelatinous arthritis; caries and consecutive dislocation Died Death in eight weeks from bed-sores. University Hospital. 28 Male, 25, 1884 Gelatinous arthritis and caries Recovered Useful limb. University Hospital. 29 Male, 14, 1884 Suppurative arthritis do. do. 30 Male, 25, 1885 Syphilitic arthritis Died Death on 7th day from secondary hemorrhage. University Hospital. 31 Maie, 16, 1885 Syphilitic arthritis (heredi- tary) Recovered Useful limb; sinuses. University Hospital. 32 Male, 5, 1885 Gelatinous arthritis do. Children's Hospital. 33 Male, 16, 1886 do. do. Useful limb. University Hospital. 34 Male, 35, 1886 Chronic disease of articula- tion, 22 years do. do. 35 Male, 35, 1886 Bony anchylosis, with caries and great deformity do. Useful limb ; excision en bloc. University Hospital. 36 Male, 4, 1886 Suppurative arthritis do. Children’s Hospital. 37 Female, 3, 1886 do. do. do. 38 Male. 9, 1886 Anchylosis and deformity do. do. 39 Female, 16, 1887 Suppurative arthritis and caries do. Useful limb. University Hospital. 40 Female, 25, 1888 Anchylosis and deformity. Recurrent arthritis, 18 years do. do. 41 Male, 6, 1887 Gelatinous arthritis do. do. 42 Male, adult, 1887 Bony anchylosis, with de- formity and suppuration do. do. 43 Female, adult, 1887 Fibrous anchylosis; limb painful and useless do. do. 44 Male, adult, 1887 Gelatinous arthritis do. do. 45 Male, 1888 Suppurative arthritis and caries do. do. 46 Male, 45, 1888 Suppurative arthritis and caries do. do. 47 Male, 35, 1888 Fibrous anchylosis, with deformity and recurrent arthritis Died Death in 5 weeks. Gluteal abscess. Pennsylvania Hospital. 48 Female, 6, 1888 Arthritis, 3 years Recovered Useful limb. University Hospital. 49 Female, 37, 1888 Arthritis and anchylosis, with deformity do. do. 50 Male, adult, 1888 Suppurative arthritis do. Useful limb. Pennsyl- vania Hospital. 51 Male, 45, 1888 Acute suppurative arthritis do. Useful limb. University Hospital. 52 Male, 11, 1888 Gelatinous arthritis and con- secutive dislocation do. do. knee-joint. 535 Table of Fifty-Eight Additional Cases of Excision of the Knee.— Continued. No. Sex, age, and date. Nature of affection for which operation was required. Result. Remarks. 53 Male, 8, 1888 Gelatinous arthritis and caries Recovered Useful limb. Children’s Hospital. 54 Female, 25, 1889 Fibrous anchylosis and re- current arthritis do. Useful limb. University Hospital. 55 Male, 55, 1889 Suppurative arthritis and caries do. Fibrous union only. Uni- versity Hospital. See No. 65. Useful limb. University Hospital. 56 Male, 25, 1889 do. do. 57 Male, 25, 1889 Male, 19, 1890 Caries and partial anchylosis do. do. 58 Chronic disease of joint Died Death in 5 hours from shock. Pennsylvania Hospital. 59 Male, adult, 1890 do. Recovered Useful limb. Pennsylvania Hospital. 60 Male, adult, 1890 do. do. do. 61 Male, 6, 1890 do. do. do. 62 Female, 20, 1890 do. do. do. 63 Female, 19, 1890 Tubercular arthritis do. Useful limb. University Hospital. 64 Male, 6, 1890 Arthritis and partial ancliy - losis, with deformity do. Children’s Hospital. 6o Male, 57, 1891 Fibrous union after previous excision do. Re-excision. See No. 55. Useful limb. Pennsyl- vania Hospital. 66 Male, 36, 1891 Arthritis and caries, 20 years do. do. 67 Female, 25, 1891 Arthritis and caries do. Useful limb. University Hospital. 68 Female, 9, 1891 Gelatinous arthritis do. Useful limb. Children’s Hospital. 69 Male, adult, 1891 Caries and abscess of tibia do. Useful limb. University Hospital. 70 Female, 30, 1891 Arthritis and fibrous anchy- losis do. do. 71 Male, child, 1892 do. do. Useful limb. Children’s Hospital. 72 Female, adult, 1892 Arthritis and caries do. Recovered from operation. Became insane. Penn- sylvania Hospital. 73 Female, young, 1892 Necrosis of lower end of femur do. Partial excision (lower end of femur) ; useful limb. Pennsylvania Hospital. 74 Male, adult, 1892 Tubercular arthritis do. Useful limb. Pennsyl- vania Hospital. 75 Male, 52, 1892 Arthritis and caries do. Recovered after amputa- tion for recurrent caries. University Hospital. 76 Female, child, 1892 Gelatinous arthritis do. Re-excision for recurrent disease ; ultimately, use- ful’limb. Children’s Hos. 77 Male, 7, 1893 Recurrent disease after ar- threctomy do. Useful limb. University Hospital. 78 Female, adult, 1893 Tubercular arthritis do. Fibrous union. Univer- sity Hospital. 79 Female, adult, 1893 Caries do. Useful limb. University Hospital. Children’s Hospital. 80 Female, 12, 1893 Gelatinous arthritis, with de- formity do. 81 Male, 12, 1893 Traumatic suppurative ar- thritis do. Useful limb. Children’s Hospital. 82 Female, 10, 1894 Fibrous anchylosis do. do. 83 Male, adult, 1894 Tubercular arthritis; ab- scess of thigh and leg Died Death from mania-ii-potu. University Hospital. 84 Male, youth, 1894 Gelatinous arthritis, with deformity Recovered Useful limb. University Hospital. 536 EXCISIONS AND RESECTIONS. have to add 58 more, making a total of 84 operations. The two pa- tients recorded as “still under treatment,” when Vol. III. was pub- lished, both recovered, and of the 58 additional cases 53 terminated favorably and only 5 in death, the whole 84 cases therefore giving 77 recoveries (2 after subsequent amputation) and only 7 deaths, a mor- tality of but 8.3 per cent., while a useful limb is known to have been obtained in at least 63, or 78.2 per cent. In view of these figures I confess to have read with some surprise, in the account of a recent dis- cussion on the subject in a neighboring city, the apparently uncontra- dicted assertion that surgeons generally do not favor knee-joint exci- sion, but look upon the operation with distrust. Certainly an operation after which only one patient in twelve perishes, and which secures a useful limb in three-fourths of the cases in which it is employed, is preferable to amputation, which ordinarily is the only alternative, and is entitled to confidence rather than distrust. I have been encouraged by the good results afforded in my hands by knee-joint excision, to extend the age-limit which I had formerly adopted, in either direction, and my table now includes successful operations in a child of 3 and in an adult of 57. Arthrectomy in Knee-Joint Disease.—The operation of arthrectomy, or evasion of joints, introduced by Wright, of Manchester, consists in laying open the joint, as for an excision, and then cutting away with knife or scissors, or scraping away with the sharp spoon, all the soft tissues of the articulation, without removing any portion of the bone, or at most using the gouge only superficially. In the case of the knee, the ligament of the patella is divided, and its segments are afterward brought together again with chromicized catgut sutures. The semi- lunar cartilages are of course removed. When the case does well, union occurs by fibrous anchylosis, the joint-cavity being obliterated by firm adhesions. The result of this operation, in the knee, at least, is very satisfactory, the shape of the articulation being preserved and the limb being extremely useful; it is, however, a more tedious pro- cedure than excision, and, the cure being effected by fibrous and not by bony anchylosis, there is a good deal of tendency to subsequent contraction, requiring the use for a long time of external support. I have resorted to arthrectomy of the knee in eleven cases, ten of the patients recovering from the operation, though in one instance recur- rent caries required consecutive excision, which was followed by rapid cure. The eleventh case terminated fatally on the thirty-seventh day, from causes unconnected with the operation, the wound having done well throughout. The nine other patients recovered with useful limbs. Patella.—I have twice practised total excision of the patella: once, as a primary operation, in a case of compound fracture with comminu- tion, the patient making a good recovery ; and once, as a secondary procedure, in a case originally of simple fracture, in which another sur- geon had unsuccessfully employed bone-suture, and in which, when the patient came under my care, the knee-joint was full of pus, and the patella was carious. This patient improved temporarily after the operation, but subsequently large congestive abscesses formed in the leg, and death ultimately resulted from chronic septic infection. A legitimate resource in certain cases of compound fracture, the opera- BONES OF THE LEG—ANKLE-,) OINT. 537 tion of complete excision of the patella is necessarily attended by con- siderable risk, and seems to me to have but a limited field of application. Bones of the Leg.—Beside the case referred to in YTol. III., page 501, of resection of the tibia and fibula for deformity, I have operated in two cases of anterior curvature from rachitis (cuneiform osteotomy) —in one of these cases three times—and twice for non-union following the same procedure. I have also successfully excised the entire shaft of the tibia in a case of acute necrosis, rapid reproduction of bone tak- ing place from the periosteal sheath, and the patient making an excel- lent recovery . In another case I removed about one-third of the shaft; also with good results. The operation for rachitic curvature I have found disappointing, for although union as a rule occurs without diffi- culty, and the leg appears straight and firm, the deformit}7 is apt to recur (on account of the morbid condition of the bones), and in a few years may be as marked as before the operation. To prevent this, if possible, the patient should be required to wear a firm artificial support long after consolidation appears to be complete, should take such reme- dies as cod-liver oil and phosphorus, and should be placed in such hy- gienic conditions as may assist in eradicating the disease. Ankle-Joint.—Excision of the ankle I have practised in 13 cases, as shown in the annexed table, two patients having died some months after the operation, two having submitted to subsequent am- putation (successful), and nine having recovered without further inter- ference, one of these, however, having a sinus still persisting when last No. Sex, age, and date. Nature of affection for which operation was required. Result. Remarks. 1 Male, 31, 1875 Caries of ankle-joint Died Death in 4 months from phthisis. Wound did well. Children’s Hos- pital. 2 Male, 20, 1880 Chronic arthritis do. Death in 9 months from phthisis. University Hospital. Children’s Hospital. 3 Male, child, 1885 do. Recovered 4 Female, child, 1888 Caries; sinuses do. University Hospital. 5 Male, 10, 1888 Caries do. Pennsylvania Hospital. 6 Male, adult, 1888 Compound fracture and dis- location do. Useful limb. Pennsylva- nia Hospital. 7 Male, adult, 1888 Compound fracture and dis- location do. Useful limb. University Hospital. 8 Female, adult, 1889 Caries do. Disease recurred and leg amputated 16 months afterward. University Hospital. 9 Male, child, 1889 Necrosis do. University Hospital. 10 Male, adult, 1890 Caries do. Sinus persisted. Univer- sity Hospital. 11 Male, adult, 1890 do. do. Disease recurred and leg amputated 4 months af- terward. Pennsylvania Hospital. 12 Male, adult, 1890 Gelatinous arthritis do. Pennsylvania Hospital. 13 Male, 40, 1890 Compound fracture do. Useful limb. University Hospital Table of Thirteen Cases of Excision of the Ankle. 538 EXCISIONS AND RESECTIONS. seen. In traumatic cases the operation is a very satisfactory one, as it is in cases of chronic disease in children; but in adults, particularly in tuberculous cases, it is very difficult to be sure that all the morbid tis- sue has been removed, convalescence is greatly prolonged, and recur- rence in the neighboring parts is apt to be met with, so that, upon the whole, I am disposed, in this class of cases, to look upon amputa- tion as preferable, being a more certain means of affording relief, and enabling the patient to return sooner to the active duties of life. In the after-treatment of ankle-joint excisions I have latterly ceased to use the special splint recommended in Vol. III., page 640, and have employed a simple gutter of binder’s-board, long enough to reach above the knee, and extending several inches below the foot, the limb, as an additional precaution, being placed in a large fracture-box. Astragalus.—I have removed the astragalus 16 times, in 9 cases for caries or necrosis, and in 7 for club-foot. In two cases of the former category the os calcis ivas removed at the same time, one patient making a good recovery and the other dying some months subsequently from pulmonary tuberculosis, and in a third case consec- utive amputation was successfully practised for recurrent disease. Of the club-foot cases six were examples of pes varus and one of pes valgus. The patient in this last case was a girl of 10 years, who made Table of Sixteen Cases of Excision of the Astragalus. No. Sex, age, and date. Nature of affection for which operation was required. Result. Remarks. 1 Male, 49, 1873 Caries Recovered Episcopal Hospital. 2 Male, 50, 1880 do. Died Calcaneum also removed. Death in 5 months. Uni- versity Hospital. 3 Male, adult, 1884 do. Recovered University Hospital. 4 Female, adult, 1884 Necrosis do. do. 5 Male, child, 1885 Caries do. do. 6 Male, adult, 1885 Pes varus Died Anterior tarsus also re- moved. Foot became gangrenous; amputation of leg. Death. Univer- sity Hospital. 7 Male, adult, 1886 Caries Recovered Disease recurred and leg amputated. University Hospital. 8 Male, child, 1889 do. do. Calcaneum also removed. University Hospital. 9 Male, child, 1890 Pes varus do. Useful foot. Children's Hospital. 10 Male, child, 1890 do. do. Scaphoid also removed. University Hospital. 11 Male, child, 1890 Caries do. Scaphoid also removed. Pennsylvania Hospital. 12 Male, 10, 1890 Pes varus do. Useful foot. Pennsylvania Hospital. 13 Male, child, 1892 do. do. Useful foot. University Hospital. 14 Male, 15, 1892 do. do. Useful foot. Pennsylvania Hospital. 15 Female, 10, 1892 Pes valgus do. Died from diphtheria 3 months after operation. Children’s Hospital. Use- ful foot. 16 Male, child, 1894 Pes varus do. Pennsylvania Hospital. ASTRAGALUS. 539 a good recovery, with the foot in excellent position, but died three months afterward from diphtheria. Of the varus cases five were suc- cessful, the scaphoid as well as the astragalus having been removed in one of these, and one terminated fatally. This was a case of very great deformity in an adult, and amputation would have been a safer remedy than excision. A great part of the anterior tarsus was removed as well as the astragalus, and considerable force was used in bringing the foot into position; gangrene ensued, and in spite of prompt ampu- tation death followed. The following table exhibits in a condensed form the results of my personal experience in excisions of the six larger joints:— Table Showing the Besults of 193 Cases of Excision of the Six Larger Joints. Recovered. Died. Undetermined. Total. Mortality, percent. Shoulder 9 0 0 9 0.00 Elbow 22 G1 0 28 21.43 Wrist 1 0 0 1 0.00 Hip 45 12 V1 58 21.05 Knee 773 7 0 84 8.33 Ankle ll4 2 0 13 15.38 Aggregates 165 27 l2 193 14.06 1 One died after amputation. 2 Undetermined case omitted in calculating percentages. 3 Two recovered after amputation. 4 Two recovered after amputation. ORTHOPAEDIC SURGERY. BY DE FOREST WILLARD, M.D., CLINICAL PROFESSOR OF ORTHOPAEDIC SURGERY IN THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE PRESBYTERIAN HOSPITAL, PHILADELPHIA. The derivation of the word “orthopaedic” is variously given by authors; some regarding it as having been derived from o>'/op, straight, and -acdeoco, to educate—an excellent combination of ideas — while others, more properly, claim that the term is derived from o>9o?, straight, and -on?, xaidos, a child; from the straightening of children it has been enlarged to include the straightening of deformities oc- curring at all ages. The orthography of the word when e is used instead of ce leads many professional men, as well as others, to suppose that the latter portion of the word is derived from the root ped, the foot; thus limiting and narrowing the application of the term. The retention of the diphthong is, therefore, especially useful and suggestive. Mr. Fisher, in the article on Orthopaedic Surgery in Vol. III., would limit the term to subcutaneous work; but this is certainly unjustifiable, as there are many orthopaedic operations which are not subcutaneous. Excisions, erasions, osteotomies, open tenotomies, etc., are certainly very essential procedures in the correction of deformities. Orthopaedic surgery is simply one of the divisions of general surgery. It deals with all classes of deformities and malformations. For its proper understanding the surgeon must acquire a thorough mastery of general surgery, and must add thereto an accurate knowledge of the various accessory mechanical means to he employed; in short, it in- cludes the prevention and the operative and mechanical treatment of all deformities, congenital or acquired, hut especially of those affecting the osseous and muscular systems. The following pages are to be regarded as supplementary to Mr. Fisher's article, already referred to, and follow the same order of ar- rangement, as far as practicable. Club-Foot. Subcutaneous Tenotomy of the Tendo Achillis.—Division of the tendo Achillis is best accomplished, and with least risk of accident, by making a puncture—not an incision—in the skin with an exceedingly sharp-pointed tenotome, and completing the section with a blunt-pointed instrument with a short cutting edge, thus preventing either punc- 541 542 ORTHOPEDIC SURGERY. ture of the skin upon the opposite side or enlargement of the external wound. In old contractions, and in secondary operations, a second section may be demanded, the latter being made at the insertion of the tendon into the calcaneum. If the foot is fixed firmly in a gypsum dressing after the operation, and the proper position of the joint is maintained, there will be no risk of a deficiency of tissue or of a superabundance. In some cases, three inches may safely be inserted in this tendon without risk. The amount of material which nature will pour out for the re- pair depends upon the primary position of the ends of the tendon. If the foot is dressed in the original position, and the two ends are but slightly separated, say one-quarter of an inch, the amount of material poured out will be equal only to the amount needed for repair of this interval; should the foot be subsequently extended so that the gap is increased to one inch, this exudate will be elongated to four times its capacity, and the result will be a weak tendon with only one-fourth its necessary structure. After tenotomy, therefore, the foot should always be placed in the fully corrected position, fixed with plaster-of- Paris or other splint, and kept at absolute rest for two weeks, after which the patient can walk about on the cast for one or two weeks more. Proper apparatus should then be applied. The tendon is sometimes divided by open incision, the exact amount of lengthening being secured by longitudinal splitting and flaps cut from opposite sides, the flaps being then sutured with catgut. This procedure gives no greater accuracy than does the subcutaneous method when a fixed position is maintained, and even with asepsis is not as free from danger. The statement of Mr. Fisher, that section of the tendo Aeliillis is always to be avoided in spasmodic equinus, does not at all agree with American practice, since it has been found that great benefit has been obtained from the improved mechanical position of the foot after tenot- omy. Moreover, the greatly increased powers of locomotion secured by the operation add markedly to the functional activity of all the muscles, and secondarily to the mental gain of the individual. Even when recontractions occur in severe spastic cases, a second section will usually result in permanent benefit. The slight degree of equinus in which the foot can only be brought to a right angle, especially when there is an associated condition of cavus, is often accompanied by much inconvenience and pain. Tender callosities make locomotion an act of great discomfort, and the gait is laborious. Section of the tendo Achillis gives great relief. In the so-called “non-deforming club-foot” a very considerable amount of deformity really exists, and tenotomy is often serviceable. Anatomical Changes in Congenital Varus.—The astragalus is the bone most distorted by muscular action, by pressure, or by weight- bearing. The tarsus is not only misshapen at birth, but even the slight pressure of clothing upon the infant foot during the first few months of life may cause such further malformation that difficulty will be experienced in any attempt to replace the foot in its normal position. As soon as the patient begins to walk the deformity will rapidly increase. CLUB-FOOT. 543 Morton says that the astragalus is sometimes so misshapen as to be unrecognizable, and partially displaced forward so that it even does not articulate with the tibia and fibula. In old cases the distortion is ex- ceedingly great, the neck especially becoming misshapen and rotated. The os calcis, from pressure, is often twisted, and forms laterally an oblique angle to the line of the leg, which is very difficult to overcome even after operation. The other bones of the foot, particularly the cuboid and scaphoid, from continuous pressure become wedge-shaped, and their replacement in adult life is almost impossible. In addition to this, all the ligaments, fasciae and connective tissue upon the inner side of the arch become shortened, while the tissues and ligaments upon the outer side are greatly elongated. Treatment of Congenital Varus.—Infantile talipes cases are fre- quently neglected by physicians for many months, during which time the exceedingly rapid growth of the bones during the first three months of life, together with the pressure of the clothing, tends to greatly in- crease the bony distortion and render subsequent rectification difficult. The proper time to commence the treatment is immediately after birth. The most common methods of correcting varus may be classified under the following heads: (l) Manipulation; Mechanical devices for straightening; (3) Multiple tenotomies with forcible immediate rectification followed by fixation in the corrected position; (4) Open incision; (5) Tarsotomy; (6) Tarsectomy; (7) Amputation. (1) Manipulation.—Hand stretching of all the contracted tissues with massage of the disabled peroneals is by far the most effective means of rectification of an equino-varus. If thoroughly performed, it will nearly always avoid the necessity for operation, and even when par- tially employed it is a great service in securing pliable feet. Rectifica- tion can be employed many times during the day to the point of im- parting only slight pain to the infant. The amount of improvement is usually in exact proportion to the amount of intelligent manipulation which is received. (2) Mechanical Appliances.—Any simple splint will answer for keep- ing the foot in position. The exceedingly small size of the heel makes retention difficult without adhesive plaster, but with care excoriations can be prevented. A piece of sole leather, or felt, or tin, or aluminium, cut and fitted in the shape of a half boot and applied along the inner side of the leg and foot, will keep it in place. As the foot grows, gyp- sum bandages frequently applied in advancing stages of rectification are useful when parents have not time to practise manipulation. These plaster boots, if slit open and the foot straightened frequently, are very useful, especially in dispensary work. Wolf’s plan is to cut out from time to time a section of the cast upon the convexity of the arch, to forcibly straighten the foot, and to fix it in the corrected position by a few turns of plaster bandage. As soon as the position is sufficiently improved to admit of the reten- tion of an apparatus, an appliance that will admit of manipulation with- out removal of the brace is the best for cases occurring among the poor, or with those who cannot give time to the treatment. Such forms of 1 Trans. Amer. Surg. Assoc., vol. viii., 1890, p. 71. 544 ORTHOPEDIC SURGERY. apparatus are articulated opposite both ankle and medio-tarsal joints, and are acted upon by elastic or by spring force. Other useful appliances are operated upon by screw or cog-wheel, or lever power.1 The object to be secured is the unfolding of the varus, the elongation of the contracted tissues, and the strengthening of the weakened muscles. The forms of apparatus are almost numberless. Time for Operation.—The preliminary course of manipulation and mechanical treatment already outlined, gives a mobile and flexible foot, and will, in many instances, secure a good result without operation. In stubborn cases, however, and in individuals where detail cannot re- ceive proper attention, tenotomies become necessary. The proper time for this procedure will vary with each individual case. In those which fail to improve, and when the position is so abnormal that retention of apparatus is impossible, early sections are helpful; but in the majority of cases delay is admissible in cases which are doing well until the child attempts to walk. If the cure of a case of equino-varus is not suffi- ciently advanced to permit the sole of the foot to be placed squarely upon the ground when the child begins to walk, the rule should be to delay operation no longer, since every step will rapidly deform the bones. Asepsis.—In every case the most rigid care should be given to pre- vent the entrance of suppurative germs. Scrupulous cleanliness of hands, instruments, alid dressings is important. It is a difficult task to thoroughly cleanse and prepare an adult foot that is covered with callosities, and much time, patience, and hard scrubbing are essential. The preliminary use of a hot flaxseed poultice for several days is of service. (3) Multiple Tenotomies and Immediate Forcible Straightening with Subsequent Fixation in the Corrected Position.—Every contracted tis- sue should be divided, some cases requiring more cutting than others, but the tibialis anticus and posticus are nearly always at fault. The rules for their section are fully given in Mr. Fisher's article. If the plantar fascia is resistant it should also be cut, and the varus forcibly corrected, reserving the section of the tendo Acliillis until the close of the opera- tion in order to retain its fulcrum power. The advice is often given to correct the varus at one operation, and to postpone the operation for equinus until a later date. When a surgeon lias free control of his patient, and time is of no consequence, such a course is sometimes of advantage; but in the majority of cases it is wiser to thoroughly correct the varus by forcible measures, and then, just at the end of the operation, to divide the tendo Acliillis, after which the relief of the equinus can be accomplished provided the astragalus is not too distorted to assume its relation between the malleoli. Immediately after complete and thorough rectification tjie foot is loosely encased in a plaster-of-Paris bandage, which puts the parts per- fectly at rest. It may remain two or three weeks without disturbance if thorough attention has been given to asepsis of the foot, instruments, and dressings. Metal splints or other apparatus are often used, but are not as comfortable as the gypsum, if it is evenly, lightly, and carefully applied. A walking apparatus of any desired form should subsequently be used, and the parents should be educated to manipulate and practise 1 Agnew’s Surgery, 2d ed., vol. iii., p. 342. CLUB-FOOT. 545 massage on the foot for months and even for years to prevent relapse, to which there is necessarily a constant tendency. The most troublesome resultant condition to overcome will be the tendency to inversion of the toes. This is best obviated by full correc- tion at the time of the operation, the subsequent long-continued use of everting manipulations and gymnastics for ankle, legs, and thigh, and the employment of apparatus extending to the pelvis so as to compel eversion. The spiral spring of Doyle is also useful. Operations in Older Children and in Adults.—When a club-foot has been subjected to weight-bearing for a number of years, the distortion of bones and the contraction of tissues become exceedingly great, and most forcible measures become necessary. Unless months or years are to be consumed in the treatment, it should be commenced by operative measures. Multiple and free sections of all contracted tendons and tissues should be the rule, and full and complete rectification at the time of operation should be accomplished if possible. The division in the worst cases may include not only tendons and fasciae, but also the shortened internal ligaments, and sometimes every- thing but the skin; thus making a section as complete as an open inci- sion, except that it is subcutaneous and does not leave the scar of the latter operation. Necessarily the internal plantar artery is divided, but I have never seen any serious result therefrom. A very strong-shanked tenotome is needful for the plantar section. Tearing of the skin upon the inner side of the arch is rarely occa- sioned, and even should it happen, the operation may be completed by clean open section, just as if the latter had been undertaken as a primary procedure. When the surgeon lacks strength to straighten the deformity he may employ Thomas’s wrench, or the powerful instruments of Bradford,1 Morton,2 and others. The use of these tarsoclasts is attended with danger to the soft parts, and pressure must not be prolonged. Hand pressure over a smooth wood fulcrum is safer. (4) Open Incision.—This operation, commonly known as Phelps’s, at- tacks the deformity by a complete open division of all the contracted tissues in the concavity of the arch, by elongation of this space, and by filling the gap with granulation tissue. When the internal lateral ligaments are divided, the foot can be elongated, and becomes a better walking member than when the convexity of the arch has been dis- turbed by bone removal. The incision extends from a half-inch in front of the internal malleo- lus. across the sole as far as necessary. The artery and nerve should be avoided if possible, but section of both tibial tendons and of all the con- tracted fasciae is necessary, and sometimes division of the abductor pollicis, flexor brevis, and the entire internal ligaments is demanded. (5) Tarsotomy.—Astragaloid osteotomy has been occasionally em- ployed with success, and is a perfectly feasible operation. After thor- ough tenotomy, fasciotomy, and stretching, an incision is made from the tip of the inner malleolus to the inner side of the head of the first meta- tarsal, nearly parallel to the tibialis anticus tendon. Care should be exercised lest the scaphoid be mistaken for the astragalus. After 1 Bradford and Lovett, Orthopaedic Surgery, 1890, p. 484. -Trans. Amer. Orthop., Assoc., vol. i., and Agnew’s Surgery, 2d ed., vol. iii. p. 343. 546 ORTHOPJEDTC SURGERY. division of the neck of the latter with a small osteotome, forcible straightening is completed. Thorough antisepsis is essential. (6) Tarsectomy.—No positive rules based upon the age of a patient can be laid down as regards excision of the tarsal bones. The justifia- bility of operation must depend upon the conditions encountered. There are cases in adults which can easily be cured without mutilation of the tarsal arch, and there are instances in young children (but not in in- fants) where such a procedure may become the proper surgical course. The first element, therefore, in determining the propriety of excision would be the rigidity of the foot. This will depend largely upon the alteration in shape of the osseous tissues, and secondly upon the density of the contractions in the fasciee and tendons. Some surgeons advocate the removal of the astragalus even in young children; but the large majority of American surgeons reserve such operations for older patients, and for more resistant cases. The second indication for excision will, of course, be the degree of deformity, and the possibility of securing a good walking foot which can be planted squarely upon the sole, and which can be brought to extension at least slightly beyond a right angle with the leg. In many cases in adults the operation is perfectly justifiable, and will greatly im- prove the locomotion of the individual. Another element in reaching a decision will be the condition and control of the patient. In many instances where time is of no conse- quence, where care and attention will be given to the instructions of the surgeon, and where the nursing of the patient will be assiduous, the less radical measures may be employed, and will be successful. But in a case where it is certain that careful attention will not be given and that even the most careful instructions will be disobeyed, where time is of great consequence, and where it is certain that the failure of one operation will be followed by the refusal of another attempt at rectifi- cation, an excision becomes perfectly justifiable, though it would not have been so under the conditions first named. Relapsed cases especially demand the operation. Another argument in favor of tarsectomy is that it sometimes places the foot in such cor- rected position that the use of apparatus can be dispensed with more speedily than when a less radical operation has been performed. This is often an element of importance. If, however, only one foot is in- volved, it is highly improbable that a patient will for many years be able to dispense with apparatus, as the unevenness of the gait tends to roll the foot upon its outer surface, especially if, as in many cases, the peroneals are paralyzed, and there is difficulty in maintaining the foot in the good position which has been secured by operation. No surgeon, though careful to an extreme degree, can depend abso- lutely upon the varying conditions of materials, instruments, solutions, etc., which he has to use about a wound; hence the opportunities for admission of germs are not wanting, and occasionally suppuration will result. Wilson1 gives the mortality in 435 cases as 1.6 per cent. A list of sixteen different forms of tarsectomy is given by Young,2 but ex- cision of the astragalus and wedge-shaped resection of the tarsus are the two chief operations. 1 Trans. Amer. Orthopaedic Assoc., 1893, vol. vi., p. 160. 2 Orthopaedic Surgery, p. 380. Phila., 1894. CLUIi-FOOT. 547 Tarsectomy, while frequently justifiable, is mutilatory. It does not give as good motion at the ankle joint as can be secured when the astrag- alus remains in place, and when the deformity can be so treated that the foot can be flexed to a point beyond a right angle with the leg. Many an astragalus which seems hopelessly distorted, and so enlarged that it cannot be brought between the malleoli of the tibia and fibula, yet, with properly applied but strong force may be placed in situ, when in time the walking efforts of the individual will adapt it to proper rela- tions. After all operations the atrophied and weakened muscles must be strengthened by persistent massage, to maintain the foot in the cor- rected position. The incision for a tarsectomy should commence in front of, and below, the external malleolus, extending sufficiently forward to give a good exposure, and avoiding, if possible, the peroneal and extensor tendons. Disarticulation of the astragalus, the preferable operation, is not an easy matter, and the posterior tibial artery is in danger when the oppo- site ligaments are reached. A curved, blunt knife is serviceable. The removal of the astragalus, when insufficient to permit complete rectification, may be followed by excision of the cuboid, or an irregular wedge-shaped excision, as advocated by Davy, may be performed. When a wedge is to be removed, a chisel is preferable to a saw when the articulations are not followed. Both rubber and gauze drainage are advisable until the first dress- ing. The foot should be firmly fixed with gypsum, or other rigid dress- ing, until healing is nearly completed, when gentle passive movements should be instituted to restore the function of the part, and afterward the patient should walk about upon the cast until a proper apparatus is adjusted. Wedge-shaped excisions with either chisel or saw are sometimes necessary in adult cases when the cuboid is especially distorted. In some cases the lines of the articulations are followed, but more com- monly the wedge section is made irrespective of these lines. Such an operation shortens the foot more than an excision of the astragalus, and more than an open incision on the inner side of the arch. (T) Amputation may occasionally be justifiable in cases of extreme deformity occurring in adults. Extension in the Treatment of Club-Foot.—The structural shortening of a foot may often be greatly benefited by the frequent and forcible application of an extension shoe, like that of Adams, described in Mr. Fisher’s article,1 or by the use of Shaffer’s apparatus.2 Valgus.—The deformity which is most likely to be overlooked by a careless surgeon is the variety of valgus in which the flexion (or rather hyper-extension) is apparently beyond the right angle. Close observa- tion, however, will show that this is only apparent; that the appear- ance is caused by the undue amount of mobility at the transverse tarsal joint, while the relation of the calcaneum to the tibia and fibula is still faulty. The tendo Achillis is really too short, and each step only tends to bend the foot more and more at the calcaneo-cuboid and astragalo- scaphoid articulations, thus increasing the deformity. 1 Yol. III., p. 686, supra. 8 Bradford and Lovett, Orthopaedic Surgery, 1890, p. 471. 548 ORTHOPAEDIC SURGERY. Tenotomy of the tendo Achillis in addition to that of the peroneals is always beneficial in these cases, provided an apparatus is subsequently adjusted with an arched leather or steel insole, which not only supports the normal arch of the inner portion of the foot, but is high enough to give support to the side of the scaphoid as well. The sole of the shoe should also be thicker along the entire inner side of the heel and ball of the foot, so that the tread will be upon the outer side. If steel uprights are necessary, a pad should be placed opposite the inner ankle, and an elastic strap attached opposite the ball of the great toe so as to raise the inner side of the foot. Flat Foot.—Gymnastics, massage, electricity, and improvement of general nutrition are essential elements in the treatment of flat foot. The tibialis anticus muscle must receive especial development by exer- cises systematically carried out.1 Walking on tiptoe is often service- able, but weight and pulley movements are especially indicated. The best shoe to be worn is that already described for the treatment of valgus. The supporting arch beneath and upon the inner side of the scaphoid may be made first of sole leather, and afterward of spring steel, or of a combination of these materials. The operative treatment may consist in: (1) Tenotomy of peroneal tendons; (2) Tenotomy and forcible inversion with elevation of scaph- oid ; or, (3) Tarsectomy. In ordinary cases the best results are ob- tained by tenotomy of the peroneal tendons, followed by forcible inver- sion and elevation of the arch, with subsequent fixation by gypsum in the varus position for several weeks. The patient may then walk about upon the plaster cast, and afterward wear the shoe described above. In inveterate cases wedged-shaped excisions of the tarsus, with or without fixation by pegs, followed by careful support, will assist in locomotion. Calcaneus.—In cases where the tendo Achillis has become perma- nently lengthened, it should, under the most thorough aseptic precau- tions, be divided in an oblique direction, or slit and shortened the requi- site amount to secure a normal position. The divided ends are then sutured with chromicized catgut or sterilized silk. The form of suture is of little importance, so that strangulation of tendon tissue is avoided. The wound is then closed and primary union secured. The foot should be dressed with plaster-of-Paris, so as fully to relax the calf muscles for three or four weeks. An apparatus with stop joint and elastic assistant should be subse- quently applied. Deformities of the Toes. Hammer Toe, or Talon Toe.—In Mr. Fisher’s article it is said that certain authors who recommend division of the extensor tendon are mistaken. I have, however, on several occasions seen cases in which the deformity could not be relieved until the extensor as well as the flexor tendon had been divided, as the first phalanx would otherwise per- sist in assuming its former upright position. The best method of maintaining the toes in the straight position after 1 Roth, Lateral Curvature of the Spine, p. 55. London, 1889. BOW-LEGS. 549 tenotomy is by passing an elastic ribbon or & tape through slots cut in an aluminium foot-plate, the dimensions of the slots being smaller than the ribbon. The latter is thus held in any desired position without knots. Stockings with toes are usually uncomfortable and expensive, and when the plate is used the tip of the hose should be removed. Hallux Valgus.—As a result of inflammation of the metatarso- phalangeal joint, pus is not infrequently formed, and the end of the metatarsal bone may become carious, necessitating amputation. The toe may sometimes be retained in position by a sole-plate with an elastic ribbon run through a slot, as recommended in hammer toe; or a pro- jecting arched sepL.m may be placed between the first and second toes. Osteotomy of the first metatarsal close to its anterior head permits the toe to be brought into good line, and often avoids the necessity for amputation. In suppurative cases, however, amputation is usually pref- erable, or excision of the metatarso-phalangeal joint may be substituted. Bow-Legs. Lateral Curvatures of the Legs.—These are usually remediable by apparatus and manipulation. Frequent and forcible manipulation is exceedingly important. Braces should be so constructed that pressure is made upon the apex of the curve, while counter-pressure is made at the inner malleolus and inner condyle. Manual, Forcible, Immediate Straightening.—In young patients, when parents will not, or cannot, attend to the proper application of apparatus, immediate straightening by fracture over a smooth, wooden, half-cylindrical fulcrum is occasionally advisable. Sometimes a green- stick fracture results; more frequently straightening is accomplished without actual rupture of the bone fibres. of the straight position is maintained by plaster-of-Paris for six weeks, and it is wise to support the limbs by apparatus until the condition of the child is such that there is no longer danger of recurrence. The force must be applied suddenly, but judiciously, so that no injury to epiphyses will result. The compression is so momentary that slough- ing never follows. Osteoclasis.—Instrumental fracture by the osteoclast should only be employed when the bones are too strong for the manual power of the surgeon, and in America the operation is not so popular as osteotomy, since the exact point of fracture cannot be as readily secured, and the tissues are frequently so pulpefied that sloughing results; moreover, in the region of the joints the procedure is accompanied by considerable injury to the epiphyses. Osteotomy.—A bone section made with a clean, sharp osteotome, or Adams’s saw, through an aseptic wound which can be speedily closed, leaves for the surgeon only the treatment of simple fracture, .and sup- puration should be one of the rarest of results, unless a wedge has been removed. Cuneiform osteotomy is now only occasionally em- ployed, since the wedged-shaped gap produced by the straightening of a bone after simple osteotomy readily fills with callus and a strong limb results. 550 ORTHOPEDIC SURGERY. Anterior Curves of the Tibula and Fibula.—These seldom yield to apparatus, but with osteotomy excellent results may be obtained.1 Even very angular projections maybe straightened without removing a wedge. Drainage is seldom required. When it becomes necessary to remove a wedge, the piece may he chipped awTay or cut out with a chisel, but the operation should be avoided when possible, since the resulting compound fracture is a much more serious condition than the simple fracture which follows linear section. The use of an Esmarch bandage or tourniquet is not advisable, since the outflow of blood serves an excellent purpose in preventing the ingress of air. The dressings should be thoroughly aseptic, and they need not be removed as long as they remain sweet and clean. The best subsequent fixation splint is plaster-of-Paris, applied while the deformity is slightly over- corrected. In the process of fixation by a gypsum splint, it is desirable to enclose the fractured region with the first turns of the bandage, since the proper position of the limb can then be much better maintained by an assistant with a firm grasp upon the limb below and above the point of injury. A few moments will suffice to render these preliminary turns sufficiently rigid to prevent any displacement, after which the less essential portions above and below may be adjusted. Great care should be taken, while the cast is soft, not to make indentations by the fingers or otherwise, as each depression produces an elevation or mound upon the inner surface, which, when hardened, may give rise to great suffering or even to sloughing. Care should be taken to saw open and tighten the cast as shrinkage of the tissue occurs. Operation with the Saw.—The osteotome is more frequently employed than the saw for section of a hone. While the use of the osteotome requires a larger wound of the soft tissues, and is not actually a sub- cutaneous operation, yet it is in many respects cleaner and more satis- factory, and is less liable to be followed by suppuration. Particles of sawdust, if they do not become incorporated and vitalized, may set up suppuration, acting as foreign bodies. The use of the saw is a slower and a more difficult operation, and if carelessly used the instrument will produce a certain amount of tearing of the soft tissues. The choice between these two modes of treatment will rest largely upon the experience of the operator. Genu Valgum. Knock-knee, in common with the other deformities of rickets, is less frequently found in the United States than in Europe. It is essentially a disease of the poor of great cities. When knock-knee is combined with bow-leg and bowed femur, two or three sections may become necessary. Occasionally, especially in colored children, a peculiar cork- screw leg is produced by severe rickets. Frequent and forcible straight- ening by hand is the most effective measure. The supracondvloid oste- otomy of Macewen, as described in Mr. Fisher’s article in Yol. III., is so satisfactory in genu valgum that it has practically superseded all other procedures. 1 International Clinics, Jan., 1892, p. 111. DEFORMITIES OF THE UPPER EXTREMITIES. 551 Deformity of the Lower Extremities from Muscular Contraction. Severe grades of muscular contracture frequently take place at the knee, hip, and ankle as a result of infantile paralysis, of spastic paraly- sis, hip-joint and ankle-joint disease, injuries, etc. These contractions are frequently so great as to place the limb mechanically in such a flexed position that walking would be impossible even were the muscles in their ordinary condition of strength and vigor. The straight position, therefore, becomes necessary. The deformity should he overcome by section of the contracted tissues, whether fasciae, tendons, or muscles. In section in front of the hip, the tensor vaginae femoris and the sartorius and rectus may be divided with perfect safety; hut in severe grades, where the band is in close proximity to the anterior crural nerve, open division is safer. Under thorough aseptic precautions no suppuration will follow. Never should section of the iliacus and psoas be under- taken except by the open method. The adductors, as a rule, can be divided subcutaneously. Thorough attention should be given to strict cleanliness of the parts. At the knee, when the hamstring tendons alone are divided, the only care necessary is in regard to the external popliteal nerve, which may be felt upon the inner side of the biceps ten- don. When, as is frequently the case, the fascia of the popliteal space is contracted, open incision with strict asepsis is the only safe method. In the treatment following division of the adductors, it is impossible for any splint to hold the thighs apart unless the knees are fixed. A simple dressing of plaster-of-Paris fixes the knees, after which the limbs may be fastened wide apart until the gap in the adductors has been filled with fibrous tissue. At the ankle and foot all contracted tissues are to be divided, follow- ing the rules indicated in the remarks on paralytic talipes. By such simple operations many cases of contracture following the different forms of paralysis may be very greatly benefited, and patients long helpless may be restored to a good walking basis. At first it is impossible to do without artificial helps, such as braces, wheeled crutches,1 and axillary crutches; but exercise will soon develop the muscles. While the shock of multiple tenotomies is considerable, yet the results to be secured justify the slight risks. In cerebral spastic palsy tre- phining the skull is indicated only in cases with decided cranial de- pression, especially when there is a history of traumatism at birth or afterward. Bony deformities following joint disease may be corrected by forcible straightening, by osteotomy, or by excision. Deformities of the Upper Extremities. Division of the tendons of the upper extremities, at wrist, hand, or fingers, is rarely as successful as tenotomy in the lower extremities. ’Bradford and Lovett, Orthopaedic Surgery, 1st ed., p. 59; Trans. Amer. Orthopaedic Assoc., 1891, page 382. 552 ORTHOPEDIC SURGERY. Wrist Drop.—Shortening the tendons by open incision, splitting and stitching them, is desirable and safe under perfect asepsis. In se- vere flexion of the hand following paral}Tsis, lengthening the tendons by open incision, splitting and resuturing, is sometimes advisable to give better mechanical position to the hand. Massage, electricity, and elon- gation of the muscles is often helpful in restoring the hand to useful- ness. Division of the contracted muscles by open incision directly through the fibres below the internal condyle lias been practised, the arteries, veins, and nerves being carefully avoided. The hand is then dressed in the extended position and the gap becomes filled with fibrous tissue. Club Hand.—Club hand is usually associated with other deformities, but is rarely double. The palmo-ulnar variety is the most common. When the deformity is moderate, it may be corrected by persistent manipulation, together with the employment of gypsum splints or me- chanical devices. Tenotomy is seldom’advisable, but open incision with splitting and splicing of shortened tendons, and shortening of the elon- gated ones, is advisable in serious cases when all other means have failed. Amputation should not be performed, as even a distorted hand is partially useful. Supernumerary or Deficient Fingers.—Supernumerary fingers, or polydactylism, is a condition that shows a remarkable hereditary tend- ency. The deformity is frequently double, and is often associated with a similar condition of the toes. Treatment.—As operative interference is usually desired for cosmetic purposes, it should be instituted early. In boys, the utility of the part should he first considered. No absolute rules can he laid down, as the surgeon must be guided by the location, articulation, and degree of perfectness of each member, those of least value being sacrificed. Any remaining projecting portions of the metacarpal heads may be chiselled away. In one remarkable instance the amputated finger is said to have been reproduced twice.1 When there is a deficiency of fingers, plastic surgery will sometimes benefit the appearance of the hand; but amputation is not advisable, as even two misshapen fingers are very useful. In a case at present under my care, five last phalanges with perfect nails are joined, but not articulated, to the carpus. Deformities of the toes need not be operated upon except when they give inconvenience or pain. Hypertrophy of fingers or toes occasionally occurs, and is irremedia- ble except by amputation. The whole nutrition of the fingers is in- creased,2 but it does not appear to be a condition of acromegaly. Webbed Fingers, or Syndactylism.—Two or more of the fingers, or of the toes, may be joined at their bases or tips, or throughout their en- tire extent. Usually the bond consists only of skin and connective tissue, but in rare instances the bony phalanges are connected. Treatment.—The difficulty in cure after division of the web arises 1 C. White : On the Regeneration of Animal Substances. 2 Journal of Mental and Nervous Disease, vol. xviii., 1893, p. 443. DEFORMITIES OF THE UPPER EXTREMITIES. 553 from the tendency to readhesion which must always exist at the com- missure. This is best corrected by cutting V-shaped or oval flaps, as advised by Agnew,1 by dissecting flaps from the palmar and dorsal aspects of the web and suturing them across the cleft after division, or by raising longitudinal anterior and posterior flaps from separate fingers and suturing them in position after wrapping them around the raw incised surfaces (Didot). Should these procedures fail, a flap may be cut from the breast or thigh and turned into the cleft, the hand being firmly held by gypsum bandages until union has occurred, when the base of the flap may be cut away. Writer’s Palsy.—Scrivener’s palsy is an example of want of co- ordination in muscular power which is seen in a variety of muscles, and is observed in many classes of artisans and mechanics when one set of muscles is obliged to constantly repeat a series of movements. It is not merely a local nerve exhaustion, but often indicates a disturb- ance of the central nervous system, and is a reflex neurosis. The earliest symptom is muscular fatigue, followed by cramp and the want of co-ordinate movement. Numbness, tingling, and pain soon extend up the arm. The very earliest symptoms of this malady should induce the patient, if circumstances permit, to refrain from the use of the affected member, even placing it upon a splint or in a sling. Massage and electricity are not useful unless preceded by rest. Atten- tion to the general health is of the utmost importance. For those who are unfortunately compelled to continue their avocations, and. for tem- porary assistance, mechanical contrivances for holding the pen should be attached to the hand by means of rings and broad bands so as to re- lieve the muscles. The strong muscles of the forearm should be used for moving the pen instead of the weaker ones of the hand. The oppo- site hand should at once be systematically educated to take its propor- tion of work, a process which will be tedious of accomplishment, but which may be secured by perseverance. Dupuytren’s Contraction of Fingers.—This cicatricial-like contrac- tion of the palmar fascia and of its digital prolongations condenses the subdermal tissues, blit does not involve the true skin nor the tendons except in very old cases. In rheumatic families as many as three or four members may he similarly affected. Keen’s tables2 show that a majority of cases present a constitutional taint; but Abbe3 favors the theory of traumatic and nervous origin. Treatment.—Open division is more precise than multiple subcutane- ous sections, and is no more painful. The hypodermic injection of co- caine, or local anaesthesia by the spray of chloride of ethyl, or the application of ice and salt, is sufficient to benumb the part. In open division the hand should be rendered bloodless for accuracy of section. One or more sections may be made, either diagonal, transverse, V- shaped, or oval, and the division should be so thorough that recontrac- tion will not occur. 1 Principles and Practice of Surgery, 2d ed., vol. iii., p. 372. 2 Philadelphia Medical Times, March 11, 1882, p. 370. 3 Med. Record, March 3, 1888. 554 ORTHOPAEDIC SURGERY. Lateral Curvature of the Spine. The literature of the causation of lateral curvature would fill vol- umes, and yet the true solution of the problem has not been reached. The arguments and conclusions brought forward in Mr. Fisher’s article are still as forcible and convincing as they were when published, and no more rational theory has been promulgated. It may still be said that while muscular debility, inequality in the length of the legs, inequality in the weight of the upper extremities, faulty positions of standing or sitting, neuroses, etc., are operative as causes, yet that many of these conditions exist in numerous instances without any deforming result. There must exist, therefore, in addition, a condition of ligaments, intervertebral discs, and bones—some de- ficiency of elasticity and flexibility—which, though undemonstrable by microscope or by chemistry, yet is certainty recognizable as a clinical fact.1 Future knowledge will doubtless solve the problem A discus- sion of these theories will be found in Young’s work.2 The theory of rotation as advanced by Mr. Fisher is still as rational as any that has been advocated, namely, that the posterior portions of the vertebrae, being firmly supported by numerous muscular and ligamentous at- tachments, are not easily influenced by the unequal forces brought to bear upon them, while the comparatively free anterior bodies of the vertebrae are easily swung from their position. Treatment of Lateral Curvature.—The treatment of lateral curvature may consist of (1) Gymnastics, including Swedish movements and massage; (2) Mechanical measures to prevent and diminish the deformity; and (3) Forcible attempts to remove the rotation. (1) Gymnastics, etc.—It is admitted by all orthopaedic surgeons that increase of muscular power is an essential element in the prevention and cure of this distortion; consequently, well-regulated gyunnastic movements should be a part of the education of all growing boys and girls. By this means the number of cases of lateral curvature will be very largely diminished. As a means of cure, the systems of muscular movements employed are various. Each teacher of Swedish movements has individual, as well as general, views, and many of them are helpful. So with gym- nastics: no one class of exercises should be alone relied upon. In gen- eral terms it may be said that the truncal muscles, especially upon the side of the convexity of the longest curve, are those requiring the most development. The surgeon should, however, decide in each indi- vidual case as to the necessities. This can best be done by observing the effect of certain groups of movements as demonstrated upon the bared back of the patient. That position and muscular action can affect the distorted chest and the rotated vertebral bodies, will be very evident if the surgeon grasps the pelvis of the patient and directs her to strongly rotate the upper portion of the body to right or left. This action will be especially noticeable if one arm is elevated alongside the head while 1 Beeley, Trans. Amer. Orthopaedic Assoc., 1891, p. 84B. 2 Orthopaedic Surgery, p. 180, Philadelphia, 1894. See also Trans. Amer. Orthopaedic Assoc., 1890. f LATERAL CURVATURE OF THE SPINE. 555 the other is held at a right angle to the body; and still more, if with arms in the same position the trunk is flexed to a right angle with the thighs, and is then twisted to the right or left. The muscular movements that can be practised by the patient at home are exercises on a chest weight, with pulleys lowered to the floor so as to cause flexion and development of the posterior muscles; hori- zontal bar; trapeze or rings; dumb-bells, clubs, and self-suspension by head and arms, the hand upon the side of the concavity of the curve being placed uppermost on the rope. Other home exercises may be the various forms of Swedish move- ments; lying upon the abdomen with head and shoulders raised with- out assistance of the hands; lying with the body projecting over the edge of the table while the pelvis is held in position, etc. Horseback exercise (riding astride), rowing with both hands—or if with one hand using that on the debilitated side—tennis or croquet played with the hand on the concave side of the larger curve, swim- ming and other sports, are all beneficial if followed by a period of rest in the supine or prone position upon a flat couch. It is advisable that patients with lateral curvature should sit or stand but little; they should either walk or lie flat; in fact, recumbency should be insisted upon as an essential element of the treatment. Massage is helpful in connec- tion with Swedish movements, and forcible manipulation wflll accom- plish much. It is especially important that the backward and lateral flexibility of the spine should be increased. Under the direction of a surgeon, or of a teacher, the postural move- ments advised by Roth,1 Sayre,2 Bradford,3 Taylor,4 and others, may be employed with advantage. The patient should also be instructed in proper methods of sitting, lying, etc., a flat couch being the best for the supine jDosition. A light book carried upon the head helps to secure a good carriage. (2) Mechanical Appliances.—Mechanical devices for lateral curva- ture have been invented by the score, but most of them are useless. Except when the spine is rapidly bending it does not need support; mus- cles require strengthening, not weakening. However, supports are occasionally necessary. Of the fixation or jacket supports, the appli- ance of Bartow is the most rational in cases of moderate deformity, since its action tends always to produce a normal conformation of figure. It is made by taking a plaster cast of the trunk while in a state of sus- pension, from which cast a counter cast or model is afterwards secured. This is then remodelled by paring away all abnormal projections and filling in with soft plaster all depressed portions, until the representa- tion of a normal figure is secured. Upon this more or less perfect model a leather jacket is fitted, which, when hardened, is adjusted to the pa- tient’s trunk. A plaster jacket is sometimes employed, though harmfully, unless pieces are cut out of it from time to time and straightening thus accom- plished, or unless it is applied under forcible restitution, effected in one of the methods described below. 1 Bernard Roth, Lateral Curvature, p. 24. London, 1889. 2 Medical Record, Nov. 17, 1888, p. 538. 3 Bradford and Lovett, Orthopaedic Surgery, p. 160. 1890. 4 Trans. Amer. Orthopaedic Assoc., 1890, vol iii., p. 136. 556 ORTHOPAEDIC SURGERY. Rigid forms of apparatus, made of steel and webbing, are numerous.1 They aim to make pressure upon the projecting ribs, while a crutch-head assists in elevating the depressed axilla. The effect that they produce is slight, but they are useful as reminders to the patient that the erect posture must be maintained. Shaffer’s instrument is light and conve- nient. When rapid increase of deformity is taking place, it is sometimes necessary to employ one of these means of support until gymnastics, etc., can restore sufficient muscular power to enable the body to maintain its equilibrium. The corsets of thick, heav}7 webbing some- times used are very objectionable. Beeley2 has drawn attention to a most important point in the con- struction of spinal apparatus, by insisting upon the careful and accurate fitting of the pelvic band. (3) Forcible Restitution.—Many efforts have been made from early periods to replace the distorted portions of the trunk, and these methods have recently been resuscitated. Adjustable pads and levers, placed against the projecting ribs while the pelvis and shoulders were secured, have long been in use. Present plans include forcible bending of the body over a fulcrum, either a strap or a fixed bod}7; forcible twisting by the appliances of Brackett,3 W^eigel,4 Schede,6 Lorenz, Hoff a/ and others, the patient being erect or suspended; or heavy-weighting of the projecting parts while the patient is in a stooping position, as in Beeley’s apparatus. The weights upon the straps in the latter appli- ance may be fifty or sixty pounds, and should be continued as long as they can be tolerated by the patient. Many of the instruments above alluded to are regulated by adjustable screws and pads, and are trouble- some and expensive. To restore the rotated bodies of the vertebra is still an uncertain procedure, although a certain amount of gain may he accomplished. Torticollis. Much of the difference of opinion between authors is explained hy the fact that they have failed to distinguish spasmodic and intermittent wry- neck from structural shortening of the muscles. The latter is a con- dition which ordinarily may be permanently relieved by myotomy with subsequent massage and gymnastics of the muscles; the former is a most troublesome and intractable disease which resists all forms of treatment, and which appears to depend upon a central nerve lesion. In the intermittent variety the distress is often excessive from the involuntary painful contraction interfering even with sleep. The seat of the disease lies in the cord, at the root of the spinal accessory or upper spinal nerves, or from some lesion along their course. The most common causes are local traumatism, sudden nervous shock, direct effect of cold, and some constitutional diseases, such as rheumatism. Ordinarily adults are affected. Diagnosis.—The diagnosis of wry-neck from cases of cervical spinal 1 Bradford and Lovett, op. cit., 1890, p. 165. 2 Trans. Amer. Orthopaedic Assoc., 1891. 3 Boston Med. and Surg. Journal, May 11, 1893. 4 Trans. Amer. Orthopaedic Assoc., 1893, vol. vi., p. 265. 8 Deutsche med. Wochenschrift, 1892, Bd. xviii., S. 249. 6 Zeitschrift fur orthop. Chirurg., 1891. TORTICOLLIS. 557 caries is occasionally confusing at first examination, but, is cleared up by closely watching the symptoms. Hysterical contractions also are often perplexing. Torticollis from injury of the sterno-mastoid during birth is not uncommon,1 and licematoma of the muscles should be closely watched for some time after birth. Treatment of Wry-Neck.—For the spasmodic variety, gelsemium carried to the point of constitutional poisoning has been lauded by Sinkler and others; deep injections of chloroform, strychnia, atropia, morphia, etc., have all been employed with varying degrees of benefit; electricity and massage have cured a few cases; arsenic and belladonna, and scores of other drugs, have met with temporary success. Myotomy of the sterno-mastoid is seldom sufficient in these spasmodic cases, even though performed by the complete open method, since the scaleni, tra- pezius, complexus, and even the splenius and rotators, may be involved. For the simple cases, the drugs and measures already enumerated, with manipulations and the use of apparatus, are sufficient to effect a cure, and the prognosis in a large proportion of acute cases is favorable. Cases of structural shortening will usually require myotomy, while those of the intermittent variety not infrequently resist medication, myotomy, neurotomy, neurectasy, and even neurectomy. Young, Lovett,2 and others have shown that there is sometimes a curious rela- tion between ocular defects and torticollis. Permanent contractions of the sterno-mastoid are remediable by my- otomy of the sternal or clavicular divisions, or both; and in severe cases by a similar section of the mastoid insertion. While open section under antiseptic precautions is the safer procedure, yet in females, in order to avoid a scar, the slight amount of risk involved by subcutaneous division is justifiable in mild cases. If a blunt-pointed tenotome is carefully carried close behind the rigid muscle, accident can scarcely occur. I have once only seen death occur, from septic pleurisy, when in the hands of a most dexterous operator an unusually high pleura was punctured. A very simple, but effective, dressing after myotomy consists of an axillary or thoracic belt, and a head bandage, the two connected by a rubber strap. Neurectomy.—The first excision of the spinal accessory nerve was per- formed in 1866 by Campbell de Morgan.3 He made his incision at the posterior border of the muscle, and having found the trapezial branch traced it back until the main trunk was visible. Noble Smith4 has collected much valuable material in regard to this operation, and Bowlby 5 relates a number of cases; Smith employs an incision ante- rior to the sterno-mastoid, as it permits a more certain division of all the nerve filaments. Simple neurotomy is not advisable, since even the removal of a half-inch of nerve has been non-productive of relief. A certain amount of atrophy and paralysis must necessarily follow an ex- cision. The centre of either an anterior or a posterior incision should be about opposite the upper border of the thyroid cartilage, or a little above the 1 Trans. Amer. Orthopaedic Assoc., 1891, p. 30. 5 Ibid., vol. i., p. 46; vol. ii., p. 230. 3 Brit, and For. Med. Chir. Review, vol. xxxviii., 1866. 4 Spasmodic Wry-neck, p. 55. London, 1891. 6 Injuries and Diseases of the Nerves. 1893. 558 ORTHOPEDIC SURGERY. middle of the sterno-mastoid muscle. It is not always easy to find the spinal accessory, but it should he remembered, that it runs diagonally from the inner and upper angle to the outer and lower angle of a par- allelogram formed by two horizontal lines drawn, one from the angle of the jaw, the other parallel to the first, from the border of the thy- roid cartilage. These lines with the anterior and posterior borders of the sterno-mastoid form a parallelogram. The nerve enters the muscle about two inches below the mastoid. Ligation of the Nerve.—Mayo Collier 1 applied a tight wire ligature to the spinal accessory, with permanent relief from the spasmodic move- ments; but it is difficult to see that this method could be as safe as neurectomy. Neurectasy, or Nerve-Stretching.—The spinal accessory may be reached by an anterior incision downward from the lobe of the ear, by which the digastric and stylo-hyoid muscles will be exposed; the nerve may be hooked up and stretched between these and the sterno-mastoid, but it should be remembered that strong traction must necessarily influence the medulla. The nerve may also be reached at the posterior border of the sterno-mastoid. The results of this operation are usually unsatisfactory, and neurec- tomy is preferable. Resection of the Posterior Cervical Nerves.—These nerves may be reached by a three-inch incision parallel to, and an inch outside of, the spinous processes, cutting through the trapezius, the edge of the splenius, and the complexus. When the nerves are reached, all the fibres should be excised for at least a third of an inch. The suboccipi- tal is difficult of access. The resultant muscular paralysis is not consid- erable, but wasting must necessarily occur. Keen 2 made his incision transversely, three inches long diagonally across from the spine to a half inch below the lobe of the ear, dividing the trapezius and the complexus, but avoiding the great occipital nerve. The posterior division of the second cervical was first exsected, then the suboccipital. The external border of the posterior division of the third was exposed below the great occipital, and excised. By this means the nerves supplying the chief external rotators of the head, that is, the splenius, the rectus capitis major, and the obliquus inferior, were cut off. An electric forehead-light will greatly facilitate the speed of the operation. Congenital Malformations of the Hip. The condition commonly known as congenital dislocation is much better described as a malformation of the acetabulum, or femoral head and neck, or both. Many variations of malformation are met with, most of which are due to the misshapen head and neck of the femur. These cases are accompanied by more or less sliding motion at the hip, according to the degree of deformity in the acetabulum, and the pa- tients have a waddling gait to a greater or less extent. In a number of cases heredity is easily traceable. Not infrequently a history of lancet, June 21, 1890. 2 Annals of Surgery, Jan., 1891. CONGENITAL ABSENCE OR DEFICIENCY OF BONES. 559 violence during delivery, in a foot presentation, is obtainable. Occa- sionally an anterior displacement is encountered. The plan of long-continued extension, as practised by Dr. Buck- minster Brown, consumes so much time and requires such absolute con- trol of the patient that it will seldom succeed. Prolonged extension, however, for six months or a year, is essential so as to bring the femoral head well into position before resorting to mechanical meas- ures. Bradford 1 has devised an apparatus which permits continuous extension both in the supine and in the sitting position. Mechanical Appliances.—A wide waist and pelvic band, made of leather and fitted accurately over a plaster cast of body and thighs, with locking and unlocking hip-joint, is useful.2 A long Taylor or other extension hip splint is, after extension in bed, most helpful, and subsequently a walking splint should be worn. Operative Measures.—The most favorable cases for operation are those in which the bone is freely movable. Hoffa’s3 plan of procedure is to free the trochanter from all the retaining muscles, bring the head of the bone forcibly downward and forward into its normal site, and excavate the rudimentary acetabulum as deeply as the thickness of the ilium will permit. The saving of the head is an important element.4 In the discussion upon this subject before the German Surgical So- ciety. Hoffa said that the operation should be performed between the third and sixth years, as the head and neck of the femur afterward become altered, and it is then impossible to draw the head down to its normal site. When the deformity is double, the ligamentum teres is usually abgent, causing a slip, or sound, on rotation, in which case an operation is unde- sirable. The consensus of opinion is not in favor of operative over me- chanical methods. Congenital Absence or Deficiency of Bones. The bones of the lower extremities are more commonly absent than are those of other portions of the body. The cause may be inferred to he the same influences of position, etc., that make club-foot much more frequent than club-hand. Occasionally all the extremi- ties are absent, the trunk alone being present. More frequently one extremity is absent, or so dwarfed, distorted, and misshapen that its components are barely recognizable. The head and neck of the femur may be distorted, or a large portion of the shaft may be missing, the thighs being much shortened; in one case under my care, the dis- tance from perineum to knee was less than an inch. Congenital crural asymmetry is not uncommon, the difference in length of the thighs sometimes amounting to an inch or more. Tilting of the pelvis is common in these cases, but lateral curvature only occasionally re- sults. 5 The fibula is occasionally absent, or it may be represented merely by a band of tissue. 1 Trans. Amer. Orthopedic Assoc., 1891, p. 308. 2 Phila. Med. Times, Nov., 1880. 3 Trans. Twenty-third Congress German Surgical Society, April 18, 1894; Jour. Amer. Med. Assoc., July21, 1894. 4 Trans. Amer. Orthopedic Assoc., 1891, vol. iv., p. 139. 6 Centralblatt fur Orthop. Chirurg., Juli, 1885; Trans. Amer. Orthop. Assoc., 1891, p. 15. 560 ORTHOPAEDIC SURGERY. The upper extremities are sometimes so shortened and misshapen as to hear a resemblance to fins. The radius and ulna may be bent or absent, and congenital defects of the fingers are not rare. The most common deficiencies are where two or more fingers are consolidated into one, or where some fingers are entirely absent. In these cases there are usually associated deformities in other portions of the body. While these bony defects are irremediable in themselves, yet surgery can frequently lessen the deformity and greatly assist in facilitating locomotion. Subcutaneous or open myotomies and tenotomies, osteot- omies, etc., with or without subsequent employment of apparatus, will accomplish much, and plastic surgery will often be helpful. INJURIES OF THE HEAD. BY CHARLES B. NANCREDE, A.M., M.D., PROFESSOR OF SURGERY AND OF CLINICAL SURGERY IN THE UNIVERSITY OF EMERITUS PROFESSOR OF GENERAL AND ORTHOPAEDIC SURGERY IN THE PHILADELPHIA POLYCLINIC, ETC. Treatment of Scalp Wounds. An insignificant scalp wound, if it become inf ected, may lead to peri- ostitis, purulent osteitis, osteophlebitis, and encephalitis; or, again, from the periosteum the infective process may, by continuity of tissue, through osteophlebitis, initiate thrombosis of the cerebral sinuses, with consequent pyaemia. While this is an uncommon, it is a possible, com- plication, and treatment should aim to prevent, this as well as tetanus. The necessary precautions to this end, about to be detailed, are equally necessary prerequisites to trephining for disease or injury, and will not be repeated when dealing with those subjects. As scalp wounds often lead directly down to unsuspected and severe lesions of the skull and brain, no precautions should be viewed as being too troublesome. First drench the parts with carbolized water,1 cut with scissors or, better when possible, shave all hair from the edges2 and immediate neighborhood of the wound, and scrub the scalp with a nail-brush wet with dilute acetic acid one part, alcohol seven parts.3 This in turn should be removed with abundance of sterilized water and green soap containing 5 per cent, of hydro-naphthol. Finally, thorough irrigation with mercuric chloride solution should precede the examination of the wound by the disinfected finger. If an}7- doubt exists as to bone injury, the scalp wound should be enlarged. A strictly aseptic or antiseptic dressing should finally be applied, and with this addition the advice given in my article in Vol. V. still holds good. As antisepsis would be hard to secure, the employment of the hair to coaptate scalp wounds recommended in that article should not be attempted. The modified commendation of sutures there given should be extended to the advice to employ them in all cases when requisite, when an aseptic condition of the wound can be secured. Of course, here and elsewhere, the 1 Boiled water should be used for the solution, and when no antiseptic is obtainable is in- finitely better than unboiled water, being at least aseptic. 2 If operating for brain tumor or epilepsy the whole scalp should be shaved. 3 This serves to remove all greasy substances, at the same time acting as a germicide, but ether will do; if preparing for an intracranial operation for disease, after the preliminary shaving some surgeons employ a soft-soap poultice for a short time, followed by the applica- tion of an antiseptic dressing for twenty-four hours before operation ; this latter expedient should always be adopted in cases of epilepsy and brain tumor. 561 562 INJURIES OF THE HEAD. crude method of employing lint wet with a bichloride solution should be discarded for the more efficient methods now in vogue.1 Treatment of Phlegmonous Erysipelas of the Scalp. Under no circumstances should my former advice be taken, to apply poultices after opening pus collections, a moist antiseptic dressing, cov- ered with rubber tissue or some substance impermeable to moisture, being invariably to be employed, the incisions being made after the preliminary preparation of the parts just advocated. Trephining. Preparation for Trephining.—In addition to what has just been advised, when demanded by the nature of the case, the cerebral fis- sures should be marked on the scalp with an aniline pencil or nitrate of silver point, after the preliminary cleansing, when a moist antiseptic dressing covered with cotton wool and oiled silk should be secured in place, only to be removed after the patient is anaesthetized. When time permits all this should be done at least twenty-four hours before operation. When done for epilepsy, tumor, etc., that is, where no scalp wound exists, a soft-soap poultice may be kept on for a few hours after, or instead of, the alcohol and acetic acid wash. Slight elevation of the head, or the semi-recumbent position, is the best for operation, because lessening the hemorrhage. When this is specially to be avoided, as in children, the Esmarch tourniquet may be applied; if it does not succeed, as is frequently the case, the vessels should be secured by needles armed with catgut passed through the scalp beneath them, or by catch-forceps. The bone should be marked with a drill or the centre-pin of the tre- phine, removed for the purpose, at the upper and lower extremities of the Rolandic fissure, before the flap is cut. The flap, including the perios- teum, should be large, with a semilunar or horseshoe outline, its base so disposed as to contain the chief scalp-vessels. The hemorrhage being controlled, the bone is removed by trephine or chisel as seems best.2 Bleeding from the large diploic veins may be arrested by concen- trically crushing in the surrounding bone with some blunt instru- ment, or by plugging with a bone chip, or with antiseptic wax. I have recently resorted to temporary plugging with fragments of antiseptic gauze or with an aseptic match-stick. Special precautions must be observed when both walls of the frontal sinus are broken. Most thorough disinfection of the sinus should precede perforation of its posterior wall, and at the conclusion of the operation the cavity must be carefully tamponed with iodoform gauze, remembering that symptoms of secondary compression may result from swelling of the tampon, by imbibition of wound fluids. The orbital margin should be resected, if necessary, to remove infected bone or foreign bodies. Should the dura mater require incision, a point is raised about one- 1 While I usually employ bichloride of mercury, it is hardly requisite to say that any other efficient germicidal or germ-inhibiting substance may be used instead. 2 When the fragments are to be replaced, they must be kept in a warm antiseptie towel, or sponges, or solution, until needed. TREPHINING. 563 fourth of an inch from the margin of the opening with mouse-toothed forceps, a small opening is made with the knife, and the incision—which must include only about four-fifths of the circumference—is completed with blunt-pointed scissors; in this way the large veins of the pia mater will escape injury. After the dura mater has been reached, nothing but boiled water should be used for irrigation, because possibly danger- ous 1 and certainly interfering with the localization of nerve centres by the faradic current. Vessels of any size, crossing the proposed line of incision of the dura mater, should be first secured by passing beneath them—through the dura—a curved needle armed with a fine catgut ligature. Wounded vessels of the pia mater must be secured by gently tying with fine catgut, the first half of the knot being drawn only tight enough to occlude the lumen of the vessel, as the walls are very frangible. When this plan fails, small wire serre-fines,2 to which fine silk threads are tied, may be left for forty-eight hours, or until they spontaneously separate. Gauze packing cannot be relied upon as a permanent measure for arresting serious bleeding from either the pia mater or the brain substance, although efficient for oozing from the small vessels of the latter; irrigation with hot water, or sponge pressure, will, however, usually suffice for this. A wounded sinus must be promptly compressed, ligated laterally, the opening plugged with a bunch of catgut, or the whole channel included between two ligatures placed on each side of the wound by means of a curved needle; antiseptic tamponnade is all that I have employed myself or seen employed, the plug being cautiously removed at the end of about forty-eight hours.3 When the operation has been completed the dura mater must be care- fully sutured with fine catgut, a piece of pericranium4 being substituted for this membrane if it has been removed, or a piece of dentist’s heavy gold foil5 being slipped beneath the margins of the osseous opening so as to repress any tendency to brain protrusion. This last measure has been suggested in trephining for epilepsy to prevent the formation of adhesions between the scalp and the brain or its membranes. If thought best the bone fragments may be replaced, or the minced-up fragments may be strewn over the membranes when these are intact. Only large fragments, perforated and secured by catgut to the scalj) flap, are permissible if large openings in the dura mater exist. Plates of decalcified bone, or celluloid,6 cut to fit the opening, but having a notch at one side for drainage, have been employed to fill up bony defects; but these measures are of questionable value, excepting where the opening is exceedingly large or peculiarly situated. The question of drainage here arises. Unquestionably when an ex- pert in brain work is operating for epilepsy or brain tumor, in most in- stances no drainage will be requisite, but for the average operator I consider the following rules to be the safest. I must here trench—as I have done in my preceding remarks—-upon the province occupied by the supplementary article of Dr. Keen, but it seems to be unavoidable. 1 Some recent experiments seem to prove this. 2 Ordinary haemostatic forceps are too heavy. 3 See Park’s cases, Med. News, Dec. 3 and 10, 1892, page 16. 4 Keen. 6 Bradford ; Park, Clinical Contributions to the Subject of Brain Surgery, reprint from Med. News, Dec. 3, 10, 1892, p. 20. 6 Yon Eiselberg. Verh. der Deutsch. Gesell. fur Chirurg., XX. Congress, 1891. 564 injuries of the head. In operations for epilepsy, for insanity,1 or for fractures where no serious lesion of the dura exists, and asepsis has been secured, capillary drainage, preferably by catgut, may be employed. Where large bone fragments have been replaced, only capillary drainage is available. In compound fractures with lesions of the dura, where there is doubt as to the attainment of perfect asepsis, tube drainage had better be employed for forty-eight hours. Tube drainage is always indicated for abscess.' Prompt union of the flap should be secured by accurate coaptation with medium-sized interrupted silk sutures, placed one-third of an inch apart, with intermediate stitches of fine silk or horsehair. If capillary drainage be used, the threads must be kept parallel, in close contact, and cut off square, and the protective must extend some distance beyond their ends. Tube drainage should not be kept up, except for pus, beyond twenty- four hours. With an experienced operator Horsley’s plan is probably safe, viz., accurate suturing of the whole line of incision except for about an inch at the most dependent point, “where any tension of wound discharges can relieve itself by escape between the edges,” but capillary drainage is safe, effective, and should always be employed when in doubt. The primary voluminous antiseptic dressing must be carefully renewed so as to make gentle pressure over the centre of the flap at the end of twenty- four hours, if tube drainage has been employed, since this should then be dispensed with; otherwise the dressing need not he disturbed, unless the symptoms indicate retention of discharges, when they must be given vent by means of a sterilized probe gently introduced along the track of the drainage-tube, or between the stitches if no drainage has been used.11 After from five to seven days I have usually removed the stitches, supporting the flap with gauze strips and collodion, and applying a boric acid and cotton dressing instead of the antiseptic gauze. Temporary Resection of the Cranial Wall as a Substitute for Trephining.—The soft parts are incised down to the periosteum in the form of the Greek omega, and allowed to retract; the periosteum is divided close to the border of the flap, the bone is chiselled through along the line of the periosteal incision, and the bridge of bone at the base of the omega is divided subcutaneously with a narrow chisel; the osteo-cutaneous flap is then lifted up with elevators and replaced after completion of the operation. Specially constructed chisels have been recommended, but ordinary narrow bone-chisels will suffice in careful hands. Use of the Chisel instead of the Trephine.—This instrument is preferred by Mr. Chiene and by many German and American opera- tors. Unquestionably for the cutting out of cracks it is preferable to any other instrument, and doubtless in experienced hands is as safe, or safer, for perforating the cranium than a trephine; but for the average operator the trephine is, in my opinion, the better instrument. 1 See Park, op. cit., for cases where drainage was dispensed with. 4 Iodoform gauze is employed for drainage by some operators. Unless hemorrhage is to be controlled by tlie pressure I can see no advantage in this, and some disadvantages. 3 See Horsley’s papers as to the advantages accruing from this liquid compression, which serves to repress the tendeney to hernia cerebri and prevents firm cicatricial adhesion between the flap and the membranes, or the brain. TREPHINING. 565 Osteoplastic Resection of the Cranium.—Defects left by injury or disease may be repaired by removal of the cicatrix, freshening the bone edges, and transplanting, from the contiguous parts, a properly shaped flap consisting of skin, periosteum, and the outer table of the skull; the wound left by removal of the flap may be covered with skin- grafts after Thiersch’s method.1 Mortality after Trephining. — Wagner and Seydel give statistics showing that by an immediate resort to trephining the mortality varies from 1.23 per cent2 for recent accidents, to 1.6 per cent.3 for epilepsy, brain tumors, etc.; when compound fractures are not operated upon until after the lapse of twenty-four hours, or more, the mortality rises to 33.33 per cent. Indications for Trephining.—In compound fractures, the surgeon should always operate, not for compression, but in order to disinfect. This can only be properly done by elevation of fragments, or even their removal, to admit of paring with a chisel to get rid of dirt, and of free antiseptic irrigation. The slightest fissure,4 as by imprisoning a hair, has been the starting-point of sepsis; so that where there is the slightest doubt, all cracks should be carefully chiselled out and thoroughly disinfected. Lacerations of the dura mater should be re- paired by suture. The form of flap must depend somewhat upon the original wound, but it should be large, to repress any tendency to hernia cerebri. Should simple fractures be trephined? Bearing in mind the imme- diate risks of encephalitis, and the future ones of epilepsy and insanity, there can be but one opinion as to the advisability of operating for all varieties of accessible fracture. An exploratory incision, made with strict antiseptic precautions, will resolve any doubt in cases of head-injury, and if no bone lesion be found will heal promptly, adding nothing to the risks. Trephining in Fractures of the Base.—When accessible these should receive the same treatment, the chief objects of operation being disinfection and drainage,5 and but rarely elevation of fragments.6 After-Treatment of Trephining.—Liquid diet is to be recom- mended for the first three days, but this is often productive of furred tongue with an unpleasant condition of the mouth; the use of a tooth- brush wet with a saturated solution of chlorate of potassium will usu- ally give relief. In comparatively slight cases of operation, for epi- lepsy, etc., the patient may get up in a week, and he allowed solid food as soon as he desires it, while in more severe cases, especially where much hone has been removed, and particularly where the brain has been compromised, he should not get up until some time in the third week. 1 Schonborn, J. Wolf. Verliandl. der Deutsch. Gesellscb. fur Chirurg., XX. Congress, 1891. 2 W. Wagner (Konigshutte). Yolkmann’s Sammlung klinischer Yortrage, Nos. 271, 272; Chirurg. No. 85, 20 April, 1886. 3 Antiseptik und Trepanation, von K. Seydel. Munchen, 1886. 4 See author’s case reported to Phi la. Co. Med. Society, May 8, 1889. 5 See Allis, Annals of Surgery, vol. x. Warren, Amer. Journ. Med. Sciences, vol. xcix. 6 See article in Yol. V. for case where this was necessary. 566 INJURIES OF THE HEAD. Attention to the bowels, and the use of the cold-water coil or ice-bag for headache, high temperature, or incipient encephalitis, may also he requisite. While I have never seen anything but good done by low diet and local bleeding with the internal use of calomel, and while I believe that thereby in many cases incipient stasis in the cerebral vessels of the inflamed area is obviated, thus preventing the accu- mulation of germs which overcome the resistance of the tissues. }’et the injudicious use of such means may be prejudicial to the pa- tient. Knowing as we do that diffused (septic) meningitis with open wounds results from infection through the wound, or by germs in the circulation—harmless while few in number, yet capable of fatal mis- chief if allowed to accumulate at any point—I cannot but think that, in injuries where no external invasion atrium exists, the mechanism of in- tracranial suppuration is that which I have given, and that the therapeu- sis suggested is the proper one. If this be true, suppuration cannot be induced by the lowered resistance of the tissues induced by a few days’ diminution of nutriment, while this may, and often does, in conjunc- tion with the use of the drugs mentioned,1 prevent such a slowing or stasis of the cerebral circulation as might admit of the accumulation of germs in dangerous numbers at the injured point. It is quite probable also that intestinal sepsis is obviated by such a germicidal substance as calomel, and while unproved, it is possible that the prolonged em- ployment of mercury may inhibit the development of germs in the circulating fluid, thus explaining the clinical fact that this drug exercises a beneficial influence in various inflammations. Treatment of Contusions of Bone. I must still most emphatically recommend operation when the local symptoms indicate the presence of osteomyelitis, not primarily for the evacuation of subcranial pus, but in order to freely remove the infected bone; this, when promptly done, is the only effectual means at our dis- posal for preventing osteophlebitis, subcranial suppuration, or pyaemia. This measure has been successfully employed where bone trouble, initi- ated by old ear disease, has caused septic thrombosis of the lateral sinus,2 this channel having been cleaned out and disinfected after complete removal of all infected bone and ligation of the internal jug- ular vein.3 I would therefore add to the words in my former article.4 “What if no pus between the dura mater and bone he found?” “Pro- ceed at once to remove all infected bone well into healthy tissue, thor- oughly disinfect, and drain. ” The same remarks apply to the statement5 that “nothing more can be done surgically than to evacuate pus wherever accessible, etc.,” for possibly removal of affected bone and ligation of the jugular vein may save lives in the future as it has done in the past. Too much attention cannot be paid to the condition of the kidneys and intestines, which eliminate not onl}T large amounts 1 See Vol. V. 2 Med. Press and Circular, p. 495, 1886. Other cases have since been reported. 3 Macewen, Diseases of Brain and Spinal Cord. 4 Vol. Y., page 11. 5 Ibid., page 13. BASAL FRACTURES. 567 of ptomaines, but certainly, in the case of the former organs, even germs themselves.1 When explaining “Teevan’s law” in my former article, it was not also mentioned that splintering is in inverse ratio to momentum, and that much diminution of the fracturing force is effected by its trans- mission through the different layers of the skull, which are of varying density; this helps to explain the extensive shattering of the internal table. Basal Fractures. Prognosis.—Where there are only non-fatal intracranial lesions complicating the fracture, provided septic meningitis and cerebritis can be prevented, a large percentage of recoveries takes place: thus Wagner reports that twenty-three consecutive cases, that is, all in which the patients survived their injuries more than forty-eight hours, terminated favorably.2 Treatment.—If the line of fracture traverse the petrous portion of the temporal bone,3 the external auditory meatus must be carefully cleansed, all cerumen, dust, or blood being removed, after which care- ful irrigation with warm mercuric-chloride solution (1-2000) should be employed, or hydrogen peroxide may be injected, or the use of the latter may precede that of the former; when thorough disinfection has been accomplished, an antiseptic gauze dressing must be secured over the ear. Where the vault of the pharynx or roof of the nasal cavities is implicated by the fracture, these cavities must be cleansed, first by a hot boric-acid solution, employing for this purpose the posterior nasal syringe, or the same thing may be effected by prolonged spraying of the nose and pharynx. Solutions of thymol, various proportions (1 to 2, 3, or I) of listerine and water, or boro-salicylic solution, may be used at the onset instead of the boric-acid solution, and some one of them must be employed afterward as often as once every two or four hours. After cleansing, boric acid or safe amounts of sterilized iodoform may be insufflated into the naso-pharynx, while the nostrils must be lightly plugged with loose rolls of some variety of antiseptic gauze.4 In accessible portions of the base, as some portions of the occipital and temporal bones, and the orbital plate of the frontal bone, operative inter- ference may, in suitable cases, render valuable service by effecting drainage, and by affording a better opportunity for disinfection.5 The recent suggestion to immobilize the fragments by a plaster-of- Paris cap has not as yet been carried into practice, and would seem to be of too little practical value to warrant the annoyance and the inter- ference with other measures which it would entail. 1 This statement has been as positively denied as asserted. 2 W. Wagner (Konigshutte), op. cit. 3 J. 0. Warren contends that a blow on the ear will fracture the base, the fissure passing along the upper wall of the auditory meatus, the petrous bone being weakened by its fora- men ; he has demonstrated this upon the cadaver. 4 Of course such attempts at asepsis are only approximately successful, but (Wagner, op. cit.) even partial asepsis has markedly lowered the mortality of these cases. 5 Punctured wounds of the orbit must be so treated, by enlarging the opening, disinfecting, and introducing a drainage tube. See also Allis, loc. cit. ; Warren, loc. cit. 568 INJURIES OF THE HEAD. Intracranial Hemorrhage. Extra-Dural (Subcranial) Hemorrhage.—In addition to what I have urged in my previous article, I must again call attention to the fact that symptoms of pressure may be delayed for many days—even eleven—after the injury.1 This may be due to a renewed hemorrhage, or to the sudden yielding of brain function so often seen after long- persisting hemorrhagic or serous effusion, although no appreciable addition to the pressure occurs. The peculiarities of the hemiplegia met with in these cases are that at the onset it is partial, affecting per- haps only one centre, and that it progresses always by attacking adja- cent centres either above or below that primarily implicated. Thus the arm may be first involved, next the leg, and then, as the blood gravi- tates, the face may become affected, until finally, when the base is reached, the third nerve becomes first irritated and then paralyzed, pro- ducing the well-known pupillary symptoms. Moreover, when the patient is in a condition for it to be demonstrated, there is no sensory paralysis, this at once distinguishing the lesion from an apoplectic one, or from hemorrhage into the brain substance, the re- sult of laceration. Ferrier says that “ strictly cortical lesions of the mo- tor area do not cause anaesthesia in any form, and it may be laid down as a rule, to which there are no exceptions, that if anaesthesia is found along with the motor paralysis, the lesion is not limited to the motor zone, but implicates also, organically or functionally, the sensory tracts of the internal capsule or the centres to which they are distributed.” The practical bearing of the above sentences is admirably illustrated by a case of Mr. W. Thornley Stoker, from whose article I have transcribed the quotation.2 While the respiration is slow, stertorous, and, perhaps, very irregular, the pulse, although possibly slow at first, afterward becomes frequent, the result of indirect pressure producing paralysis of the vagus. The temperature is usually elevated, sometimes reaching 104° F., especially on the side opposite the clot. Treatment.—To emphasize what was urged in Vol. V., a mere pres- entation of the statistics of VVeisemann is only requisite, these showing such vastly better results than I could demonstrate by my former statistics, that the position then taken is amply justified. Thus of 147 patients treated without operation, 131, that is, 89.1 per cent., died, while of 110 who were trephined, only 36, that is, 32.7 per cent., died, and in the fatal cases the autopsy demonstrated that if another opening had been made, the clot might have been reached and removed, and some probably would have recovered.3 These results have been obtained (1) by prompt operation, (2) by improved technique, and (3) by asepsis and drainage. Operation.—Although the clot is usually situated upon the side of injury, the' trephine opening must not therefore necessarily be made there, unless the localizing symptoms warrant this site being selected; 1 Ransolioff reports a case where no symptoms appeared until the morning of the eighth day. Annals of Surgery, vol. xii., p. 116. 2 Annals of Surgery, vol. vii., p. 401. 3 Ueber die Indicationen zur Trepanation mit besonderer Berucksichtigung, etc., Deutsche Zeitsclirift f. Chirurg., Bd. xxi. undxxii., 1885. INTRACRANIAL HEMORRHACtE. 569 moreover, both middle meningeal arteries have been found ruptured in one reported case, and under such circumstances the skull would of course require to be opened on both sides. As it cannot be ascertained before opening the skull whether the trunk, or the anterior or posterior branch, of the artery has been rup- tured, a sufficiently large semilunar flap should be raised to give access to the whole middle meningeal distribution. The crown of a large tre- phine, one and one-quarter inches (3-4 centimetres) in diameter, is ap- plied behind the exter- nal angular process of the frontal bone, on a line parallel to Reid's base line, and on a level with the upper- most portion of the orbital margin. (Fig. 1673, A.) If the clot is found here it must be gently removed by the finger or a Volk- mann’s spoon, aided by a stream of warm sterilized water.1 If bleeding continues, the vessel can usually be secured by one of the methods suggested in my former article, en- larging the bone opening if necessary for this purpose by the rongeur; I have myself, however, been compelled to tie the external carotid artery to arrest otherwise uncontrollable hemorrhage, coming, as the post- mortem examination showed, from a wound of the main meningeal trunk as it passed through the foramen spinosum.2 Should the anterior trephine opening show no clot, a second must be made in the same line just below the parietal boss (Fig. 1673, _B), this showing that the bleed- ing vessel is often the posterior branch of the artery.3 The anterior opening may now be closed with its own button, only the posterior being utilized for drainage (which should be by tube or iodoform gauze); or through drainage may be instituted. If only one bone opening has been requisite to remove the clot and secure the vessel, and if in the recumbent posture good drainage cannot be insured, the opening must be enlarged, or a second, more favorably located perforation must be made. Where a general excessive oozing persists from the small ves- sels, antiseptic tamponnade may be requisite, as in one case in my own practice and in more than one reported by other surgeons. Fig. 1673. A, Anterior point tor application of trephine for middle meningeal hemorrhage. B, Posterior point for same. C, Point of perforation for cerebral abscess secondary to ear disease. 2), Foramen for mas- toid vein. E, Point of perforation for cerebellar abscess. P, Parietal eminence. 1 Weak bichloride solution may be employed if preferred. 2 Stroke (Berliner klin. Wochenschrift, 1892, No. 34, S. 860) reports his inability to secure this vessel by a ligature; he was compelled to leave a pair of haemostatic forceps applied for two days, when they were removed without further bleeding taking place. See also Symonds, Trans. Clin. Soc., Loudon, 1886, vol. xix., pp. 12-26 and 159-163. 3 Although other rules have been given, I have found this reliable upon both the cadaver and the living subject. 570 injuries of the head. Subdural Hemorrhage—It has been suggested that as the middle cerebral artery can be easily reached by prolonging upward and back- ward the anterior bone-opening just mentioned, by means of the rongeur, the dura might be opened, the clot removed, and the main trunk sought for and tied in the Sylvian fissure if found to be the source of hemorrhage; but as subdural bleeding usually comes from numerous small meningeal or cortical vessels beneath the point of frac- ture, it is rarely possible to find the bleeding points, though, of course, if a clot were found it might be turned out and drainage instituted.1 It must not be overlooked that hemorrhage by contre-coup2 sometimes exists at a point opposite to the seat of external injury, and, if the symptoms indicate, must also be sought at that point.3 Diagnosis of Head Injuries from Alcoholic Coma and Apoplexy. Phelps4 has insisted upon the fact that, after recovery from shock. “ an early, continuous, and very constant symptom in all classes of head injury,” with encephalic lesions, is a rise of temperature; and that this “is a constant phenomenon, whatever the nature of the lesion or wherever situated,” being probably “due to an affection of the cortex as a whole.” In a very few exceptional cases the temperature may at first be depressed, but then it usually rises promptly to from 101° to even 109° F., usually not higher than 104.8°, notably in cases which are re- coverable. In alcoholic coma, as pointed out in my former article, the temperature is depressed, ranging from 96° to 98° F., with slow or nor- mal pulse, the depression of temperature being proportionate to the depth of the coma. In apoplexy, Phelps, in common with Bourneville, has found that at the outset the temperature is subnormal, and then nearly normal, remaining so if recovery ensues, but rising markedly if the case is to terminate fatally. Fungus Cerebri. Ten years’ further experience only more firmly convinces me that the comparatively low mortality I assigned to this condition, if properly treated, was warranted by facts. If a septic encephalitis be not the cause, or if the patient survive this disease, nature is fully competent to deal with the protrusion; absolutely nothing beyond aseptic, unirri- tating dressings, with support—not pressure—is requisite, the shrink- age of the enveloping layer of granulation-tissue effecting the reduc- tion of the fungus. 11 have done thus once, evacuating fully six ounces of bloody fluid and old clots nearly three weeks after the primary injury. The source of the hemorrhage was not detectable ; bleeding recurred in moderate amount and death occurred with elevated temperature a few days after the operation. 2 Brain laceration is nearly always thus caused. 3 See page 5(33 for methods of arresting hemorrhage from the vessels of the pia and brain substance. 4 Phelps, Clinico-Pathologieal Study of Injuries of the Head with Special Reference to Lesions of the Brain Substance, Jsew York Med. Journal, Jan. 14, 21, and 28, 1893. CEREBRAL AND CEREBELLAR ABSCESSES. 571 Wounds of the Membranes. Wounds of the dura mater when possible must be sutured with fine catgut; any deficiency may be repaired by a piece of pericranium, or pos- sibly the future evils of adhesion between the scalp and brain may be obviated by placing over the brain an aseptic piece of heavy dentist’s gold foil, cut so as to extend a short distance beneath the margins of the bony defect. Cerebral and Cerebellar Abscesses. These are never primary, but are secondary to such conditions as puru- lent periostitis and osteitis of the cranial bones; injuries to these bones, to the soft parts covering them, or to the underlying intracranial con- tents; or suppurations in the course of the lesser circulation, as in abscess of the lung, foetid bronchitis, chronic empyema, etc. Ab- scesses from chronic suppurative ear disease, the most common cause, will be found treated of elsewhere. Operations upon the nose, such as those for the removal of polypi,1 have also produced abscesses of the brain—in one case there having been a focus of suppuration in each frontal lobe—so that it is well to bear in mind the possibility of there being more than one pus collection.2 Zeller reports a case in which a phlegmonous process in the orbit was the starting-point of a brain abscess.3 Symptoms.—As large abscesses, for instance one in the temporo- splienoidal lobe, increase the general intracranial tension by augment- ing that of the cerebro-spinal fluid, the symptoms, in the absence of a clear history as to the sequence of the phenomena, are often obscure, and even at times misleading; fortunately, however, the pressure is usu- ally so transmitted through the semi-solid brain substance that the neighboring centres are those most and first involved. In a general way the symptoms are those of pus formation, of general disturbance of cerebral function, and, in special cases, focal symptoms, as for in- stance, sensory, acoustic, or motor aphasia. Optic neuritis is often pres- ent, and occasionally reverses the rule, being more marked upon the side opposite the abscess. Tenderness upon pressure or to percussion over a limited area, with local elevation of temperature, is frequently noted. The chill which so commonly precedes an abscess in other localities is quite common, but the subsequent elevation of temperature, if it occur at all, is soon replaced by a normal or a subnormal tempera- ture,4 possibly rising near the termination of the process, often with de- lirium and with a second subsidence of the thermometer. The other symptoms, such as headache, vomiting, etc., are not peculiar to abscess, and have been noticed in iny former article. No special focal symp- 1 Parke, Medical News, Dec. 3, 1890, p. 617. 2 Ransohoff, Journal of the Med. College of Ohio, 1892. 3 Crawford Renton, Annals of Surgery, vol. iv., p. 334. 4 See a case of Murdock’s (Annals of Surgery, vol. ii., p. 81) where the fact that the pus was subdural, that is, a circumscribed collection due to adhesions probably arising from meningitis, gave a high temperature throughout, contrasting forcibly with the condition where the brain tissue is alone involved. 572 INJURIES OF THE HEAD. toms need mention, as they are variously grouped, and as no two cases are alike; unfortunately when the abscess occupies the frontal lobes, no localizing symptoms will appear until, perhaps, late, from secondary pressure, when they are more apt to be misleading than of service in arriving at a diagnosis. For the differential diagnosis the reader is re- ferred to the remarks on meningitis, mastoid disease, extradural ab- scess, thrombosis of the lateral sinus, and pyaemia. I would urge that while the rule given as to the most probable time for the appearance of symptoms of cerebral abscess holds good in most instances, yet such cases as Weir’s1 show how late in the case pus formation may occur. Operation.—Special care should be exercised in the administration of the anaesthetic, as respiration often becomes embarrassed or ceases just about the time that the abscess is reached. WAiere possible—as it often will be—no anaesthetic should be employed, ether being the one selected, if any be used. After elevating a proper flap at the point in- dicated by the scalp-wound, the osteomyelitic bone, or the seat of frac- ture, or when none of these exist—an unlikely contingency in the class of cases I am now considering—the bone, wherever the focal symp- toms indicate, should be removed, a crucial incision should be made through the dura mater, and then pus should be sought for by passing a grooved director 2 in one or more directions toward the supposed locality of the abscess, after reaching which the track of the director must be enlarged by a small Volkmann’s spoon, a drainage-tube— a metallic or glass one is preferable—introduced, and the cavity washed gently out with sterilized water or some weak germicidal solution.3 If the trephine opening is not favorably located for drainage, it will in some instances be proper to make a second bone perforation opposite the most dependent portion of the abscess cavity, passing thence a director into the abscess, and then proceeding as already suggested; the first bone opening can be closed by its own bone-disc, kept in warm aseptic water and nicked on one side to allow an exit for pus or wound fluids. To insure the patency of the drainage-tube, a small portion of the edge of the flap should be excised, or a piece cut out opposite the trephine opening. Great care in suturing and dressing should be taken to insure primary union of the flap, lest hernia cerebri oc- cur. The tube must be very gradually shortened, and after its final withdrawal the case must be jealously watched for some weeks, lest a re-accumulation take place.4 Additional Methods for the Determination of the Fissures of Rolando and Sylvius. As it is presupposed that the surgeon is familiar with the ordinary terms used in cerebral topography, no explanation of these will be given; he is also supposed to be acquainted with the location of the cerebral sinuses, etc., and only to require assistance in locating the fis- sures mentioned to be able to find any of the cortical centres. 1 Annals of Surgery, vol. v., p. 505. 2 The sharp aspirator needle is unsafe and, as I have found, becomes plugged with brain- tissue. Cliiene uses a pair of small sinus forceps, and other surgeons boldly plunge in a bistoury. 3 Introducing a small amount of ethereal iodoform has been tried successfully. 4 Fenger and Lee, Trans. Amer. Surg. Association, vol. iii., pp. 65 et seq. DETERMINATION OF THE FISSURES OF ROLANDO AND SYLVIUS. Fissure of Rolando. —This starts half an inch behind the mid-point between the glabella and inion, usually running downward and for- ward at an angle of 67° for about 3f inches, the lower third of the fis- sure pursuing a more vertical course; but all skulls are not formed alike, so that the “cranial index” must be found, which is ascertained by dividing the transverse diameter of the head by the antero-pos- terior diameter; thus, if the “cranial index” be 75 the angle of the fissure will be 69°, while the angle will increase one degree for every two degrees of increase in the cranial index, and vice versa.1 In chil- dren the fissure is situated more anteriorly, owing to the relatively smaller size of the anterior cerebral lobes, and in those under nine years the angle may be even as low as 52°. A simple instrument constructed of two strips of parchment paper readily enables the surgeon to mark out this fissure. One strip—from II to 16 inches long—should be graduated in inches and fractions thereof, from the mid-point in both directions; to this is secured—one-half inch behind the middle point—the second strip at an angle of 67°; having as- certained the middle of the biaural line on the shaven scalp, the sur- geon places the long strip in the median line thus ascertained, from the nasion to the inion, moving it until both scales read alike; for in- stance, the graduation should mark at the inion six and one-half inches, and the same at the nasion; the oblique strip is now 55.7 of the whole Fig. 1674. Chiene’s Method of Finding the Fissure of Rolando. distance between these points behind the nasion, and only requires to have its anterior margin marked on the scalp for 3f inches to indicate the fissure. More elaborate cyrtometers may of course be employed, but this suffices. Mr. John Chiene has recommended something even simpler; thus, ascertaining with a piece of string the midpoint between the inion and nasion, folding a piece of note-paper diagonally as indi- cated in the diagram, bringing the point A to 7); now folding back A so that the line A F corresponds to G F and removing the triangle G G" F- unfolding the paper, the line F G' will make with the line F D an 1 For all ordinary purposes 67° may be considered correct. 574 INJURIES OF THE HEAD. angle of 67.5°, since each of the folded segments equals 22.5°; now placing F D along the antero-posterior line in the middle of the head, one-half inch behind the mid-point, the line F G' need only be traced on the scalp to indicate with sufficient accuracy the fissure of Rolando. (Fig. 1674.) Fissure of Sylvius.—As the lower limit of the fissure of Rolando lies about one-lialf inch above the Sylvian fissure, it is often important for this, as well as for other jiurposes, to locate the latter. By causing the patient to alternately contract and relax the temporal muscle while tracing the temporal ridge with the finger, the point where the secon- dary ridge for the attachment of the temporal fascia crosses the coro- nal suture, that is the superior steplianion, can be determined, whence a line must be drawn which shall be perpendicular to the middle of the zygoma; a line drawn from the mid-point of this perpendicular line, passing upward and backward (nearly straight for its anterior half, more curved posteriorly) to within about half an inch of the centre of the parietal protuberance, will correspond to the course of the fissure of Sylvius. There are other methods of determining this,1 but the one mentioned is that which I have myself always employed. The lower limit may be determined by drawing one line from the stephanion to the asterion, and a second passing through the bregma and the exter- nal auditory meatus, their point of intersection being about 1 cm. above the Sylvian fissure and over the lower extremity of the Rolandic fissure. Trephining in Epilepsy. Since this subject will be treated of in another article, the only addition to what I have already said in Vol. V. concerning epi- lepsy resulting from old compound fractures, scars of the brain or membranes, exostoses, etc., is that all scar-tissue in the brain and membranes should.be freely excised as well as the depressed or thickened bone. The possible presence of displaced vessels or of much enlarged veins in these brain scars must be borne in mind. 1 Reid’s method is draw “a line from a point 1£ inch behind the external angular process of the frontal bone to a point f inch below the parietal eminence; the ascending branch of the fissure starts from a point £ inch back from the anterior end of this line and 5 cm. back of the external angular process. ” (Dana, Med. Record, Jan. 12, 1889.) SURGICAL DISEASES OF THE HEAD. BY W. W. KEEN, M.D., LL.D., PROFESSOR OF THE PRINCIPLES OF SURGERY AND OF CLINICAL SURGERY IN THE JEFFERSON MEDICAL COLLEGE; SURGEON TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL AND TO THE ORTHOPAEDIC HOSPITAL AND INFIRMARY FOR NERVOUS DISEASES; CONSULTING SURGEON TO ST. AGNES’S HOSPITAL AND TO THE WOMAN’S HOSPITAL, PHILADELPHIA; MEMBRE COR- RESPONDENT ETRANGER DE LA SOCIETE DE CHIRURGIE DE PARIS, ETC. Since the earlier volumes of this Encyclopaedia were published, itm mense progress has been made in the surgery of both the central and the peripheral nervous system. In this article I shall consider only the surgery of the brain, exclusive of traumatisms. As long ago as 1871, Broca located a cerebral abscess in the speech centre; but modern brain surgery really begins with the modest re- port of a case by Macewen in 1879,1 and with a subsequent paper by the same author in 1881.2 These publications unfortunately, however, at- tracted but little attention, and surgeons were blind to the. opportuni- ties for a great advance until Dr. Hughes Bennett and Mr. Godlee3 narrated a case of sub-cortical tumor of the brain diagnosticated by localizing symptoms alone, and successfully removed. In October, 1886, and April, 1887, Mr. Victor Horsley published4 two most im- portant papers, which had a most important influence both in establish- ing the proper technique of operations upon the brain, and in diffusing a knowledge of its possibilities. In America, Roberts, Amidon, Seguin and Weir, Starr, McBurney, and myself, besides many others, have published numerous articles, which will be utilized in the following pages. In Germany the most elaborate and important paper is von Bergmann’s “Chirurgische Behandlung von Hirnkrankheiten.” 6 In France Lucas Championniere, Chipault, and others have published a number of excellent papers. One fact should be especially noticed: that all of this practical pro- gress would have been impossible had it not been for the quiet but persistent scientific work in laboratories, especially in Germany and England, by Fritsch and Hitzig, Ferrier and Horsley, and many other co-workers. No better argument could be adduced to prove the actual practical value of such scientific laboratory work, and no better induce- ment could be held out to American and other philanthropists for pro- viding such means of research by ample endowments. 1 Glasgow Medical Journal, 1879. 2 Lancet, 1881, vol. ii., p. 541. 3 Ibid., Dec. 20, 1884. 4 British Med. Journal. 5 Archiv f. klin. Chir., Bd. xxxvi. 575 576 SURGICAL DISEASES OF THE HEAD. Technique of Cerebral Operations. We owe the modern technique of cerebral operations principally to Mr. Horsley and Dr. Macewen. The entire head should always be shaved. The loss of part of the hair produces such a grotesque appear- ance that from an aesthetic point of view it is desirable; and for the surgical reason that we must take every means to avoid infection, it is still more desirable to shave the entire head. Moreover this often re- veals unexpected scars. . After the head has been shaved, the patient of course should be protected against taking cold by a silk handkerchief or a cap. Marking the Cerebral Fissures.—The fissures of the brain should then be marked on the shaven scalp by means of an aniline pencil, espe- Fig. 1675. daily the median fissure, the fissure of Eolando, and in some cases the fissure of Sylvius, the fissure of Bichat, and others. The median fissure is easily marked, as it is about an eighth of an inch to the right of the median line, the left cerebral lobe being a little larger than the right. For marking the fissure of Eolando I have used with the best advan- tage Horsley’s earliest cyrtometer (Fig. 1675), as modified by Hr. Mor- ris J. Lewis. This consists of an antero-posterior arm 14 inches long and a lateral arm about 6 inches long. The lateral arm is fixed upon the antero-posterior arm at a point half an inch back of its middle, Horsley’s Cyrtometer as Modified by M. J. Lewis. Fig. 1676. Horsley’s Hater Cyrtometer. at an angle of 67°. The zero point of the scale on the antero-posterior arm is at the middle and is graduated in inches forward and backward. The lateral arm should be graduated for a distance of inches, which TECHNIQUE OF CEREBRAL OPERATIONS 577 will mark the end of the fissure of Ro- lando. In using it, the antero-posterior arm is placed one-eighth of an inch to the right of the median line, and in such a position that the inion and the glabella will each correspond to the same figures on the scale. For instance, if the distance from the glabella to the inion is 13 inches, the reading on the scale, front and back, will be 6£ inches each. The zero point will correspond to the middle of the distance between the two points named, and the lateral arm will start half an inch back of this mid-point. Mr. Horsley has de- vised another cyrtometer (Figs. 1676, 1677), much more elaborate, and so ar- ranged that the angle of the lateral arm can be changed to correspond to very broad or very long heads; but in practice I have found the simple cyrtometer the more easily used, and suf- ficiently accurate. It can be made by any one out of an ordinary piece of stout paper if one of metal is not at hand. Buchanan, of Pittsburgh,1 has devised a simple modification of this, consisting of a triangular piece of aluminium, the radius of which is inches and the angle 67°. . (Fig. 1678.) Another method has been de- vised by Chiene, of Edinburgh, by taking a square of paper and folding it diagonally from the same corner twice, which will divide the apex into four angles of 22i° each. Three of these angles will give us 67£°, and when applied to the head will mark the fissure of Rolando with very fair accuracy. (Fig. 1679.) The fissure of Sylvius begins 1-| inches pos- terior to the external angular process, on a line drawn from this process by the shortest route to the inion. From this it proceeds in a straight line toward and a little below the parietal eminence. The fissure of Bichat runs in a line from the external auditory meatus to the inion. For the location of the|other fissures of the| Fig. 1677. Horsley’s Later Cyrtometer Applied. Fig. 1678. Buchanan’s Cyrtometer. Fig. 1679. 1 Amer. Jour. Med. Sci., July, 1898, p. 20. Chiene’s Method of Fixing the Fis- sure of Rolando. 578 SURGICAL DISEASES OF THE HEAD. brain the reader is referred to the edition of Gray’s Anatomy, edited by myself.1 The day before the operation the head should be shaved anew, if necessary, scrubbed with soap and water, then with ether, then with a sublimate solution 1-2000 only, as stronger solutions are apt to vesicate. A sublimate dressing, the three or four inner layers which are wet with the solution, should then be applied and left in place until the operation, when the disinfection should be repeated. Of course all the ordinary precautions as to thorough cleansing of the finger-nails, hands, and arms of the operator and his assistants, and of the instru- ments and dressings, should be scrupulously carried out. The best position for the patient is the semi-recumbent, in order to diminish hemorrhage. Three points should be marked on the bone: viz., the two ends of the fissure of Eolando and the point at which the centre-pin is to be placed, if the trephine is to be used, the reason for this being that, once that the scalp is raised, the position of the fissure of Eolando and the exact point for trephining are not easily re-deter- mined. The marking of the bone may be done with a small gouge, or with the centre-pin of another trephine, the rongeur forceps or other in- strument serving as a hammer. Access to the Brain.—In very many cases the ordinary operation of trephining will suffice to give access to the brain. As the first step in linear craniotomy, tapping the lateral ventricles, elevat- ing fragments, and numerous other operations on the brain, this will be always the most feasible and favorite method of operating. Where we de- sire simply to get under the bone, as in linear craniotomy and in most cases of fracture, at least the recent ones, a small trephine (half an inch or an inch) will answer the purpose. When, however, access to any considerable portion of the brain is desired, either an inch-and-a-half trephine should be used, or multiple adjacent openings should be made by an inch trephine, the intervening bridges of bone being chiselled or sawn away, or bitten away by the rongeur forceps. If the opening is too small it can readily be enlarged in any direc- tion by the same forceps, of which two forms are here shown. (Figs. 1680, 1681.) Another method, however, has recently obtained great favor, and very justly, from the much larger area of the cerebral surface which it ex- poses, both for determining the fissures and convolutions and for opera- tive attack, and also from the better reestablishment of the integrity of the skull. As long ago as 1863, Wolff " proposed and performed on animals a temporary or osteoplastic resection of the bone. He first ex- Fig. 1680. Luer’s Double Rongeur Forceps. Fig. 1681. Hopkins’ Rongeur Forceps Modified by Weir. 1 Op. cit., p. 681, Philadelphia, 1887. 2 Arch. f. klin. Chir., Bd. iv. TECHNIQUE OF CEREBRAL OPERATIONS. 579 posed the bone covered by the periosteum. Three sides of bone were then chiselled through, the periosteum being divided. The fourth side was chiselled carefully under the periosteum, and the bone was then turned back on the latter as a hinge. To Wagner, however,1 is due the credit of a greatly improved method of temporary osteoplastic resection suggested by Wolff’s experiments. At the desired point an omega- shaped (£) incision is made through the soft parts, directly down to the bone, to which the scalp is carefully left attached. The external table of the skull is then chiselled through, either by ordinary chisels, or, better, by the chisels employed by wood or ivory carvers, which can be had at any good hardware store, or by the special chisels devised by Hartley or Pyle. These, however, I find too long. They should not be over five and a half inches in length, which makes them much more manageable. The diploe having been reached, care should be exercised, in going through the vitreous table, not to wound the dura mater. To this end an osteotome and not a chisel should be used to cut through the inner table. The blows of the mallet, as has been said by Mr. Chiene, should not be rude, forcible blows like those of a carpenter, but rather like those of the sculptor. One or more elevators then being inserted under the edges of the bony flap, the portion of the bone be- tween the two ends of the omega is fractured, and the united flap of bone and scalp is turned downward, the scalp serving as a hinge. Macewen drills or saws the bone along the line of fracture, under the soft parts. This method of operation, however, will be difficult of execution in case the skull is very thick. Fowler’s case2 showed this to be a serious difficulty. Hence I would advise, in all adults, that first of all a small trephine-button (say half an inch) should be re- moved at the summit of the incision, in order to determine what the thickness of the skull is, and whether an osteoplastic resection is feasible. If the skull is over a quarter of an inch thick I would much prefer multiple adjacent trephine-openings, with removal of the inter- vening bony tissue. Otherwise the Wagner-Wolff method is undoubt- edly by far the best method of opening the skull. A bony flap as large as 11 by 9 centimetres has been made by Wagner. When the operation is completed, the bone is simply turned back on its hinge, a bit of it is gnawed away by the rongeur forceps if drainage is to be employed, and the bone is held in place by the ordinary sutures through the scalp alone. Care should be taken not to cut away the margins of the vitreous table, which will project from the under surface of the mar- gins of the opening in the skull, in order that when the flap of bone is replaced it may lie upon them as supports, and not press upon the brain. Before turning the flap back into position the edges of the fractured portion should be freed from any splinters. Dr. Griffin, of Lincoln, Nebraska, has thus avoided serious disaster from the penetration of the dura by such a splinter. When the cranial cavity is opened, the dura may be separated from the bone by Horsley’s dural separator (Fig. 1682). This will en- able the surgeon to examine the inner surface of the skull and to detect irregularities. With care, the little finger may readily be inserted be- tween the dura and the bone—and afterward if need be, between the dura and the brain—and the bone and brain may be examined over a 1 Centralbl. f. Cliir., 1889, No. 47. 2 Med. Record, June 16, 1894. 580 SURGICAL DISEASES OF THE HEAD. large area. As a rule the dura should be opened. The added danger is slight and the additional information may be very great. The open- ing in the dura should correspond to that in the skull, its margin being about a quarter of an inch from the margin of the opening in the bone. Care should be taken not to wound the large veins immediately be- neath the dura, for the sudden loss of a large quantity of blood from the brain induces severe shock and may even produce speedy death. These veins may best be avoided by lifting the dura by rat-tooth forceps while making the first incision with the knife, and then using blunt- pointed scissors. If we have to deal with a tumor which has pro- duced great intracranial pressure, it is often best to make one or more very small incisions in the dura first, and then to enlarge them or not, according to circumstances. Hemorrhage from branches of the middle meningeal artery is best arrested either by haemostatic forceps, by direct ligature at the point of section, or, usually to greater advantage, by pass- ing a ligature through the dura and under the vessels by means of the finest Hagedorn semicircular needle. One of the most troublesome problems in cerebral surgery is hemorrhage from the large vessels in the brain itself. Some of the larger arteries may be directly tied, and this is the best way of arresting the bleeding. The veins, however, are Fig. 1682. Horsley’s Dural Separator. extremely fragile and difficult to secure. Not uncommonly it may be necessary, for either arterial or venous hemorrhage, to pass a small semicircular Hagedorn needle partly through the brain sub- stance and around the bleeding point. The ligature, which should be of non-chromicized catgut, should be tied with great gentleness, care being taken to see that the traction is equal on both ends of the ligature, so as not to tear the fragile vessel. The knot should not be tied too tightly, lest it cut through. Very often hemorrhage from the brain may best be arrested by pressure, either by gauze or sponges, with or without hot water, at from 105° F. to possibly 115°. In hemorrhage from the sinuses, if-the lips of the wound can be seized by hsemostatic forceps, this will quickly arrest the bleeding The forceps may be left in place for from 36 to 48 hours, being entirely enclosed in the dressing to prevent infection. Pressure upon the sinuses, however, or plugging them with iodoform gauze, will usually control the hemorrhage. As the large cerebral veins approach the superior longitudinal sinus, they suddenly broaden into large bays, called the para-sinoidal spaces. These should always be avoided if possible, and if wounded they must be either plugged with iodoform gauze or secured by hsemostatic for- ceps, or occasionally by ligature. After opening the dura, we should first observe whether the brain bulges, and also the amount of the bulging, which is an index to the TECHNIQUE OF CEREBRAL OPERATIONS. 581 degree of pathological increase in the intracranial pressure, due to tumor, abscess, internal hydrocephalus, etc. Next the color should be observed. Lividity, or a yellowish tinge, will probably indicate a tumor. Old lacerations show a dirty yellowish-brown. (Edema of the mem- branes is not uncommon, sometimes to such an extent as to obscure to a great measure the sulci and the convolutions. I once saw it on one side of the brain, of a dense reddish color, caused by bloody serum for which no evident cause was discovered. On nicking the membranes, the serum will escape, and the sulci and convolutions may then be rec- ognized. Absence of pulsation usually indicates a large tumor, abscess, or cyst. The consistence of the brain should always be determined by touch, and the exactness of one’s appreciation of its density by touch grows, of course, with experience. The brain being exposed, we can ascertain the location of any motor centres by faradization. If this is to be done, no antiseptics should be employed after the dura has been laid bare, as they all dull the reaction of the cortex to electricity. Only sponges, or sterilized gauze wrung out of hot water, should be used. Sachs has demonstrated that this faradization and recognition of the motor centres can also be done through the unopened dura. An ordinary faradic bat- tery suffices. The current should be just sufficient to stimulate the thenar muscles. A double brain electrode which I devised some years ago I have found very useful (Fig. 1683). The points should be steril- ized by carbolic acid and the handle wrapped in antiseptic gauze. When the brain is faradized, the face and the four extremities should be uncovered, and one observer asked to note the phenomena in each of these five regions. At the same time the points stimulated by the bat- tery should be determined by exact measurements, taken laterally from the middle line and antero-posteriorly from the fissure of Rolando. A stenographer should be present to record from dictation the observed phenomena rapidly and exactly. Should any centre or centres, or any abnormal portion of the brain, be removed, it should be done thoroughly, and in doing this it must be remembered that it is safe to cut much more freely antero-posteriorly than vertically, since in the latter direc- tion adjacent centres are more quickly encroached upon than by an antero-posterior excision. In ordinary cerebral operations it is best not to drain, but to close the wound completely, leaving if need be a little gap between two of the sutures both anteriorly and posteriorly for the escape of wound fluids. If these accumulate at the end of 24 hours, and sometimes at a later period, a pair of haemostatic forceps or a probe may be inserted between two stitches, and the redundant fluid pressed out. In operations for cysts, drainage is not uncommonly required, and in those for abscesses, gunshot wounds, hemorrhage, etc., it is a necessity. As a rule, rubber tubing is the best. Folded rubber dam is often useful. When the operation is completed, the dura should be sutured by in- terrupted or continuous catgut stitches. The point of the needle should be introduced toward the bone, so as to allow plenty of room for the Fig. 1683. Keen’s Double Brain Electrode. 582 SURGICAL DISEASES OF THE HEAD movements of the needle-holder and the eye of the needle in the open- ing in the skull. Closure of the Opening in the Skull.—If the osteoplastic method of temporary resection of the skull has been used, the method of clos- ing the opening has already been indicated (p. 579). If a trephine button has been removed, however, the technique is different. Fol- lowing the indications of Ollier, Dr. Macewen in his first paper advised that the opening in the skull should be closed by replacing the bone. If the button of hope is to be replaced in one large piece instead of in small fragments it must be most minutely cared for. The surgeon may place it, as I commonly do, in a teacup containing 1-2000 bi- chloride solution, the teacup being placed in a basin which is partly filled with hot water from time to time, and by a thermometer kept at a temperature of from 100° to 105° F. It may also be kept, of course, in a carbolic acid solution, 1-40, or even in warm, previously boiled water. Macewen cut it up into small fragments and laid them on the dura, but this has been found an unnecessary labor and pro- longation of the operation. I have replaced the entire trephine button, an inch and a half in diameter, more than a dozen times, and where it has had suitable care have never once seen it produce the slightest trouble even in adults. In one case where the dura had been removed, I per- forated the button at the centre-pin fossa and passed a chromicized cat- gut stitch through this and around the periphery, and thus sewed it to the under surface of the flap of scalp, with a perfect result. Whether it will be best in many cases to replace the bone is as yet an undecided question. If the bone is diseased it should not be re- placed. In those cases also in which we wish to bring about any change in the intracranial pressure, as for instance in cases of headache and of irremovable tumors, where we operate to relieve the pressure, the bone should not be replaced. In several cases in which I have done secon- dary operations, after a previous trephining or after fracture with loss of considerable bony tissue, I have found the opening closed by a firm fibrous membrane, which would give excellent protection to the brain excepting from sharp, penetrating objects. To protect the brain from such possible accidents I usually cover an oval piece of tin, somewhat larger than the opening in the skull, with silk, and sew it inside a skull cap. In many cases, most commonly from old fracture with large loss of bone substance, it is desirable to close the deficiency by a secondary operation. For this purpose the procedure of Koenig1 is by far the best. In this case a gap, 8 by 5 centimetres, existed in the temporo-frontal region. The scar and fibrous tissue were removed. Then a flap of ad- jacent scalp of similar shape, but a little larger than the opening (to allow for shrinkage) was cut through on three sides down to the bone, but not separated from it. The fourth formed its pedicle. By a rather narrow, small chisel, the outer table of the skull under the flap so out- lined was chiselled loose, becoming of course fractured into small pieces which remained adherent to the under surface of the flap. This flap of scalp and bone fragments was now shifted so as to fill the bony defect, and was sutured into place, the raw surface of diploe from which the flap 1 Central!)!, f. Cliir., 1890, No. 27 TECHNIQUE OF CEREBRAL OPERATIONS. 583 had been chiselled being then covered by Thiersch’s method of skin- grafting. In a case reported by Czerny 1 the subsequent changes in such a bony flap are shown. After closing the bony defect by this method, he was subsequently obliged to do a second operation. On re- flecting the flap of bone with which he had filled the opening, he was gratified to find that there had developed on its inner surface a smooth, bony plate, practically a reproduction of the vitreous table. Titze 2 put this method to its severest test. In a case in which he was obliged to remove the dura mater, when his osteo-cutaneous flap was slid into place, the rough inner surface of the bone came in direct contact with the pia mater. The wound healed, however, by primary intention, and without the slightest difficulty from the rough surface of the bone. The explanation of this is probably to be found in Czerny’s observation just quoted. The most extensive operation of this kind that I have seen reported is by Schonborn.3 In this case there was a large transverse defect on the upper forehead. The scar was extirpated, opening the sub-arachnoid space. A flap of scalp and bone, 6 or 7 centimetres broad and 25 or 26 centimetres long, was formed just posterior to the defect, through the hairy portion of the scalp, by two transverse incisions, the two ends of the flap being its pedicles. This flap was then shifted for- ward, the outer table of bone having been chiselled away with it and transplanted with the flap to its new position. The raw surface left behind the defect was then filled by Thiersch’s method of skin-graft- ing. As by this operation a large part of the forehead was covered by hair, it caused the patient much annoyance. Four months afterward, the scar of the first operation, behind the original bony defect—that is, the skin-grafts—was dissected out, and the flap of scalp which had been displaced to the forehead was dissected loose from the un- derlying bone, which was not disturbed, and was then shifted back to its original position. The bony defect, being found well closed, was then covered in its turn by Thiersch’s method. Besides such filling of defects in the skull by replacing the original trephine button, or by Koenig’s method, other plans have been devised for closing the opening. Thus Ricard 4 filled a defect of 5 by 4 centi- metres, in the frontal bone, by using the hip-bone of a dog and a bit of the femoral condyle. The bone was bared of all its soft parts, includ- ing the periosteum. Three months later no loss of substance was per- ceived. I attempted the same procedure in one case by taking a por- tion of the skull of a lamb, but the attempt was a failure, largely I think from the fact that I did not provide for drainage, and hence the wound fluids accumulated between the soft parts and the transplanted bit of bone, which underwent a harmless necrosis and ultimately was re- moved. In another instance I filled the defect by decalcified ox-bone, but without a favorable result, the decalcified bone becoming absorbed and not replaced by bony tissue. It is probable that in all similar cases the decalcified bone simply forms a scaffolding, on which in many cases fibrous, and occasionally bony, tissue is built. Fraenkel5 proposed to insert a plate of polished celluloid, and after trying it successfully in 1 Verhand. Deutsch. Gesellsch. f. Chir., 1892. 2 Arch. f. klin. Chir., Bd. xlv., 1893, S. 227. 3 Beil. Centralbl. f. Chir., 1891, S. 88, and Verhand. Deutsch. Gesellsch. f. Chir., 1891, S. 225. 4 Gaz. des Hop., 23 Juillet, 1891, p. 785. 5 Centralbl. f. Chir., 1890, S. 821. 584 SURGICAL DISEASES OF THE HEAD. dogs, recommended its use in man. Hinterstoisser1 inserted such a plate on the fourth day after the operation, stitching the periosteum over it, and obtained primary union, with disappearance of the brain symptoms. In discussing this case, Fillenbaum referred to two other successful cases, and von Eiselsberg2 has also reported two cases. One of them was entirely successful after 8 months. In the second case, on the fourth day a clot was discovered under the plate; the latter was removed, and after two weeks was reinserted, with a favorable result two months subsequently. Seydl3 filled a gap of 5 by 4 centi- metres by inserting six or eight pieces of bone and periosteum from the patient’s tibia. The scalp, or the osteoplastic flap of bone and scalp, separated by Koenig’s method, having been replaced and secured by ordinary inter- rupted sutures, best of silkworm gut, an ample sublimate or sterilized dressing should he applied, as there is apt to he considerable oozing after the operation. The dressing is covered with rubber dam and re- tained in place by a wet gauze bandage, then by an ordinary muslin bandage, and, in the case of children, by a night-cap. As soon as the dressing is moistened to its margin by serous or bloody discharge, the wound should be redressed, and attention should be given to the evacu- ation of any retained fluids. If a drainage-tube has been used it should be removed at the encl of 24 or 48 hours, except in cases of abscess or allied conditions, when it must remain for some days. Usually by the fifth or sixth day half the stitches may be removed, and the remainder by the seventh or eighth day. Absolute quietude both of body and mind should be insisted on, especially for the first week. No letters, visitors, or other causes of excitement should be allowed for some time. Al- though less severe restrictions may sometimes he required, yet as a rule this regimen should be enforced for at least two weeks, and occasionally to some extent for months, after such an operation. Secondary Operations.—In these, which are not uncommonly re- quired, the brain, its membranes, and the bone will all be adherent, and must be dissected apart with great care. Some of the brain tissue will of course be torn away, and occasionally more or less decided paresis of the corresponding centres may be produced. After primary removal of a motor centre there is of course entire paralysis of the part supplied by it, and the pressure caused by the blood-clot which accumu- lates after an operation, and by the later cell proliferation, is apt to cause widespread paralysis, sometimes amounting even to hemiplegia. As a rule, after some weeks this disappears to a greater or less extent, leaving the affected muscles, however, somewhat paretic. The same effect may follow a secondary operation, but the paresis or paralysis is apt, I think, to be less pronounced, unless the cerebral traumatism has been extensive. If at either a primary or secondary operation anjT of the dura has been removed, and especially if there has been also removal of any brain substance, there will be a very marked tendency to proliferation of the cerebral tissue, with risk of the formation of a fungus cerebri. Some years ago4 I suggested that this might be prevented, and the loss 1 Wien. med. Presse, Bd. xxxi., 1890, S. 1670. 2 Centralbl. f. Cliir., 1891, S. 926. 3 Ibid., 1889, No. 12. 4 Amer. Jour, of the Medical Sciences, Sept., 1891, p. 227. TECHNIQUE OF CEREBRAL OPERATIONS. 585 of substance in the dura made good, by taking a portion of the peri- cranium from the under surface of the flap in the scalp, turning its osteogenetic surface upward, and sewing it to the dura by interrupted sutures. I have had to do this in two cases, which were perfectly successful. Sometimes when the bone is not replaced there will be great bulging of the flap, due it may be, in some instances, to what might be called a subcutaneous fungus cerebri, together with accu- mulation of the cerebro-spinal fluid. Fig. 1684, taken from one of my patients, shows this to a very marked degree. In a later, similar case, a secondary operation for the removal of a piece of necrosed bone gave me an opportunity to see under the scalp, and thus to verify the fact that the major part of the protru- sion was due to such a fun- gus cerebri, the remaining swelling being due to cerebro- spinal fluid. This emphasizes the need for immediate and entire closure of the scalp wound in cases in which the brain substance has been lacerated either by the original injury or during an operation, in order to prevent an open fungus cere- bri with all its dangers. The limits of our operative procedures are constantly being widened. As has already been mentioned, by the dural separator, the probe, and the finger, a large part of the inner surface of the skull may be explored. The brain may be depressed by the finger, or by a knife-handle or spoon- handle, used with gentleness, and the surgeon can easily see an inch or more beyond the opening. Toward the base of the skull the brain may be lifted, with or without the dura, and the floor of the skull be ex- plored almost to its centre, so that from the front we can discover the anterior clinoid process, laterally the entire anterior and posterior sur- face of the petrous bone, and posteriorly the bone under the cerebellum, while from the exterior also both the finger and the eye can reach the foramen magnum. In several instances I have separated the dura from the skull over the sinuses, so that they could be explored and their condition ascertained. The brain may be punctured almost with im- punity with a blunt instrument, such as a grooved director, so as not to wound the large vessels; and the lateral ventricles may be tapped from almost any direction. Fig. 1684. Bulging of Scalp After Removal of Dura and Brain Sub- stance. Transplantation of Cerebral Tissue.—Salviati,1 Prus,2 and Thompson 3 have experimented on the transplantation of cerebral tissue 1 Wien. med. Presse, 1889, S. 888. 2 Annals of Surgery, vol. ix., 1889, p. 225. ? New York Medical Journal. Jan. 28. 1890. 586 SURGICAL DISEASES OF THE HEAD. from one animal to another with some degree of success. Whether this can ever be done from an animal to man, is doubtful, but further experi- ments in animals are desirable. Abscess of the Brain. Causes.—By far the most common cause of abscess of the brain is suppuration of the middle ear. This is the cause in perhaps 50 per cent, of intracranial abscesses, and will be considered in connection with other intracranial lesions of similar origin. Next to disease of the ear, traumatism is the most frequent occasion of brain abscesses. They arise sometimes even from simple contusions from which recovery may apparently have taken place for weeks or even months or years. Thus Mr. Darner Harrisson 1 has reported a case arising ten years after the injury. Souques2 also reports one arising eleven years after fracture. In a very remarkable case published by Macewen 3 a very large secondary cerebral abscess seemed to have had its origin in an old encysted abscess, the cause of which is not given. The acute abscess had destroyed practically the whole of the temporo- sphenoidal lobe, and involved the third frontal and ascending convolu- tions. After several ounces of pus had been evacuated, the old en- cysted abscess was seen floating like a tennis-ball in the cavity of the secondary abscess. In addition to this, abscesses may arise from exposure to cold, and in at least three cases4 the origin of the trouble seems to have been an attack of influenza. In Clutton’s case there was also thrombosis of the lateral sinus and the internal jugular vein, as well as generalized pyaemia, yet the patient recovered. Schindler5 has also recorded a case following inflammation of the frontal sinus, probably a result of grippe. Treves6 has recorded a case following phosphorus necrosis of the upper jaw. Griffith 7 recites one caused by caries of the orbit. Walton8 reports a very remarkable case, and the first reported, of successful diagnosis and evacuation of a cerebral abscess following fetid pneumonia. Virchow demonstrated the occurrence of these abscesses after gangrene of the lung, and Nathe9 reports cases following pulmo- nary abscess, gangrene, infective pneumonia, pleurisy after wound of the lung, endocarditis, empyema, and bronchiectasis. Occasionally also tubercular abscesses are found in the brain. Pathological Anatomy.—An intracranial abscess may exist be- tween the dura and the skull, extra-dural abscess, which almost always arises from caries of the petrous portion of the temporal bone (vide infra) ; or, secondly, between the dura and the brain, sub-dural abscess; or, thirdly, in the substance of the brain, cerebral or cerebellar abscess. 1 Brit. Med. Journal, Apr. 21, 1888. 8 Gaz. Med. de Paris, 1888. 3 Brit. Med. Journal, 1888. 4 Zeller, Berl. klin. Wocliensclir., 1892, No. 34, S. 869; Clutton, Brit. Med. Journal, 1892, vol. i., p. 807; Williamson, Manchester Med. Chronicle, March, 1891. 6 Centralbl. fur Chirurgie, 1893, S. 24. 6 Lancet, 1892, vol. ii., p. 1349. 1 Manchester Med. Chron., May, 1889, p. 167. 8 Boston Med. and Surg. Journal, Nov. 17, 1892, p. 473 9 Deutsch. Arch, fur klin. Med., Bd. xxxiv., S. 161. ABSCESS OF THE BRAIX. 587 Excepting extra-dural abscess, we have as yet no means of accurately distinguishing these forms during life. If the abscess has arisen from traumatism, it will generally lie under the site of the injury, in which case a scar will commonly be a guide to its location. It may, however, exist on the opposite side of the head, caused by laceration of the brain from contre-coup. Its position should be determined much more by the localizing cerebral symptoms than by the history, or by the scar, which may be at a distance, as for instance in Macewen’s case,1 in which though the cicatrix was on the forehead the abscess existed in Broca's lobe, and as in Harrisson’s case already alluded to. The differential diagnosis between abscesses in the cerebrum and in the cerebellum will be considered under Abscess from Ear Disease. The abscess may contain only a drachm or two of pus, or on the other hand may involve the greater portion of one hemisphere. Intracranial abscesses are commonly single, but in cases of pysemic or tubercular origin they are more apt to be multiple. If of large size they frequently burst into the lateral ventricles. Thus Koerner 2 records that there were 10 instances of rupture into a lateral ventricle in 100 cases of abscess, and in one, rupture into the fourth ventricle. These ruptures are invariably fatal. Symptoms.—The symptoms of intracranial abscess are threefold: 1, Those due to the suppurative process; 2, those due to pressure; and 3, the focal or localizing symptoms. 1. Symptoms due to the Suppurative Process.—The general rule that suppuration is attended with a rise of temperature has its most important exception, as shown by Hulke in 1886, in intracranial abscess, in which, unless the abscess be extra-dural, the temperature is commonly and often constantly either normal or subnormal, even when the patient is desperately ill. Sometimes there is a slight rise at the be- ginning, and again toward the end of the disease there may be a second rise, often accompanied by delirium, only to be followed by another fall and a still later rise if life is sufficiently prolonged; but if the patient is in grave peril, with the ordinary symptoms of intracranial lesion and with a subnormal temperature, abscess should be the first thought in the surgeon’s mind. A chill not uncommonly occurs, but may be absent. The ordinary phenomena of illness, that is, anorexia, vomiting, general malaise, are present. According to Somerville, when there is pus in the brain the urinary chlorides will be below normal in quantity, and the phosphates above. If the abscess is large, possibly peptonuria may exist. 2. Symptoms due to Pressure.—Headache is usually exceedingly severe, so that the patient is constantly moaning. It may be lo- cated over the lesion, but is often either general, or misleading in its position. The pulse, as pointed out by Hulke, is always slow, and may fall even to 30 or 40. The respiration may be Cheyne-Stokes in char- acter. The mind becomes dull, and the apathy may gradually deepen into coma, the bowels and bladder being then evacuated involuntarily. Convulsions of the epileptiform type sometimes occur, but not uncom- monly are absent. Sensation is not generally impaired. Optic neur- itis is not a reliable symptom, excepting perhaps in extra-dural abscess. 1 Loc. cit., p. 303, case i. 2 Arch. f. Ohrenbeilk., Bd. xxix.* 1889, S. 15. 588 SUKGICAL DISEASES OF THE HEAD. When present, it may exist on either one or both sides. It is apt to be most marked on the same side as the abscess, but this condition may be reversed. The pupil on the same side as the lesion is commonly dilated, and more or less immobile, but the rule is not absolute. Marked fluc- tuations in the general condition of the patient often occur. 3. Focal or Localizing Symptoms.—If the abscess exist in the left temporo-sphenoidal lobe, it may compress Broca’s convolution and produce motor aphasia. Paralysis of the levator palpebrse (ptosis), or of the other muscles supplied by the third nerve or the sixth, may be pres- ent. In the Rolandic region abscess may produce paralysis of the op- posite side of the face, or of the opposite arm or leg, according to its situation. Sometimes, if the pus begins low down and creeps upward, the centres will be involved in the order named. If the sixth nerve is involved there will be distinct squint. If the abscess arises in the frontal lobe, from injury or from nasal disease, localizing symptoms are not apt to occur; and the same is true of abscess in the’ occipital lobe, unless the disease involves the cuneus, when blindness of the same half of each retina will occur (homonymous hemianopsia). If the angular or supra-marginal gyrus be affected, there may be monocular Argyll-Robertson pupil, as has been pointed out by Oliver.1 It is doubtful whether the local temperature of the two sides of the head is a reliable guide. Sufficient observations have not been made to determine this point. The left side of the head, it must be remembered, is normally of a somewhat higher tempera- ture than the right. Pressure and percussion may be of value to localize the abscess, but too much reliance must not be placed upon them. According to Ferrier, pain which is not spontaneously com- plained of, but which is elicited by percussion, is of greater value than tenderness on pressure. Differential Diagnosis.—(1) Meningitis.—The diagnosis between abscess and meningitis is often very difficult. Meningitis following traumatism, however, is apt to develop within the first few days, but abscess does not commonly occur before the end of the first week. In meningitis also there is apt to be very early mental dulness, deepening into coma, or oftener, especially at the beginning, actual delirium, with photophobia, contraction of the pupils, high general temperature, and marked stiffness of the muscles at the back of the neck. The or- dinary causes of cerebral abscess also are usually absent. (2) Mastoid disease following suppurative disease of the middle ear will sometimes cause very serious cerebral disorder without producing an abscess. Trephining the mastoid, which should always be done at an early period, will eliminate this factor from the problem. Ordinarily also the symptoms of mastoid disease—oedema, swelling, pain tender- ness, otorrhoea, particularly an otorrhoea of long standing—will be present. It must be remembered, however, that cerebral abscess is not uncommonly a sequence of mastoid disease. (3) Tumor is ordinarily very slow in its development, and, at least in 1 Amer. Journal Med. Sciences, Oct., 1888, pp. 849, 355. By the term “ Argyll-Bobertson pupil” is meant a pupil which is more or less contracted, but in which the iris, although il will vary with accommodation and convergence, will not contract in response to the stimulus of light thrown on the retina. ABSCESS OF THE BRAIN. 589 the motor region and a few others, has distinctly localizing symptoms at an early stage. Abscess, on the contrary, although it may begin long after an injury, when once it has started follows an acute course. Moreover the ordinary causes of abscess, such as aural disease, trauma- tism, pulmonary disorders, etc., will commonly not be present in cases of tumor. Optic neuritis, on the other Hand, is almost always present in tumor, far more frequently than in abscess. Again, the common locations of abscess are either the temporo-sphenoidal lobe or the cere- bellum, but tumors are comparatively rare in these two situations. In other parts of the brain, on the abscess is rare and tumor much more common. The temperature is not apt to rise in tumor, but in abscess is apt to show a prolonged subnormal fall. In syphilis, tumor is much more common than abscess. Treatment of Intracranial Abscess.—Dupuytren, Detmold, More- house, and others evacuated abscesses of the brain many years ago, but the modern surgery of these cases has arisen during the last ten years, since cerebral localization now enables us to diagnosticate, local- ize, and therefore reach such abscesses with comparative accuracy. As soon as the existence and location of an intracranial abscess have been determined, operation should be instantly resorted to, since if let alone all such cases end in death. The operation cannot possibly be more dangerous than the abscess, and although a large number will die on account of the extensive injury attending the lesion, yet every patient is one rescued from the grave. The head should be shaved and disinfected, as described under the head of “Technique,” and the trephining should be done at a point de- termined by the rules of cerebral localization rather than by the scar or the history of the lesion. Of course if there is a fistula discharging pus, this will lead directly to the abscess. The dura having been opened and the brain exposed, it will bulge to a considerable extent through the opening. The normal pulsation of the brain will be absent. To determine where the abscess is we may resort to puncture of the brain. For this purpose the grooved director is the best instrument to use. The hypodermic needle and the knife have both been used, but with either there is considerable danger of wounding the vessels, a danger which with the director is absent. This should be thrust, gently and carefully, straight forward into the brain in the chosen direction, and may safely be introduced to a depth of two or two and one-half inches, unless the abscess be previously reached. If no pus is found, the director should be withdrawn as nearly as possible in the line in which it entered, and a second puncture made in another direction. As soon as the abscess is reached, an incision should be made into it with a knife, and the opening should be enlarged by a pair of haemo- static forceps, which are to be introduced with the blades closed and drawn out with them separated to a proper degree. The sharp spoon should then be used to remove the granulation tissue; but care should be taken not to do any unnecessary damage to the healthy brain. The abscess cavity is next washed out with a boric-acid solution, and a rubber drainage-tube is inserted. The tube should be brought out through an opening in the scalp, and should be secured to it by a stitch. The bone should not be replaced. If the first trephine open- 590 surgical diseases of the head. ing is not suitable for drainage a second should he made, the drainage tube being passed through both openings. An ample dressing should then be applied. As occasion requires, the drainage-tube should gradu- ally be shortened until it can be removed. Sometimes there may be a re-accumulation of pus after apparent healing, when the wound must be reopened, the pus evacuated, and treatment instituted similar to that employed in the first instance. Occasionally such a re-accumulation will occur a long time after the primary abscess. If the diagnosis is well assured and no abscess is discovered by the first trephining, the abscess may possibly be at some other point, and a second and possibly a third trephine opening should be made, in order by no possibility to miss it. Intracranial abscess is necessarily a fatal disease, and nothing should stand in the way of its evacuation if it can possibly be reached. The technique of evacuation of pus in the tem- poro-splienoidal lobe and in the cerebellum, both frequent seats of ab- scess from ear disease, will be considered presently. Diseases of the Brain Arising from Suppurative Disease of the Middle Ear. Anatomy.—If we look into a skull, we will be struck with the fact that the petrous portion of the temporal bone forms a boundary between Fig. 1685. Fig. 1686. Mastoid Portion of Left Temporal Bone Laid Open and Viewed from Behind. A, mastoid cells extending from the mastoid process below, upward and inward over B, the lateral sinus; C, the zygoma. (Burnett.) Section of Mastoid Process Showing the Mas- toid Cells and their Communication with the Middle Ear. the middle and posterior fossae. Its upper edge, along which runs the superior petrosal sinus, forms the crest of a “watershed,” with a moderate declivity forward toward the middle fossa for the temporo- sphenoidal lobe, and a very sharp declivity backward into the posterior fossa for the cerebellum. Again, on the inside of the mastoid portion DISEASES OF BRADST FROM SUPPURATIVE DISEASE OF MIDDLE EAR, 591 of the temporal bone runs a deep groove for the lateral sinus, which terminates in the internal jugular vein. Moreover, a section of the mastoid process and adjacent portion of the petrous part of the tem- poral bone shows that the layer of bone between the tympanum and the middle fossa (Figs. 1685, 1686), and also between the mastoid cells and the groove for the lateral sinus in the posterior fossa, is exceed- ingly thin. It is evident, therefore, that this bone in either of these places may readily become carious and be perforated in disease of the middle ear, and be the cause of thrombosis of the lateral sinus and the jugular vein, or of abscess either of the temporo-sphenoidal lobe or of the cerebellum. Pathology.—Barker estimates that in Great Britain, with only one-half the population of the United States, there are probably 2000 deaths annually from ear disease; and of this number a large propor- tion is caused by the cerebral complications of that affection. Of 43,730 cases of ear disease tabulated by Biirkner, 66.9 per cent, were of disease of the middle ear, and 29 per cent, were of suppurative disease of the same part. Four-fifths of these were chronic cases, and it is among these especially that the brain lesions developed. Koerner 1 showed that in 100 cases of cerebral abscess arising from ear disease, 62 existed in the cerebrum and 32 in the cerebellum, and that in 6 both the cerebrum and the cerebellum were involved. He gives also the following table as to ages:— Age. Cerebrum. Cerebellum. Total. Up to 10 years 12 2 14 11-20 “ 13 9 22 21-30 “ 19 10 29 31-40 “ 11 3 14 Over 40 “ 7 5 12 62 29 91 showing that under 10 years of age cerebellar disease is comparatively rare. This is explained, according to Hartmann, by the fact that the distance of the posterior fossa of the skull from the organ of hearing is greater in children than in the adult. Such abscesses are much more common in the male than in the female, and also much more common in the cerebrum than in the cerebellum, as shown by the following figures (Koerner):— Sex. Cerebrum. Cerebellum. Total. Male 43 18 61 Female 18 12 30 61 30 91 The right side also is more frequently affected than the left in the proportion of 59 to 38 cases, both sides being involved three times. These abscesses will of course lie either near to or next to the bone, that is, will be either in the temporo-sphenoidal lobe or in the cerebellum. Only 7 of Koerner’s 100 cases were situated elsewhere. Naturally it would be presumed that if the discharge from the ear were very fetid it would be more dangerous than if the pus were without any such odor. But Rohrer has shown undoubtedly that non-fetid dis- 1 Die otitische Erkrank. d. Hirns, d. Hirnhaute, und d. Blutleiter, 1894. 592 SURGICAL DISEASES OF THE HEAD. charges are the cause of the most dangerous cerebral complications, because the fetor is due to saprophytic rather than to pathogenic bacilli; many of the inodorous discharges, especially in the case of in- spissated pus often found in the ear (cholesteatoma), are the most dangerous of all, being filled with pathogenic organisms. Very rarely does cerebral disease of any kind follow acute inflam- mation of the ear. Terrillon 1 records a case of cerebral abscess from acute osteomyelitis of the skull. Truckenbrod 2 reports a case from acute otitis, with aphasia, agraphia, dyslexia, and convulsions of the right arm, which entirely recovered after operation. Jansen 3 records a case arising from acute otitis without any discharge. I have recently seen a similar case with Dr. S. MacCuen Smith at the Jefferson Medi- cal College. The absence of external discharge is due to the non-rup- ture of the membrana tympani. Bag insky and Gluck 1 record an acute case following the insertion of a pea into the ear of a boy five years of age. The explanation of the greater frequency of abscess in chronic cases given by Barker, is that in acute cases the mucous membrane lining the tympanum is not destroyed, and the underlying bone therefore is not affected and the disease is not propagated inward, but the deleterious products are adequately carried off by the lymphatics. But in chronic ear disease the walls of the tympanum consist of exposed and carious bone, containing numerous vessels which communicate with those of the dura mater. These cases are especially liable to septic phlebitis, which often leads to intracranial complications. In these chronic cases the disease has to be stimulated afresh before it becomes dangerous, the new infection apparently developing especial virulence. Mr. Barker5 points out that in the course of chronic otorrhoea, which may have ex- isted for years with but little trouble, patients become suddenly very ill immediately after measures have been taken for clearing out the middle ear. The new inflammation apparently is developed by incom- plete cleansing of the septic cavities, thus setting free all the dangerous material which was in the inspissated pus, and which finds a ready opening into the blood-vessels and lymphatics by the breaking-down of the barriers which had previously existed. Hence all such cases should be subjected to a course of most careful antiseptic treatment before operative interference, and the operation should be thoroughly done. Sometimes aural disease produces an abscess at a distance of an inch or two from the inferior surface of the brain, the intervening cor- tex remaining perfectly normal. The explanation, according to Mr. Barker, is that a thrombus extends into the lateral or the petrosal sinus, and from these into the veins of the interior of the brain, especially as these veins have no valves; or, secondly, that the blood-current may be reversed in these veins by reason of the thrombus. Other Cerebral Complications Arising from Disease of the Middle Ear.—These are chiefly meningitis, subdural abscess, extra- dural abscess, cerebral abscess, cerebellar abscess, and thrombosis of the lateral sinus. 1 Ball, et Mem. de la Societe de Chirurgie, Paris, tome xv., p. 555. 2 Archives of Otology, vol. xxi., No. 2. 3 Berl. klin. Woclienschr., 1891. No. 48. 4 Ibid. 6 Hunterian Lectures on Intracranial Inflammations starting in the Temporal Bone, p. 16. London, 1890. DISEASES 6F BRAIN FROM SUPPURATIVE DISEASE OF MIDDLE EAR. 593 (1) Meningitis.—Meningitis following disease of the ear differs in no respect in its symptoms from meningitis arising from any other cause, saving that it is more likely to he localized, and may be more frequently relieved by operation. The differential diagnosis from ab- scess may be made with considerable accuracy by noting the fact that the pain is much sharper and more general in meningitis, especially if it be diffused, while that of abscess is duller and more local. The pa- tient’s mental condition in abscess is marked by hebetude, while in meningitis there is apt to be delirium even early in the case. The tem- perature in meningitis will be very high, with slighter fluctuations than in pyaemia or thrombosis of the lateral sinus, and in marked contrast to the subnormal temperature of abscess. If the meningitis be localized, however, the temperature will probably not be very high, and will fluc- tuate but little; in other words, it approaches that of abscess. The pulse in meningitis will be rapid and of small volume, and often irregu- lar, and in marked contrast again to the slow pulse of abscess. In men- ingitis also the bowels are apt to be constipated while diarrhoea often accompanies the pysemic manifestations of sinus thrombosis. Optic neuritis is not present with such regularity that it can be depended upon as a differential symptom. Photophobia and intolerance of noise, flushed face and contracted pupils, all would look toward meningitis rather than abscess. (2) Subdural Abscess.—If the meningitis be a localized one it may very possibly lead to a subdural abscess, that is, an abscess between the dura and the brain. Two localities are the commonest for such abscesses (Barker). The first, especially in children, is the neighborhood of the petroso-squamosal suture above. The next and most serious is the sulcus lateralis, or groove for the lateral sinus, below. From the first point the abscess may extend into the lateral sulcus, but may also spread upward and backward over the inner surface of the squamous portion of the temporal bone, and may even perforate, first the dura and then the squamous portion of the temporal bone, commonly behind the meatus, when it may be mistaken for an ordinary periosteal abscess; or, as -in a case recently reported by MacCuen Smith, it may burst through the squama in front of the ear, or may burst through the tympanum and drain through the meatus itself. If the subdural abscess form in the lateral sulcus it may escape by the mastoid fora- men, but is more likely to involve the lateral sinus and be followed by fatal thrombosis and pyaemia. But in both varieties there may be produced a widespread septic meningitis, which will lead to death unless the surgeon interfere early. The symptoms of such a subdural abscess will be those of meningitis already described, but in addition to these there may be valuable localizing symptoms, either of convulsions, paresis, or paralysis, involving the face, arm, or leg, according to the location and size of the abscess. Treatment.—In a diffused meningitis it is doubtful at the present time whether operative interference is justifiable, although the ten- dency of surgical practice is rather toward than from operation. But in cases of localized meningitis, especially in that form which leads to subdural abscess, an operation should certainly be resorted to, and it should be both early and thorough. If the diagnosis, as is often the case, is doubtful, in view of the gravity of the prognosis the patient 594 SURGICAL DISEASES OF THE. HEAD. should have the benefit of the doubt by an exploratory operation. Opening the dura, if it has not already been perforated, will prove whether a subdural abscess is present or impending, or not. Mr. Barker, I think, is quite right in proposing that in such cases the trephine should be used over the lower anterior part of what he has well called the “dangerous area.” This is a circle with a one-and-a- quarter inch radius, with its centre an inch and a quarter behind and the same distance above the middle of the external meatus. After ex- posing the dura and opening it, the state of the serous surfaces will determine whether any further steps should be taken or not. If menin- gitis of the more plastic form be present, Mr. Barker recommends that several circles of bone should be removed in order to cleanse and drain the surface of the brain thoroughly. But in those cases in which there are definite localizing symptoms, the spot indicated by these symptoms should be reached by puncture. The most remarkable illustration of this is in an admirable case reported by Mr. Barker,1 in which he evacuated an ounce of odorless pus from the fissure of Sylvius, next to the island of Beil, with the happiest result. The cavity of the abscess may be irrigated, and drained or not, according to the conditions found. (3) Extra-Dural Abscess.—In these cases the abscess almost always arises as a result of caries of the petrous bone after disease of the ear. Here the question of diagnosis, especially the differential diagnosis from subdural abscess and thrombosis of the lateral sinus, is a mat- ter of great difficulty. The temperature, however, will usually dis- tinguish extra-dural from cerebral or cerebellar abscess, as in the former it rises to from 102° to 104° F. The pain is usually fixed above and behind the ear, with marked tenderness on percussion and pressure in the same region. Not uncommonly also there is oedema of the scalp. There may be sometimes choked disc and symptoms of cerebral pressure if the abscess reaches any considerable size. Many years since2 I re- ported a remarkable case in which the entire petrous bone became necrotic and was removed. The carotid must have been obliterated. All the special senses except touch were destroyed, and the child was reduced to an idiotic condition. (Fig. 1687.) Treatment.—The mastoid will probably already have been opened, but if not, this should be done immediately. If there is a fistula from rupture of the abscess through the bone, this will lead to the abscess. Trephining should be done at the same point as already indicated, and the dura mater should be laid bare, care being taken, of course, not to wound the lateral sinus. If this should be involved, it should be treated as pointed out below. The abscess cavity having been reached, should be irrigated with an antiseptic solution and curetted, any necrosed or carious bone should be removed, and free drainage should be provided. Bircher 3 relates a remarkable case in which he chiselled away all the necrotic petrous bone except the carotid canal, and saved his patient. Hoffmann 4 gives a table of 102 fatal cases in Fig. 1687. Necrosis of Petrous Bone. 1 British Medical Journal, 1888, vol. i.. p. 771. 2 Philadelphia Med. Times, June 15, 1871. 3 Centralbl. fur Cliirurgie, 1898, S. 482. 4 Deutsche Zeitschr. fur Chirurgie, Bd. xxviii., S. 484. DISEASES OF BliAlX FROM SUPPURATIVE DISEASE OF MIDDLE EAR. 595 which the diagnosis was only made after death. He tabulates 10 other •cases in which the diagnosis was made during life, in which 8 patients recovered after operation. No comment upon such figures is necessary. (4) Cerebral Abscess.—-Nine-tenths of all cerebral abscesses lie again in the “dangerous region.” They are more commonly encapsulated than diffused. In 100 cases reported by Koerner,1 62 occurred in the cerebrum, 32 in the cerebellum, and 6 in both. Diagnosis.—The otitis which causes cerebral abscess is almost always chronic. In 57 cases reported by Pitt,2 only two had existed for less than a year. There is usually a sudden cessation of the dis- charge, with an initial rise of temperature, nausea and vomiting, and dull pain in the mastoid region, radiating to the temples and the neck. The pulse becomes rapid, the tongue coated, and very often there is diar- rhoea. All this points to an acute septic infection engrafted on a long existing saprogenic suppuration. The headache or tenderness is often general, or frontal, and not located at the site of the lesion. After the initial rise the temperature falls to the normal, or more commonly be- comes sub-normal. The pulse becomes very slow, often falling to 30 or 40. The intellect becomes dull and sluggish and the hebetude gradually deepens into coma. The bowels are apt to be constipated, the breath fetid, and the skin muddy, while rapid emaciation is a marked symptom. Optic neuritis is of value if present, but is often absent. The localizing symptoms, as shown either by localized convulsions, paresis or paralysis, aphasia, etc., if present, are of the greatest value. The state of the pupil is not commonly a reliable symptom. The contents of these abscesses vary much in character, being in some cases a thick, greenish, and exceedingly fetid pus, and in others a thin, pale, odorless fluid, which is scarcely purulent. Differential Diagnosis behveen Cerebral and Cerebellar Abscess. —The distinction between these is extremely difficult, but equally im- portant, if it can be made, since upon it depends whether we shall tre- phine and explore the temporo-splienoidal lobe or the cerebellum. In case the diagnosis cannot be made with reasonable certainty it is always best to explore first the temporo-splienoidal lobe, and, if no abscess is found, then immediately to explore the cerebellum. Possibly tender- ness on percussion over the site of the abscess may guide us, although spontaneous pain is of very little worth. A'ertigo is apt to be present in both conditions, but the want of co-ordination in cerebellar cases is rarely present, and from the mental hebetude and bedfast condition of the patient its presence often cannot be ascertained. Optic neuritis may be present in both forms. Disturbances of speech are of the greatest importance, since they point definitely to the third frontal con- volution, usually on the left side in right-handed persons. Similarly hemiplegia would point distinctly to the motor area of the cerebrum rather than to the cerebellum. Koerner mentions crossed facial paralysis as present in 2 out of 100 cases of cerebral abscess, but it was also present in one case of cerebellar abscess. Facial paralysis on the same side as the diseased ear is no indication of localizing value, since it is caused by a direct lesion of the seventh nerve as it passes through the aqueduct of Fallopius of the diseased ear itself, and has no relation to the cerebral or cerebellar abscess. 1 Arch, fur Olirenheilkunde, Bd. xxix., S. 15. 2 Brit. Med. Jour., 1890, vol. i., p. 648. 596 SUKGICAL DISEASES OF THE HEAD. Treatment.—The treatment m many respects is the same as that already indicated for brain abscess in general, but there are some special indications of importance. Mastoid Operations.—In an}7 case of long-standing disease of the ear, if persistent headache, vomiting, or mental dulness occur, with- out any permanent rise of temperature, the external meatus should first be thoroughly cleansed antisepticallv, and then the mastoid should he opened by a longitudinally curved incision posterior to the ear, from the base of the mastoid to its tip. The mastoid antrum and the mas- Fig. 1688. Surface Guides for the Sigmoid Sinus and the Supra-Meatal Triangle (Mace-wen). The three artificial lines drawn upon the skull indicate the following: (1) The short vertical line from the posterior border of the external auditory meatus to the posterior root of the zygoma marks the base of the supra-meatal triangle. The broken line indicates the anterior border of the supra-meatal triangle. The third side of the triangle is the root of the zygoma. The broken line also indicates the course of the facial nerve. (2) The second vertical line, extending from the parieto-squamo-mastoid junction to the tip of mastoid, in the upper two-thirds of its length indicates the position of the sigmoid sinus (the curved portion of the lateral sinus). (3) The oblique line, passing from the asterion to the upper limit of the external auditory meatus, indicates in its posterior two-thirds the sigmoid sinus from its commencement to its knee or bend. toid cells should be thoroughly opened by the gouge and chisel, and the posterior wall of the meatus itself should he chiselled away to the cavity of the middle ear. In order to reach the mastoid antrum, an opening should be made one-third or one-half an inch behind, and the same distance above, the centre of the meatus. The mastoid cells lie between the antrum and the apex of the mastoid. All the inspissated pus found should he removed by a sharp spoon or with the gouge, DISEASES OF BRAIX FROM SUPPURATIVE DISEASE OF MIDDLE EAR. 597 care being taken, of course, not to wound the lateral sinus and also not to go so deep as to injure the facial nerve. The anfestlietizer should be notified to watch for any twitching of the facial muscles, and to warn the operator of his proximity to the nerve as shown by this symptom. The nerve is not commonly encountered. As an antiseptic, up to this point, the ordinary 1-1000 sublimate solution may be used, and the cavity may be lightly packed with iodoform gauze. Macewen 1 has called attention to what he has denominated the supra-meatal triangle. (Fig. 1688.) This triangle is bounded above by the root of the zygoma; in front by the posterior wall of the meatus, and posteriorly by a line uniting these two. In most skulls (about 94 per cent.) as soon as the bone is bared, this triangle is perceived as a shallow depression. The antrum always lies within this triangle, and the sigmoid sinus, that is, the curved part of the lateral sinus, always lies posterior to it. If these operative measures do not soon relieve the symptoms, and especially if the hebetude deepens and if localized convulsions or paralysis occur, with rapid emaciation, subnormal temperature, and Fig. 1689. Landmarks for Incision for Abscess of Brain, aa. Reid’s base line; c, point at which to trephine for abscess of the temporo-sphenoidal lobe 1J4 inches behind the meatus and 1J4 inches above Reid’s base line; i, foramen for mastoid vein; o, point of trephining to reach cerebellum; x, site of mastoid antrum 34 inch behind and above external auditory meatus. (Barker.) slow pulse, it is almost certain that the condition has gone beyond mere mastoid disease, and that an abscess has been developed. This, if in the temporo-sphenoidal lobe, is best reached by applying a half- inch trephine at a point an inch and a quarter behind the external auditory meatus and an inch and a quarter above Reid’s base line, which is a line drawn from the inferior border of the orbit through the middle of the external meatus. This is the point chosen for trephining by Barker (Fig. 1689, c), and has the advantage that if no abscess be found, it is far enough away from the ear and mastoid to be protected from septic infection. The dura having been exposed, it should he opened by a crucial incision. If an abscess is present the probabilities are that the brain will bulge and not show any pulsation. A grooved director should next be inserted in the axis of the temporo-sphenoidal 1 Pyogenic Infective Diseases of the Brain and the Spinal Cord. 598 SURGICAL DISEASES OF TIIE HEAD. lobe, which is, as I have shown,1 downward, forward, and inward, in the direction of the opposite wing of the nose. If this puncture is futile several other punctures may be made in suitable directions, as multiple punctures do but little damage, and, compared with that caused by an abscess, none whatever. When the abscess is found, the cavity should be treated as already described. It is always well in these cases to explore the opening for the mastoid vein (Fig. 1689, i), which lies about an inch back of the mastoid process. If pus is found oozing from this opening, as the vein empties into the lateral sinus, it is certain that there is pus in the groove for the lateral sinus, and the latter should then be well exposed by the rongeur, gouge, and chisel. The treatment of the sinus is described below. (5) Cerebellar Abscess.—The differential diagnosis of cerebellar abscess has already been given. The general diagnosis is very much the same as that for cerebral abscess, saving that choked disc is very rarely present and that the temperature is apt to be high from compli- cations. If present, the abscess is apt to be situated in the anterior part of the lateral lobes, where they are in contact with the petrous bone and the groove for the lateral sinus. Treatment.—The cerebellum may be reached at a point midway be- tween the mastoid and the inion, and sufficiently far below the line from the meatus to the inion, which corresponds to the lateral sinus, to avoid wounding the sinus. (Fig. 1689, o and x.) A semilunar in- cision should be made with convexity ujfward, the occipital bone exposed at the selected point, and then either trephined or opened by means of the chisel, which is preferable both from the irregularity as well as from the lessened thickness of the bone. In children a simple gouge will penetrate the skull very readily and the rongeur will enlarge the opening at will. If the cerebellum bulges and pulsation is wanting, it is almost certain that an abscess is present. Not only the lobe of the same side on which the opening is made can be reached by the grooved director, but the opposite lobe can be explored by an oblique puncture. Care should be taken not to injure the superior vermiform process. (6) Thrombosis of the Lateral Sinus.—One of the most brilliant chapters relating to the cerebral complications of ear disease is the modern treatment of thrombosis of the lateral sinus. It is only since 1884 that this condition has been diagnosticated during life and treated with success. The frequency and the danger of the disorder can be appreciated from the statement that Mr. Ballance estimates that in London alone there is from this cause one death a week, and that Pitt2 says that in 20- years at Guy’s Hospital, in 57 autopsies of those dying from ear disease, 22 showed thrombosis of the lateral sinus, in more than half it was sup- purating, and in 11 cases the thrombus extended into the jugular vein. In all of these pulmonary infection existed. In 4 cases the thrombus extended into the longitudinal, and in 3 into the opposite lateral, sinus. The proximity of the lateral sinus to the mastoid and the thin layer of bone separating it from the mastoid cells and antrum have already been alluded to. (Figs. 1685, 1686, p. 590.) Symptoms and Diagnosis.—As in other complications .of aural dis- 1 Buck’s Reference Handbook Med. Sciences, vol. viii., p. 216. 2 Brit. Med. Journal, 1890, vol. i., p. 648. DISEASES OF BRAIN FROM SUPPURATIVE DISEASE OF MIDDLE EAR. 599 ease, there may have been a chronic otorrhea. But it must not be for- gotten that if the membrana tympani is intact there will be no dis- charge from the ear, and yet cerebral pyaemia and sinus thrombosis may follow the otitis media and destroy life. Pitt1 says that in 9 cases out of 57 (16 per cent.), sinus thrombosis without external discharge from the ear was the cause of death. In either case an acute illness arises, characterized by headache, pain in the region of the sinus, distinct and repeated rigors, sweats, and violent oscillations of temperature; in other words, all the ordinary evidences of pyaemia which would natur- ally be expected to follow a septic thrombus in so large a venous sinus. Usually there will be tenderness and oedema over the mastoid, with ten- derness over the sinus itself, that is, in a line from the external auditory meatus to the inion. Bennett2 has called especial attention to what he deems a pathognomonic symptom, viz.: tenderness over the mastoid vein (Fig. 1689, i), and has termed it “post-mastoid tenderness.” It ex- ists even when there is no tenderness over the mastoid itself. In addi- tion to this, as has already been mentioned, since the thrombus often extends still farther in the direction of the blood-current into the inter- nal jugular vein, tenderness and other inflammatory manifestations will be found also in the neck in the course of that vein, that is, along the anterior border of the sterno-cleido-mastoid muscle. In consequence of the formation of the clot, the vein will be felt as a tense and tender cord, unless, as often occurs, a periphlebitis has developed, which will cause a more widespread brawny hardness. In some cases, indeed, the vein is entirely destroyed, and there may be developed an abscess in the neck. In one of Bennett’s cases3 the wall of the jugular vein was broken down, and the abscess communicated with the lumen of the vessel. In my own case the vein was recognized with great difficulty, being almost lost in the matted tissues of the neck. Shield4 reports a case of thrombus extending into the veins at the root of the nose, and Lanciol5 two cases of thrombosis of the cavernous sinus. Choked disc is almost invariably present in sinus thrombosis. Care must be taken not to mistake the disease for typhoid fever, especially as there are often severe headache and otorrhea in the early stages of that affec- tion. The violent oscillations of temperature and choked disc in sinus thrombosis, the different prodromata, and the abdominal symptoms and rose spots in typhoid fever, will afford the means of differential diagnosis. Not only may there be thrombosis of the lateral sinuses, but occasion- ally the petrosal and the cavernous sinuses are involved. Thrombosis of the former has no local symptoms by which it can be determined, but in the case of the latter, from the thrombosis blocking the ophthal- mic vein, there may be hyperaemia of the retinal veins with extensive oedema of the frontal veins and lids, and exophthalmos from retro- bulbar oedema. From the pressure on the nerves in the cavernous sinus we may have also neuralgia of the first division of the fifth nerve, and paralysis of the abducens (sixth), patheticus (fourth), or motor oculi (third) nerve. But any one or even all of these local symptoms may be absent. Occasionally also there may be a true pyaemia without thrombosis of any of the sinuses. 1 Loc. cit. 2 Lancet, 1893, vol. ii., p. 619. 3 Loc. cit. 4 Archives of Otology, vol. xxi., No. 7. 5 Centralbl. f. Cliir., 1892, S. 238. 600 SURGICAL DISEASES' OF THE HEAD. Treatment.—In 1SS0 Zaufal1 was the first to suggest the proper treatment of this, until then, almost uniformly fatal disease, and he was the first to carry it into effect in 1884. (See table.) In 1886 Horsley2 Thrombosis of the Lateral Sinus. Author. Reference. Recov. Died. Total. Zaufal Prag. med. Wochen., 1884, 474 and, 1891, Ko. 28 1 1 Hoffman Deutsch. Zeitsclir. f. Chir., 1888, xxviii. 484... i 1 Orlow Deutsch. med. Wochen., 1889, 193 1 1 Ballance Lancet, 1890. i., 1057 2 2 4 Keen Times and Register, Dec. 20, 1890, 559 1 1 Salzer Wien. klin. Woch., 1890, iii., No. 34 1 1 2 Keetley Lancet, 1890, i., 1116 * 1 1 Moos Arch. Otol., 1890, xix., 163 i 1 Scliwartze Handb. der Olirenheilk., ii., 1890, 844 2 2 4 Makins Lancet, 1891, i.. 1259 2 2 Weigel Zur Patliog. u. Therap, d. Tliromb. des. Sinus. Transv. Jena, 1891 1 • 1 2 Poulson Nordiskt medicin. Arkiv, 1891, xxxiii, 45 1 1 Hansberg Monatschr. f. Olirenheilk., 1892, Nos. 1 u. 2.. 1 1 Politzer Laurent, Intervention Chirurgicale dans les lesions du Cerveau, 1892 1 1 Parker Liverpool Med.-Chir. Jour., 1892, xii., 86.... 1 i 2 Glutton Brit. Med. Jour., 1892, i., 807 1 1 Lane Lancet, 1892, ii., 1044 i3 1 Pritchard. Lancet, 1893, i., 471 i 1 Parkin Lancet, 1893, i., 522 2 2 Shield Arch, of Otology, xxi., 3 l 1 Lane Brit. Med. Jour., 1893, ii., 561 8 2 10 Jones Brit. Med. Jour., 1893, ii., 563 1 1 Bennett Lancet, 1893, ii., 619 i 1 2 Beck Pathol, u. Chir. des Geliirns., 1893, 26 und 29. 2 2 Forselles Eitrige Mittelolirentzundung von Lateralsinus- Thrombose, 1893, ii., 118 3 3 Macewen Pyogenic Infective Diseases of the Brain and Spinal Cord, 1893, 332 161 4 20 Ballance Brit. Med. Jour., 1893, ii., 1274 1 1 Vickery Brit. Med. Jour., 1893, ii., 1144 1 1 Scott and Lane .... Lancet, 1893, i., 138 1 1 Sonnenberg Centralbl. f. Chir., 1893, 443 1 1 Bircher Centralbl. f. Chir., 1893, 483, .. . 1 1 Buck Med. Record, June 30, 1894, 810 1 1 Griinert Centralbl. f. Chir., 1894,211; from Arch. f. Olirenheilk., xxxvi 1 1 Clegliorn Brit. Med. Jour., 1894, i., Epit., 70 1 1 Schwabach Brit. Med. Jour., 1894, i., Epit., 57 i 1 Crockett Med. Record. June 9, 1894, 741 1 1 Miller Brit. Med. Jour., 1894, ii., 71 1 1 Herczel Wien. Med. Woch., 1894, No. 98 1 1 Walker Lancet, 1894, ii., 1160 1 1 Milligan & Brown.. Lancet, 1894, ii., 1427 1 1 Walker Brit. Med. Jour., 1895, i., 806 1 1 Milligan Lancet, 1895, i., 984 2'2 2 58 28 86 1 Three of these were cases of thrombosis of the longitudinal and not of the lateral sinus. 2 One of these was a case of thrombosis of the cavernous sinus, secondary to ear disease. 3 Not apparently included in the 10 cases in the British Medical Journal, i893, ii., 561. urged the same treatment anew. These suggestions soon bore abundant fruit. Mr. Arbuthnot Lane3 reported a case of rapid recovery fol- 1 Prag. med. Woch. 3 Brit. Med. Journal, 1889, i., 997. 2 Trans. Clin. Soc., vol. xix., p. 255. DISEASES OF BKAIX FROM SUPPURATIVE DISEASE OF MIDDLE EAR. 601 lowing Horsley’s mode of treatment, and has since reported 10 such cases operated on, with 8 recoveries1 while Ballance2 reported I cases with 2 recoveries. Other cases have been recorded by various sur- geons, and, as far as I have been able to collect them by a fairly thorough search, are included in the preceding table. My own case,3 Buck’s, and Crockett's are, I believe, the only cases thus far reported in American medical literature. I can only attribute this to the fact that the condition has been unfortunately overlooked. This makes a total of 86 cases with 58 recoveries and 28 deaths, a mortality of less than one-tliird. This is a most encouraging result when we remember that the operation is so recent, and that without operation every patient would have died. Treatment.—This cannot be too prompt or too thorough. Imperfect operations in which the lateral sinus is exposed but not opened, such as some of those of Hansberg,4 Chauvel,5 and others, should not be practised Fig. 1690. Lateral aspect of skull showing relation of lateral sinus to outer wall of cranial cavity and position of trephine opening (a). 1 inch behind bony meatus and 14 inch above Reid’s line. Reid’s base line from lower border of orbit through middle of external meatus is made to a scale of 8ths of an inch, as are also the lines perpendicular to it. (Rol.) lower end of fissure of Rolando; XX sight of tentorium, in part. The anterior X shows the point where the tentorium leaves the side of the skull to be attached to the superior border of the petrous bone; (c) corresponds to mastoid antrum, ]/> inch behind meatus and 14 inch above Reid’s base line; (b) trephine opening % inch above meatus, to explore anterior surface of petrous bone: (d) trephine opening for temporo-sphenoidal abscess, 114 inches behind meatus and 114 inches above Reid’s base line; (e) trephine opening for cerebellar abscess, 1}4 inches behind meatus and 14 inch below Reid's base line. (.Ballance.) in view of the later and better results from more thorough operations. The mastoid antrum and often the cells also, if not already operated on, should be opened and cleansed. Next the lateral sinus should be exposed, either by the chisel or the trephine, at a point one inch behind and a quarter of an inch above the middle of the external auditory meatus (Fig. 1690, a). The opening may be enlarged either by the rongeur or by the chisel and gouge. Pus will very likely be found in the groove for the sinus. If this be the seat of thrombosis it will feel hard to the touch. If no thrombus has formed it will be soft. In either case, if the symptoms warrant it, the sinus should be incised. If no thrombus is found the blood will of course escape profusely, but may be instantly arrested by the finger. Strips of iodoform gauze should 1 Brit. Med. Journal, 1893, vol. ii., p. 561. 2 Lancet, 1890, vol. i., pp. 1057-1114. 3 Med. Times and Register. Dec., 1890, p. 559. 4 Ann. des Mai. de VOreille, etc., 1892, p. 1. 5 Centralbl. f. Chir., 1893. S. 236. 602 SURGICAL DISEASES OF THE HEAD. have been provided, and the sinus should be immediately plugged with them. If a clot is found it will be apt to be excessively foul, and the sinus must be freed from this septic mass by a small spoon or cu- rette. The sinus should then be disinfected thoroughly. This cleans- ing and disinfection may have to be extensive. To do any good it must evidently be coextensive with the infected and infecting clot. We must therefore continue to curette the sinus until free hemorrhage shows that all the clot has been removed. Packing of the sinus after its free disinfection will easily arrest the bleeding. Parkin1 boldly but wisely curetted as far as the torcular Herophili and saved his patient. In one of Ballance’s cases2 the lateral sinus came away as a slough. It must be remembered that one sinus may be the seat of thrombosis as far as the torcular without involving that of the oppo- site side, since the two lateral sinuses are not usually continuous. The right sinus at the torcular is usually continuous with the superior longitudinal sinus, and the left with the straight sinus, while a separate sinus or a small cross branch connects the two lateral sinuses. In St. Thomas’s Hospital Museum is a skull with a groove for the sinus on only one side (Ballance). This cleansing of the sinus, it must be re- membered, can do no harm, since the blood current is already arrested by the existing clot, the circulation being carried by other venous channels. Sometimes ligation of the sinus would be proper. The internal jugular vein should next be exposed in the neck and ligated at a point below the thrombus, the extent of which can usually be determined by touch. This step is of the greatest importance, as, if done sufficiently early and sufficiently low down, it will prevent ex- tension of the clot into the lungs. This involvement of the lungs is the greatest danger which threatens the patient. If they become in- fected the case is hopeless. The vein should then he cut above the ligature and the upper end should be attached to the skin, the vein and the sinus being washed out as thoroughly as possible in order to arrest the septic process. Tumors of the Brain. Until 1885 no attempt had been made accurately to locate or remove a tumor of the brain. Prior to that year the diagnosis of the presence of a tumor was fairly clear in most cases, but to locate it exactly was (and unfortunately in many cases still is) difficult and uncertain, and its removal was regarded as impossible. When, therefore, Bennett and Godlee;i reported that they had successfully located and removed a tumor not visible on the cerebral cortex, the surgical world was startled. Since then a large number of tumors have been removed, a considerable number sought for and unfortunately not found, and several found and not removed. Of the patients from whom brain tumors have been re- moved over two-thirds have recovered. Causes.—The causes of tumors of the brain are as a rule unknown. A number of cases have been reported in which injury has been the pre- 1 Lancet, 1893, vol. i.. p. 522. 2 Ibid., 1890, vol. i., p. 804. 3 Med. Cliir. Trans., 1885, vol. Ixviii., p. 243. tumors of the brain. 603 sumptive cause. This usually gives rise to sarcoma, and more rarely to fibroma. In this country parasitic tumors of the brain, echinococcus or actinomycosis, are rare, although in Australia and Germany a con- siderable number have been reported, 88 cases by Kuchenmeister alone. Pathological Anatomy.—The largest statistics as to the frequency and variety of brain tumors in children and in adults are those given by Starr,1 who has collected 300 cases in either category. Starr’s Table of 600 Brain Tumors—300 in Adults and 300 in Children. Situation. O cn P c Glioma- tous. Sarcoma- aj P o Glio-sarco- matous. Cystic. Carcino- Sfi p O 5 Gumma- tous Not Stated. Total. i I.—Cerebral axis. 1. Basal ganglia and lateral veil- tricles 14 3 3 9 5 8 1 1 1 2 1 3 5 27 29 2. Corpora quadrigemina and crura cerebri lfi 1 1 2 3 0 5 1 1 21 18 3. Pons 19 11 10 5 1 o 1 1 2 3 1 38 18 4. Medulla 2 i 1 9 1 6 1 5. Base 3 2 i 3 i 1 1 1 4 1 8 10 6. Fourth ventricle 1 1 i 1 1 2 1 1 5 4 II.—Cerebellum 47 8 15 8 10 13 i 6 9 3 11 10 96 45 III.—Multiple tumors 34 4 2 3 5 2 2 1 3 3 1 43 17 IV. — Cortex cerebri 13 9 6 19 1 46 8 1 1 19 13 12 21 127 V.—Centrum ovale 6 o 111 5 7 i 4 i5 1 3 i 5 4 35 31 152 41 37 54 34 i 86 5 25 30 2 10 311 1 2 20 30 41 300 300 The first columns are children’s tumors, the second columns adults’ tumors. The table of Seguin and Weir, taken from Hale White and Bernhardt, gives percentages of the characters of the various tumors:— Seguin' and 'Weir’s Table of 580 Brain Tumors Number. Per ceut. Nature of tumor not stated 133 22.9 Tubercular tumors 13-7 23.0 Gliomata 76 13.0 Sarcomata (including cysto-sarcomata) 75 13.0 Hyaatids, cysticerci, echinococci 30 5.0 Cysts 27 4.6 Carcinomata 24 4.0 Gummata 21 3.6 Glio-sarcomata 14 2.2 Myxomata (including myxo-sarcomata) 12 2.0 Osteomata 6 + 1.0 Neuromata 4 - 1.0 Psammomata 4 - 1.0 Papillomata. 4 - 1.0 Fibromata . ... 3 Cholestomata 2 Lipomata 2 Erectile or vascular tumors 2 Dermoid cysts 2 Enchondromata 1 Lymphomata 1 Cases 580 1 Brain Surgery, p. 202. 604 SURGICAL DISEASES OF THE HEAD. It will be observed on comparing these tables that the tubercular tumors in Starr’s table are 193 out of 600, nearly one-third. In the other table they are 137 out of 580, or 23 per cent., the larger percent- age in Starr’s table being due to the greater preponderance of tuber- cular tumors in early life, they being nearly four times as frequent in children as in adults. The proportion of the gliomata is not far from the same in each, and the percentage of sarcomata in Starr’s table is slightly greater than in the other. It will be observed again on taking tubercular tumors, gliomata, sarcomata, and the glio-sarcomata to- gether, that they constitute 43d out of the 600 in Starr's table and 302 in White and Bernhardt’s table, which comprises 447 tumors of known character and 133 of unknown histology. The enormous proportion, therefore, of tubercular and the various kinds of sarcomatous tumors is very evident. Hence the presumption is in general greatly in favor of one of these two kinds of tumor being present. In childhood the pre- sumption is in favor of either tubercular or gliomatous tumors; whereas in adults the sarcomata number far more than other varieties. Starr has recently called attention to the singular fact that so few gummata have been recorded in literature, and says that his impression, derived from clinical experience, is that gumma is the most frequent form of brain tumor occurring in adults. My impression is that this is going much too far, but that undoubtedly the number in Starr’s table is proportionately far less than that of the gummata which are seen clinically. Inasmuch as they are influenced by speciflc medication, and are often either entirely cured or diminished to such an extent as to become innocuous, they rarely come either to operation or to the post- mortem table. This to a great extent explains their absence from sta- tistics. Statistics are often misleading, and apply only in a general way to any individual case, but yet they are of value as establishing a presump- tion. Given, for instance, an adult who has had an injury and is free from syphilis and tubercle, and the probabilities are very strongly in favor of sarcoma, or its congener glioma. If there be sarcoma in any other organ and marked cachexia, the presumption will be strongly in favor of a metastatic sarcoma of the brain. Or if there have been evidences of late secondary or of tertiary syphilis and no injury, the chances will be strongly in favor of gumma. Again, in a child, without injury, with an hereditary predisposition to tuberculosis, and especially if any other form of tuberculosis be present, the presumption is strongly in favor of a tubercular tumor, especially if there are any evidences pointing toward more than one tumor, or of a tumor in the cerebellum. If the tumor be a very vascular glioma, there ma}T be sud- den changes in the intensity of the symptoms, accompanied possibly by attacks of epilepsy of moderate degree, due to hemorrhage. Von Bergmann has taken decided ground against attacking tuber- cular tumors, on the ground that it is impossible to remove them thoroughly. Horsley, whose opinion always carries double weight, is decidedly in favor of removing them, and Starr rightly favors attack- ing them just as the surgeon attacks a tubercular joint or a tubercular testicle. In gummata both Hale White and von Bergmann have op- posed operation. On the other hand, Horsley, Seguin, and Starr are rightly in favor of their removal after the failure of specific treatment. TUMORS OF THE BRAIN. 605 The limit for such treatment Horsley fixes at six weeks. Starr, I think with more justice, would extend it to three months: and I would urge with Seguin that no antisyphilitic treatment can be regarded as efficient unless the dose of the iodides has been increased up to half an ounce a day, or earlier intolerance. The location of intracranial tumors is unfortunately such that as a rule they are not accessible to operation. Gowers has tabulated 637 such tumors as follows: Central hemispheres (including central ganglia) 297 Cerebellum 179 Pons 59 Central ganglia 48 Medulla 81 Corpora quadrigemina - 13 Crura cerebri 10 687 111 Starr’s table (p. 603) it will be observed that in the cerebral axis there were in adults 105 tumors, in children 80, all of them being of course excluded from operation. In the cerebellum there were 96 tumors in 300 children, as against 45 in 300 adults, showing more than double the frequency of cerebellar tumors in children, and making about the same proportion as 179 cerebellar tumors out of 637 in Gow- ers’s table. The only tumors accessible to the surgeon, with the exception of a very few in the cerebellum, are those in the cortex and centrum ovale. Those in Starr’s table number 234, of which 70 were inaccessible, and in the remaining 164 Starr estimates that there were 46 in which oper- ation was clearly indicated and 37 in which it would probably have been successful. This gives about 6 per cent. Hale White estimates that 10 per cent, of 100 tumors in the museum of Guy’s Hospital might have been successfully attacked. Knapp estimates that only 7 per cent, of 485 cases tabulated by Bernhardt could have been removed. Mills and Lloyd give 10 cases out of 100, and Dana 5 out of 29. Add- ing these together we have 1354 tumors, with only 98 that could prob- ably have been removed, a little over 7 per cent. One very important consideration in determining whether brain tumors can be removed or not is the character of the growth as to in- filtration. A tumor definitely limited by a distinct wall, as in a well- defined cyst, or in which the delimitation of the tumor is definite, as in a fibroma or osteoma, may be thoroughly and completely removed. But to some extent the tubercular, and still more the malignant, growths infiltrate the surrounding tissues without any well-defined margins. In these cases it is evident that a considerable portion of brain tissue beyond the apparent limits of the tumor must be removed if we hope for success; and unless this be done it is useless to touch them. The same rule which leads the surgeon, in a breast case, to remove all the tissues infiltrated by a carcinoma, and also the lymph-glands, should lead him also to the wide excision of a malignant growth within the brain. Unfortunately this may destroy or maim various cerebral centres, but it must be done or the operation is useless. Symptoms of Brain Tumors.—The symptoms of brain tumors are now comparatively well known, and it is not too much to expect that 606 SURGICAL DISEASES OF THE HEAD. with increased familiarity with these symptoms, in the profession, there will come an earlier diagnosis, and therefore earlier and more suc- cessful treatment than has hitherto been possible. (1) First, one of the most distressing symptoms of tumor is head- ache. This begins early, remits but little, and as a rule is excessively .severe, especially in cerebellar cases, under the tense tentorium. If it occur in those cases in which removal of the tumor is impossible, the mere relief of the headache will warrant operation. Thus Horsley1 records one case in which he removed nearly one-lialf of the occipital bone for an intracranial tumor which was irremovable, and the relief was so great that when from the growth of the tumor there was re- currence of the headache, the patient sought him and was glad to re- ceive relief anew by the removal of the other half of the same bone. Macewen also testifies to the relief of the headache, vomiting, and even the paralysis (including region of control of the sphincter) which follows such a palliative operation. My own experience in two cases of irremovable tumor is also decidedly in the same direction. Unfortu- nately the location of the headache is not a guide to the site of the dis- ease unless the tumor possibly is superficial. As a rule it is diffused rather than localized. In a few cases it is absent. (2) Pain is almost always present, either as spontaneous pain or produced by pressure or percussion. The last form, pain produced by percussion, is probably more valuable than pain upon pressure as a localizing symptom, spontaneous pain being the least valuable of all. (3) Vertigo is common, and is more marked in cerebellar tumors than in cerebral. In the former case also vertigo is often present in the recumbent as well as in the erect posture. (I) Vomiting is often noted, and is of much value as a diagnostic point, if it be “ cerebral vomiting,” that is, if it have no relation either to the ingestion of food or evidences of disturbed digestion, such as furred tongue, constipation, diarrhoea, etc. It is often a most distressing symptom. (5) Epileptic Convulsions.—These usually arise as soon as the tumor is large enough to produce pressure on the cortex. If the tumor is small and in the motor area, the convulsions may also be limited to the face, arm, or leg, and if so they are of the greatest value in deter- mining the location of the tumor. If the attack always begins, for instance, in the same arm or leg, or in the same part of the face, the localizing value is very great. Unfortunately, however, such convul- sions are apt to be general rather than local. (6) Choked Disc.—This is almost always present in tumor, and arises as soon as the tumor has attained any size, though Seguin doubts2 the frequency of this symptom. Unfortunately it gives little if any indication as to the position or character of the growth. If it exist in one eye the tumor is most likely to be in the opposite hemisphere; or if double, the lesion is most likely on the side of the least swelling. These indications, however, are only helps. Given then headache, pain, vertigo, cerebral vomiting, epileptic convulsions, and choked disc, all or nearly all of these, and the diagnosis of an intracranial growth is almost certain. Possibly also by some of them, especially by localized epileptic convulsions, the location may be 1 Brit. Med. Journal, Dec. 6, 1890. 2 Boston Med. and Surg. Journal, Feb. 5, 1891. TUMORS OF THE BRAIX. 607 ascertained with some accuracy. But there are other symptoms which enable us to locate such tumors with much additional precision. Thus there are other eye symptoms besides choked disc which help us. Paresis, paralysis, or spasm of any single muscle or group of mus- cles of the eyeball generally indicates either pressure from a coarse lesion in that portion on the cortex supplying the muscle, or infiltration of pathogenic material into the nerves themselves. Spasm is of more localizing value than either paresis or paralysis. Hemianopsia is of very great value, since it indicates a lesion of the cuneus on the same side. Thus if the right cuneus is involved, the right half of each retina will be blind, that is, the left half of each visual field will not be seen. The pupil also is apt to be dilated on the side of the tumor, but this is of no value in distinguishing between tumor and any other intracranial disease. Motor aphasia indicates that the tumor is located in the third frontal convolution, on the left side in a right-handed person and on the right side in a left-handed person. (See also Agraphia, below.) Paresis or Paralysis.—If the tumor is so located that it produces pressure on the centre for the face, arm, or leg, there may be paresis or paralysis of the face, arm, or leg of the opposite side; and if the tumor be large, a partial or complete hemiplegia may exist. The value of the late appearance of such local paralysis or paresis is again men- tioned in regard to tumors of the frontal region. Ancesthesia is rare, excepting when the internal capsule is involved, and may even then be absent. If the tumor presses upon the olfactory or any other nerve, or involves the nucleus of any nerve, it will first pro- duce irritation, and afterward destruction of the function of such nerve. Mental Symptoms.—As the tumor increases in size, stupor, deepening into coma, precedes death. At an earlier period in the disease, however, there are apt to be such mental disturbances as hallucinations and de- lusions, sometimes amounting even to delusional insanity; and there are especially apt to be a general loss of mental acuteness and of memory, and more or less childishness. The surgeon must, however, be on his guard as to the possible difficulty of distinguishing between hysteria and the symptoms of tumor. Word-deafness, sensory or amnesic aphasia, is the loss of memory of the sound of a word. A spoken word conveys no meaning to the patient, though he may be able to recognize it when written. This symptom indicates a lesion in the posterior half of the first temporal convolution on the left side. Word-blindness, or alexia, is the loss of memory of the appearance of a written or printed word. For instance, a word which would be understood when spoken is wholly unintelligible in writing or in print. This symptom is usually indicative of disease of the lower posterior portion of the parietal lobe on the left side, especially about the angular or supra-marginal gyri. Agraphia is the loss of memory of the muscular movements neces- sary for writing; so that the patient, though able to move his arm perfectly well, will have lost the faculty of writing. It is apt to be associated with motor aphasia, and usually indicates a lesion beneath the motor speech centre or Broca’s convolution, or possibly one of the posterior part of the second frontal convolution. 608 surgical diseases of the head. Apraxia is a general term denoting the loss of perception of the use, odor, color, taste, or other properties of any object. It has of course as many varieties as there are avenues b}T which the mind may be reached; for instance, sight, touch, smell, taste, hearing for lan- guage, hearing for music, etc., any of which may be lost, producing mind blindness, mind deafness, etc. An object which cannot be recog- nized by sight (mind blindness) may be very well recognized by touch. This symptom usually indicates a lesion also in the supra-marginal or angular gyrus in the left hemisphere in right-handed persons. One of the most remarkable instances of diagnosis based upon this symptom is related by Macewen.1 Diagnosis of Brain Tumors.—It is a lamentable fact that at pres- ent our diagnosis, sometimes of the existence, but more often of the location, of a brain tumor, is far from being as exact as we could wish. Chipault2 has tabulated 114 operations for brain tumor, in 47 of which the tumor was not found, either because it did not exist, or, much more frequently, because it was not rightly localized and was only discovered after death. More than one-third of the operations, therefore, have followed an erroneous diagnosis. The only consolation that surgeons can have in such cases is that the subject is so comparatively recent that our means of diagnosis are as yet very imperfect, and that all of these patients would have died just the same without an operation, though at a somewhat later period. The evidences of the existence of a tumor have already been given, and the differential diagnosis, especially between tumor and abscess, has been dealt with on page 588. Bright’s disease and sometimes lead-poisoning resemble brain tumor in some of their symptoms, such as headache, vomiting, convulsions, and choked disc. But the examination of the urine and the oedema or dropsy of Bright’s disease, and the wrist-drop and condition of the gums in lead-poisoning, enable us to make the distinction. The means of locating a tumor have been already alluded to in general terms, but it must be remembered that a brain tumor may exist, even for a long time, without any symptoms whatever, or still oftener without any localizing symptoms of value. This is particularly true in what are called the latent zones of the brain, especially the an- terior portion of the frontal lobes, the temporo-sphenoidal lobe, except a part of the left side, a considerable part of the parietal and occipital lobes, and to some extent the cerebellum. Tumors of the motor area may be located by the means already de- scribed ; tumors of the cuneus by the hemianopsia and other symptoms. Tumors involving the second temporo-sphenoidal convolution and the angular and supra-marginal gyri have also been alluded to. It is of some importance, however, to allude especially to tumors of the fron- tal lobe and tumors of the cerebellum. Tumors of the Frontal Lobe.—These are characterized first of all by early slowness of the mental processes. The comprehension is good and the conclusions are correct, if the patient is allowed time to think. But rapid mental action is impossible, and if insisted on results in confusion. There is also listlessness of manner, drowsiness in the 1 Brit. Med. Journal. 2 liltudes de Chir. Medullaire. TUMOKS OF THE BKAIX. 609 day-time, and inability to hold the attention to any subject for any length of time. These conditions Starr1 has shown to be present in one-lialf of the 23 cases which he has studied. In addition to this, the ordinary symptoms of brain tumor will be present, and as the tumor grows in size, while the mental dulness may gradually become more marked, there will be after a time, from the remote pressure, a slight paresis of the muscles supplied by that part of the motor area which receives the pressure, and this will gradually deepen into paralysis as the tumor becomes larger. This late and increasing paresis and paralsyis following such slowing of the intellect- ual powers, is of great value as indicating tumor of the frontal lobe and its steady growth. Loss of smell from pressure on the olfactory bulb or nerve, and without nasal obstruction to account for it, is also of much value. Each nostril should be tested separately, as only one nerve or bulb may be compressed. Tumors of the Cerebellum.—The general symptoms of brain tumor are not only present, but are apt to be developed with more than usual rapidity. The reason for this is thought to be that as the tumor is situated beneath the tightly stretched tentorium cerebelli, the pressure is greater and is exerted directly upon the veins of Galen and the iter e tertio act quartum ventriculum. This is followed by an internal hy- drocephalus, with rapidly developed choked disc and blindness. The headache is especially severe, and sometimes is almost the only symp- tom complained of. It may be general, sometimes even frontal, but occasionally is occipital. Tenderness to percussion over the occiput is however, a valuable sign. The knee-jerks are usually diminished in cerebellar tumor, but are exaggerated in tumors of the pons (Jacobi). The most valuable symptom, however, of cerebellar tumor is the cere- bellar vertigo or staggering. This is apt to be markedly and persistently toward one side. This symptom indicates pressure on the middle lobe of the cerebellum, or its direct involvement by the tumor. If it occurs early in the disease, the tumor is probably situated in the middle lobe; if later, it is the result of pressure upon or an extension into the middle lobe. In an analysis of 20 cases of unilateral staggering, Starr has noted that in 16 cases the patient staggered toward the side opposite to the lesion, and in 4 cases toward the same side as the lesion. There is also not uncommonly a tendency to fall backward. If the symptoms already given do not enable us to decide on which side of the cerebellum the tumor is, we should note the effects on the cranial nerves, such as strabismus, facial or lingual anaesthesia, advance or retraction of the head. These usually bear first on the side of the tumor which crowds its side of the cerebellum down upon the base of the brain, thus pressing on the nerves, or pushes the cerebellum to one side and stretches them. Paralysis of one fourth nerve, though difficult to detect, is of espe- cial value, as it always occurs on the same side as the tumor (Starr). Whether the tumor is cortical or subcortical is at present exceedingly difficult to diagnosticate. Possibly tenderness to pressure or percussion over the area of the tumor, a local rise of temperature, and the absence of anaesthesia may indicate its position. Whether the tumor is multiple or single is also somewhat difficult 1 Amer. Journal Med. Sciences, April, 1884. 610 SURGICAL DISEASES OF TIIE HEAD. to determine, but this can be done occasionally. Of course multiple tumors should not be submitted to operation. If the tumor be single, the localizing symptoms should be referable to one centre only, if the tumor be small; or to several centres which are immediately adjacent if it be large. If, however, the centres involved are multiple and far apart, the probabilities would be in favor of multiple tumor or else of a very large single tumor. In one of my cases 1 the symptoms pointed to the involvement of several centres moderately far apart, but the post-mortem examination proved the growth to be one large tumor, which could not have been enucleated, although it literally dropped out of the brain during the removal of the cranial contents. The size of the tumor can be occasionally diagnosticated by the means given in the last paragraph. In the presence of a large growth we would naturally be deterred somewhat from operating; but in view of the fatality of brain tumor and of the fact that we cannot tell whether a large tumor cannot be removed, and also of the recorded suc- cessful removal of very large tumors, we should not hesitate to make the attempt. At the worst, if the tumor is found to be irremovable, the operation may be terminated; and often with great advantage to the patient by the relief of pressure, as in Horsley’s case of removal of the occipital bone already referred to. This I have had demonstrated also myself in two recent cases in which the patients’ headaches and de- lusional insanity were entirely relieved, and their comfort greatly promoted, by the removal of the bone, the tumor being left.2 Bramann has successfully removed the largest tumor on record, weighing nine ounces. Horsley has removed one of four ounces; and Weir and my- self each one but little under four ounces. Of these four patients three recovered. Prognosis of Brain Tumors.—Should no operation be done, brain tumor is practically a necessarily fatal disease. Though life may be prolonged for some time, the suffering is so great that death is a great relief. Almost the only exception to the fatality of brain tumors is in the case of those syphilitic growths which yield to the iodides. Hence we may say that unless the indications, such as multiplicity, position, size, etc., or the presence of other growths or of disease in other parts of the body, present positive contra-indications, an operation is justifiable. The prognosis varies greatly in reference to immediate recovery and to ultimate recovery. The fullest statistics are given in Chipault’s book, in which the imme- diate results are given in 114 cases.3 As already stated, in 47 of these no tumor was found, and of these 47, 35 ended in death and only 12 in recovery. In the 67 cases in which removal was accomplished 47 patients recovered and 20 died; a mortality of less than 30 per cent. This certainly is an extremely favorable showing for so new an opera- tion. And there is no question that, as the profession is now alive to the possibility of the safe removal of cerebral tumors, many of them will come to the surgeon at a much earlier period than formerly, when 1 Amer. Journal Med. Sciences, Jan., 1894. 2 Annals of Surgery, Oct., 1892, p. 378. 3 Dr. Mary Putnam Jacobi has given a table of 85 cases with fuller details in an excellent paper in the supplementary volume (ix.) of Buck’s Reference Handbook of the Medical Sci- ences, p. 121. TUMORS OF THE BRAIX. 611 they will be smaller and the complications fewer, and the mortality will with time greatly diminish. The chief mortality lies in the cases in which no tumor is found, and in the irremovable cases. The reason for the fatality in these last two conditions, I believe, has been probably a too extensive exploration in search of the tumor or in an attempt to remove it. If therefore no tumor is found after a cautious search by the knife, the grooved di- rector, and the gentle use of the little linger; or if, having been found, it is so large or deep that it is not removable, the operation should be terminated at once. In this connection there is one indication which I believe to be of very great value, as indicative of the size of the tumor, viz., the amount of bulging. Sufficient attention has not, I think, been directed to this sign, especially as an indication to desist from further operative proce- dure. In one case 1 in which I recently operated the dura was so tense and resilient that I was certain that there was a very large tumor under it. Accordingly, instead of opening the dura widely, which would have allowed immense bulging and would have prevented the suturing of the membrane except after destruction of a very large amount of brain sub- stance, I made an incision only an inch long. Through this I explored repeatedly in different directions, and, finding no tumor, closed the small opening. The pressure was such that even through this small opening a considerable amount of brain tissue protruded, and had to be removed in order to allow suturing. The patient recovered, was freed from his headache, and lived several months after the opera- tion, in much greater comfort than before. Had I opened the dura widely I am sure that the patient would have died from the exten- sive traumatism which I should have been compelled to inflict upon the brain substance in order to close the wound, or from the subsequent fungus cerebri. For a more favorable prognosis, it is of the utmost importance that the body of the profession, especially physicians, who almost uniformly are the first to see these cases, should recognize the symptoms of brain tumor, and the importance of calling in the surgeon at as early a date as possible. After the tumor has been diagnosticated and located, no period is too early for its removal. We should treat tumors of the brain precisely as we do those of the breast or any other part of the body. In fact, in the brain early operation is more imperative, since its soft tissues are more easily injured, they cannot escape from pressure as do other soft tissues not enclosed in a bony case, and the tumor grows insidiously, since its increase in size can only be estimated by the symp- toms, and not, as in other tumors, by touch and sight. If therefore a brain tumor has been diagnosticated and located, and after three months, or often less, has not yielded to the iodide treatment carried to its limit, it is wasting time and imperilling life to wait further. Tumors of the cerebellum are peculiarly dangerous. Starr has tab- ulated 16 cases which have been operated on; in 9 of these no tumor was found; in 2 a tumor was found but could not be removed. In 5 cases a tumor was removed, and of these five, three recovered. The reason for the fatality is obvious. Such tumors are close to the fourth ventricle, the tubercula quadrigemina, and the pons, in which 1 Amer. Journal Med. Sciences, Jan., 1894. 612 SURGICAL DISEASES OF THE HEAD. are situated the most important and vital centres. Even, however, if not removable, great comfort can be given to the patient, as already stated, by the removal of the bone. The remote prognosis is a very different matter. If the tumor be malignant, it will return as a rule in the brain, as elsewhere. If it be tubercular or syphilitic, the probabilities of a permanent cure are good; and if it be benign, recurrence is of course not probable. It must be remembered that during the growth of the tumor, how- ever, certain changes have been produced by it, just as a bullet in its pathway to its resting-place has inflicted a certain amount of permanent injury; and the removal of either bullet or tumor will not remedy the damage already done. Hence, if optic neuritis has continued long enough to be followed by atrophy of the optic nerve, it is hopeless to expect that the blindness can be remedied; though I have seen it often improved, even after many years’ duration of a tumor. So, too, the paralysis of an arm or leg is apt to lessen to some extent, but we must not expect it entirely to disappear. If the epileptic habit has been formed, the removal of the tumor will probably modify, and sometimes may even stop, the attacks. Treatment of Brain Tumors.—The operative procedure in connec- tion with the removal of brain tumors may be very briefly described, since the chief points have been alluded to in connection with the section on technique. The median line and the fissure of Rolando are first to be located, and the upper and lower ends of the latter should be marked by punc- turing the bone with a gimlet or small gouge. The centre of the pre- sumed location of the tumor should be similarly marked. A large semilunar or horseshoe flap should then be made, with the position of the tumor as its centre. A large opening should then be effected in the skull, from one and a half to three inches in diameter, either by the trephine or the chisel. The dura should be opened, either to a large ex- tent, if the pressure is not too great, or first to a small extent, to admit of exploration, and the opening enlarged later if deemed necessary (see caution on p. 611). The tumor, having been found, may occasionally be enucleated by the finger; but if not, the knife, the scissors, the sharp spoon, or the handle of an ordinary teaspoon may be used to remove it, either in its entirety or piecemeal. If it be an infiltrating tumor, and therefore probably malignant, it is of the utmost importance that a considerable amount of apparently healthy brain tissue should be removed beyond its margins, so as to be certain that all the diseased tissue has been taken away. This may involve important cerebral centres; but a tumor is no respecter of persons or centres, and the surgeon must be ruthlessly thorough if he remove it at all. If the tumor be subcortical, an incision should be made in the brain, and the tumor be sought for by the little finger, inserted with great gentleness, and also by the probe or grooved director, in order to recog- nize its size, depth, character, etc. If it be so large that it is not wise to attempt its removal, the operation should be immediately terminated, the dura sutured and the flap replaced, the bone not being restored. In some cases of large tumor only a portion of the tumor has been re- CEREBRAL CYSTS. 613 moved, yet with great benefit to the patient. Sommer1 even recom- mends that this be done piecemeal so as to avoid the danger of a sudden alteration of pressure. But we are not at the end of our resources when such a partial operation has been done. Second, and even third, opera- tions have been done at the request of patients, and additional relief from the symptoms and prolongation of life have been given to them. Thus Czerny has operated twice in one case, and at the last report was contemplating a third operation. Bramann2 has operated thrice, with improvement each time; and Beynier and others have done re- peated operations on the same patients. In one unpublished case of a large angeiolithic sarcoma I have operated twice, and the patient has been greatly benefited. It is right also to call attention again to the wisdom of not doing too much at once in such cases. Experience has taught me great caution in dealing with large cerebral tumors. Hemorrhage is to be dealt with as has been described under the head of technique, to which the reader is referred for the other ordinary steps of the operation. Cerebral Cysts, Including Dermoids and Hydatids (Echinococci). Cerebral cysts are of several varieties. The most common perhaps are simple serous cysts, resulting from old blood-clots, or in some cases apparently of spontaneous origin. Not uncommonly gunshot wounds or other penetrations of the brain by foreign bodies, or by fragments of bone from fractures, are followed by the development of either blood-cysts, or, at a later period, serous cysts. Sometimes old blood-clots are only partially absorbed, and instead of becoming cystic remain practically as foreign bodies. McBurney has removed such a clot with success after four months. Next frequently perhaps will be found blood-cysts, and occasionally in tumors, especially the gliomata, there will be cystic development in the interior. The symptoms of all such cysts are practicall}7, the same as those of tumors, modified of course by their individual causes, and they demand similar treatment. Dermoid Cysts.—Turner,3 Paget,4 and Ogle5 have described der- moid cysts in connection with the dura mater and pia mater. These find a ready embryological explanation in the fact that in early foetal life the skin and the dura are in contact, the bone being a later inter- position. A portion of the skin becoming involuted under the bone will develop into such a cyst.6 Sometimes, however, such dermoids develop in the brain itself, probably from a deeper involution. Thus Kruse 7 has reported a case in which a dermoid cyst the size of a walnut was found in the fourth ventricle of a man who died of tubercle. It was filled with hair and pasty material, but strange to say had produced no symptoms of its presence. He also cites two other cases in the cere- bellum" and in the right corpus striatum.6 In the latter there were 1 Lancet, 1893, vol. ii., p. 644. 2 Arch, fur klin. Chirurgie, Bel. xlv., 1893, S. 365. 3 St. Barth. Hosp. Reports, vol. ii., p. 62. 4 Lectures on Surgical Pathology. 5 Brit, and Foreign Med. Chir. Rev., 1865. 6 Sutton, General Pathology, p. 169. 1 Deutsche med. Wochensclir., 1S91, S. 567. 8 Irvine, Trans. Path. Soc. London, vol. xxx., 1879, p. 195. 9 Bericlit allgemein. Krankenh., Wien, 1867. 614 SUKGICAL DISEASES OF THE HEAD. no symptoms. In Irvine’s case the girl, aged seven, after a fall on the back two years before, had a gradually increasing paresis of the legs with impaired sensation, the cause of which was thought to be spinal. Double internal strabismus and convulsions followed, and she died con- scious two months subsequently. Post-mortem inspection disclosed an abscess containing caseous material and hair, involving both lobes of the cerebellum and extending into the medulla. The ventricles were distended. Hydatid Cysts.—These are much commoner, especially in regions such as Australia and Germany, in which these parasites are not unfre- quently seen. Thus Escher, of Trieste,1 records the case of a child of eleven who suffered from epilepsy and other symptoms of tumor. By a syringe he established the diagnosis of hydatids, and removed a large cyst, occupying the greater part of the right frontal and parietal regions; but the patient died in a few hours. Yerco2 reports a case in a boy of eleven, with all the symptoms of tumor and a diagnosis of echinococcus. At the operation an enormous cyst was opened and drained. Death followed from meningitis. Castro3 reports a case in which two cysts were found. The patient died from meningitis. Chisholm,4 by means of an aspirating needle and then a Southey’s tube, evacuated about three ounces of the contents of a hydatid, drop by drop. Then by a small incision through a layer of brain susbtance only one-twelfth of an inch thick, a fine rubber tube was introduced, and he evacuated in half an hour nineteen and a half ounces of the contents in all. The cyst walls were so adherent that they could not he removed. The temperature rose to 106.2° F., and the patient died in twenty-three hours. Llobet6 records the case of another child, aged thirteen, who suffered from hemiplegia and Jacksonian epilepsy, but whose general good condition led him to expect a hydatid cyst. He removed the c}*st, which contained 26 grammes of fluid, without difficulty. Six months afterward, the headache, epilepsy, and hemiplegia had entirely dis- appeared, and., except for faulty memory and imperfect vision, the child was well. Another case of complete recovery is reported by Graham and Clubbe.6 The cyst contained 19 ounces of fluid; the hoy’s sight, however, never returned. Davies Thomas 7 refers to 97 cases of cerebral hydatid out of 2000 cases in various parts of the body. Of these 97 cases, two8 and possibly a third ended favorably. In America, Osier9 has collected 61 cases, of which only two were in the brain. The most important recent contribution to the surgery of echinococ- cus of the brain has been published by Mudd, of St. Louis.10 The case was very naturally, from the symptoms detailed, supposed to be one of tumor, probably a sarcoma. The patient was operated on March 20, 1891. The collapsed cyst was removed, with many others of varying sizes. The lateral ventricle also was opened and drained, having been mistaken for an additional cj'St. The escape of the ventricular fluid con- tinued for seventeen days, without doing any harm. The excavation 1 Lancet, June 27, 1891, p. 1444. 2 Centralbl. f. Chir., 1890, S. 888. 8 Jahrb. f. Kinderheilk., Bd. xx., Heft 1. 4 Brit. Med. Journal, 1892, vol. ii., p. 1296. 6 Rev. de Cbir., Nov., 1892, p. 970. 6 Australasian Med. Gazette, July, 1890, p. 243. 1 Trans. Intercolonial Med. Congress, First Series. 8 Davain, 1836, and Odile, 1884. 9 Amer. Journal Med. Sciences, Oct., 1892. 10 Ibid., April, 1892, p. 412. ACTINOMYCOSIS OF THE BRAIN. 615 left by removal of the cyst was as large as a hen's egg, and the cavity of the lateral ventricle was well exposed. The patient recovered en- tirely. This is the only case of operation reportecl in America. Of the seven patients operated on three have recovered. The symptoms of hydatid cyst are usually of an intermittent character. The blindness is apt to develop quite suddenly; and if at first unilateral, is said always to be on the same side as the cyst. The symptoms of all these various kinds of cyst, parasitic or other- wise, will as a rule be the same as those of tumor, though they are apt to be less pronounced, perhaps by reason of the fact that the cyst, being soft, does not exert so much pressure as a solid growth. In other respects the diagnosis between cystic tumors and solid tumors cannot, as a rule, be made prior to operation, except in the cases, exces- sively rare in this country and in Great Britain, of hydatid cyst. The treatment as a rule is by an exploratory operation and removal. If possible the cyst wall should always be extracted. If this is not pos- sible the cyst should be drained. Actinomycosis of the Brain. As far as I know, there are only three cases of primary actinomy- cosis of the brain reported. The first one is recorded by Bollinger.1 The patient was twenty-six years of age, and the symptoms were such that a diagnosis of tumor of the brain was made. The parasite formed a tumor in the third ventricle, and all the ventricles were considerably dilated. There was no tendency to suppuration of the tissues, as is so commonly found in cases of actinomycosis elsewhere. The presump- tion is that the parasite entered the body through the skin or mucous membrane without producing the disease at the entrance point, and reached the brain by embolism. The second case is reported by Gamgee.2 The man was 65 years old, and had suffered for several years with an abscess of obscure origin in the abdominal wall. When he first came under Dr. Gam gee’s care he had an effusion in the left side of the chest, paralysis of the right arm and leg, with slight dilatation of the right pupil, and convulsions of the right arm; death soon followed. At the post-mortem examination, besides pus in the left pleural cavity, there was a large abscess of the liver, with many masses of the ray fungus. Three abscesses in the brain also contained the fungus. Keller3 has recorded, however, the first, and I believe up to this time the only case, in which actinomycosis of the brain has been diagnosti- cated during life and operated on. The patient was a married woman, 40 years old, who had suffered from a series of abscesses following pleurisy. Suspecting that they might be of actinomycotic origin, he examined the tissues by the microscope and found the ray fungus. Two years subsequently she was admitted to the hospital, with gradually increas- ing weakness of the left arm, and from the prior invasion it was deemed likely that there was a secondary growth of the fungus in the brain. ’Munch, med. Wochenscli., 1887, No. 41. 2 Brit. Med. Journal, 1889, vol. i., p. 1172. 3 Ibid., 1890, vol. i., p. 709. 616 SURGICAL DISEASES OF THE HEAD. Afterward, epilepsy supervened, and the paralysis of the left arm be- came complete left hemiplegia, involving the face, with headache, vom- iting, and entire loss of consciousness. She was in a comatose and apparently moribund condition. Her family finally consented to an operation. Two ounces of thin green pus, containing quantities of the fungus, were evacuated. By the next day she had regained her con- sciousness. In eight days the face had recovered and the leg had begun to recover, and she was able to walk in six weeks. There still re- mained, however, after some months, a weakness of the left arm and slight contraction of the fingers. Nearly a year afterward the paraly- sis began to increase again, the vomiting and convulsions returned. The old wound was reopened and a considerable quantit}7 of pus re- moved, but she died in a few days. Post-mortem inspection showed a hernia cerebri occupying the middle third of the right frontal and parietal convolutions, and underneath, an unopened, encapsulated ab- scess, the size of a nutmeg. Very clearly, the diagnosis can rarely be made, but the earlier that operative interference can be had the better. The cure of actinomycosis in cattle by the iodide of potassium has recently attracted attention. Dr. Salmon,1 of the United States Bureau of Animal Industry, has stated that 63 per cent, of cattle so treated have recovered. This has suggested its use in man. Buzzi and Galli- Valerio2 refer to a case reported by Van Iterson 3 and record another of their own, in which, after failure of operation to cure, the adminis- tration of 30 grains of the iodide, daily, effected a complete cure in three months. The method should undoubtedly be tested in every suspected case before resorting to operation. The improvement seems to begin quickly and to progress rapidly. Surgical Treatment of Epilepsy. Four varieties of epilepsy should be distinguished from each other sur- gically. (1) The first, and by far the commonest form is the general or idiopathic epilepsy, in which the fit is apt to begin with a cry, and the convulsions are general from the start. The pathology of this form is as yet unknown. (2) A variety of this form of epilepsy is what is called focal epilepsy, in which the fit, instead of being general from the out- set, begins always or nearly always in one part, as, for instance, in the right leg or the right arm, and from that as a starting-point ex- tends over the entire body. Sometimes slight pathological degenerative changes have been observed, but more frequently the brain appears en- tirely normal. (3) The third variety is Jacksonian epilepsy, named after its distinguished describer, Hughlings Jackson, of London. Nearly thirty years ago Dr. Jackson described this form of epilepsy, in which consciousness is not lost, and the attack, beginning in the face, will extend to the arm and then to the leg, or from the leg will pass to the arm and then to the face; or, beginning in the arm, may extend to the leg or face. It will be observed that this “march of the fit,’’ as it has been called, corresponds with the topographical relation of the motor 1 Med. Record, Jan. 21, 1893, p. 84. 2 Brit. Med. Journal, Epitome, Aug. 5, 1893, p. 23. 3 La Semaine Medicate, 21 Dec., 1892. SURGICAL treatment of epilepsy. 617 centres in the brain, the face centre lying at the lowest part, the arm centre above that, and the leg centre above that. If the fit begins in the face centre, it is apt also to involve the speech centre just in front of it, and so produce aphasia. (4) Another form, which may be dis- tinguished surgically, but may cover any one of the three forms already described, is the so-called traumatic epilepsy in which the disease seems to be the direct result of an injury. I. General or Idiopathic Epilepsy.—Since it has become popu- larly known that surgery can do something for epilepsy, an immense number of patients suffering from this form of the disease have applied for relief. But fortunately the good sense of the vast majority of sur- geons has been proof against the importunities of these patients, and few operations have been done in such cases. No possible benefit can be expected in this form of the disease. There is no guiefe as to where the surgeon should trephine, or what he should do, should he go so far as to open the skull. Unfortunately this class of patients form the vast majority of all epileptics, and they are at present beyond surgical aid. II. Focal Epilepsy.—In these cases the first thing necessary for the surgeon is to make sure of the statements of either the patient, or more often of his friends, that the epilepsy is really of this type. It has occurred to me in many cases to have a history of an apparently distinct focal epilepsy given; but when I have placed the patient in hospital under the observation of a trained nurse, whose only business was to watch the patient, observe, and immediately write down a descrip- tion of the fit, I have found that the statements were entirely erroneous. Hence I regard it as a matter of imperative duty that no history, how- ever apparently exact and consistent, should be accepted without such observation. And this observation should be not only of one or two attacks, hut of a sufficient number, say half a dozen or more, to verify or disprove their asserted local and uniform beginning. Moreover, as Putnam has pointed out, the value of spasm starting in highly special- ized parts, such as the fingers, whose equilibrium is easily disturbed, is much less than that of spasm starting in the coarser, better balanced muscles of larger joints, such as the shoulder. The operative treatment of focal epilepsy has been the exposure of the centre in which the fit begins, its recognition by means of the faradic battery, and its excision. It must be confessed that the results from published cases have not been such as to give very great encouragement to continuance of this mode of practice; but, on the other hand, sufficient time has not yet elapsed to enable us to speak with certitude on the subject. Any opera- tion—an amputation, or the excision of a tumor—will often arrest epi- lepsy, focal or otherwise, for a considerable time; and we must remem- ber, therefore, that the occasional improvement sometimes induced may he the general result of the operation, and not of excision of the brain centre. Moreover, it has been argued, with some show of reason, that the excision of such a centres must necessarily be repaired by means of a scar; and it has been amply proved in many cases of traumatic epilepsy that such a scar may itself be apparently the source of irrita- tion which brings on epilepsy. 618 SURGICAL DISEASES OF THE HEAD. This, however, is to be said in extenuation of the operation, that an aseptic excision, followed by immediate primary union, leaves a scar much less likely to cause irritation than the coarse, irregular, branch- ing cicatrix which follows an infected trauma. Moreover, in not a few cases, the excision of a traumatic scar, and the substitution for it of the simple scar of an aseptic operation, has been followed by amelio- ration and, in some cases, by cure. The whole question, as yet, is under consideration, with a tendency, upon the part of surgeons, I think, to- ward less interference rather than more. The percentage of deaths is not large, perhaps from five to seven per cent., in these cases; and therefore it is reasonable to take the risk of an operation in so dreadful a disease. There is no probability that the pa- tient will be made worse. It is of great importance, in these cases, to make a large opening in the skull, best by the Wagner-Wolff method (see Technique), which allows of a much larger opening than the use of the trephine. This will enable us to recognize the convolutions, and by the battery to ascertain the exact location and limits of the desired cere- bral centre. It is possible that one of the reasons for the failure in many cases of operation for both this and the other forms of epilepsy which are suitable for interference, has been timidity as to removal of considerable portions of brain tissue. On the one hand, it is true that a wide re- moval will result in extensive paralysis of the parts supplied. But I have never yet seen this paralysis permanent. Either the opposite side takes up the work after a time, just as we learn to write with the left hand when we lose the right; or, as seems more probable, the area of brain cortex which supplies an extremity, or a part of it, as, for instance, the hand, the shoulder, or the face, overlaps and extends into neighboring brain centres, and the less used peripheral portion of the centre awakes to activity when the central portion is removed. It is to be remembered, especially, that removal of cerebral centres can be much more safely done in the antero-posterior direction than in the vertical; because if we go above or below the immediate centre in- volved, we are certain to remove parts of other and adjacent centres, and hence to produce a more widespread paralysis. In removing any portion of the cortex, one of the chief dangers is hemorrhage. The large veins in our way should therefore either be first tied, or, not uncommonly, the pia and its vessels can be stripped off from the underlying convolutions, and thus the vessels be avoided. The centre to be removed should be outline bv the knife held vertically to the surface, and all of the gray matter should be removed down to the white substance. The after-treatment of these cases is that which is described in the section on technique. In all cases, however, the medicinal and dietetic after-treatment, especially by the bromides, should also be carefully and persistently carried out if we wish to obtain the best results. III. Jacksonian Epilepsy.—While more commonly non-traumatic, yet this sometimes follows injury. A few cases are reported in which momentary faradization of the cortical centres which are evidently diseased has produced a fit en- tirely analogous to those from which the patient has suffered. In a SURGICAL TREATMEXT OF EPILEPSY. 619 healthy brain, such momentary faradization produces only a single movement of the part supplied by that portion of the cortex. I have suggested that the production of such a typical fit by momentary faradization might be of value in determining whether a cortical centre which was apparently healthy was really diseased ; but I do not know of any observations which bear upon this suggestion. In an asserted Jacksonian epilepsy, the same precautions to ascertain the truth or falsity of the statement must be insisted on as in focal epi- lepsy. • Fortunately, in cases of Jacksonian epilepsy, the patient him- self, if he is a careful observer, can aid us very much, since conscious- ness is not lost. In both this form of epilepsy and in focal epilepsy, also, the dynamometer may be of use to us. As soon after the attack as the patient can use the instrument, the grasp of the epileptic hand and of the opposite healthy hand should be compared ; the severe spasms exhaust the muscular power of the part involved in the fit; and the re- gistration of the dynamometer should be less on the affected than on the healthy side. Charcot1 and Tourette2 have pointed out also a means of distin- guishing between the effect of partial epilepsy of the genuine tyj:)e and a hystero-epilepsy, in examination of the urine. The latter author states that, in true epilepsy, there is a decided augmentation, at the moment of the fit, of the fixed residues, specially of the urea and the phosphates; and in hystero-epilepsy a sensible diminution of these. Charcot states that normally the proportion of alkaline phosphates to earthy phosphates is about three to one, and that this proportion is little altered after a fit of genuine epilepsy; although the total amount of urine, of urea, and of both phosphates increases. After an attack of hystero-epilepsy, the earthy phosphates increase to two-thirds of the alkaline phosphates, or even to an equal amount, with a decrease, how- ever, of the total amount of both urea and the phosphates. The surgical treatment of well-marked Jacksonian epilepsy is the same as for focal epilepsy, viz., the early excision of the cerebral centre involved, before the epileptic habit has been formed. The prospects of benefit or of cure are better than in focal epilepsy , especially if the Jack- sonian epilepsy has followed an injury. Though not a few cases, especially those in which the operation was done long after the epilepsy began, have not been benefited, yet so large a number have been bene- fited or cured as to make a resort to operation justifiable. The possi- bility of failure, however, should always be explained to the family and patient. The after-treatment by drugs should also be invariably pur- sued. IV. Traumatic Epilepsy.—While in a few cases the epileptic at- tacks begin within a few weeks of the reception of the injury, as a rule their appearance is delayed for some months or even years. At first the attacks are apt to be infrequent, and are often attended by only a momentary loss of consciousness (petit mal); but afterward become typi- cal epileptic attacks {grand mal). Even slight accidents, in some cases, are followed by epilepsy, probably by reason of a cicatrix in the dura or in the brain. Compound and especially depressed fractures in very many cases irritate the underlying cortex and are followed by epilepsy. 1 ProgrSs Med., 15 Novembre, 1890, p. 393. 2 Kev. de Cliirurgie, 1892, p. 418. 620 SURGICAL DISEASES OF THE HEAD. Hence in all cases of compound fracture with depression, the profession is coming to recognize the importance of immediate elevation of the bone; and if the brain tissue has been lacerated, it is probably best to excise the injured portion. The severity of the disease is sometimes remarkable. Thus in one of Horsley’s cases, after an old depressed fracture of the skull, the patient had 2870 convulsions in 13 days.1 And in Miles’s case," in which the patient had been struck on the top of his head by a lead sinker, weighing about a pound, he had as many as 3597 fits in 42 days, and as many as 219 in a single day. Yet both of these cases were cured by operation. If the epilepsy arises from trauma, the seat of injury probably is over well-known centres, motor or otherwise; but, on the other hand, it may lie over the so-called latent zones of the brain. In those cases in which the lesion lies over well-known centres, and the muscles involved in the epileptic fit correspond to those innervated by these centres, the natural inference is that the lesion and fit are related as cause and effect. But it must be strongly insisted on that the site of operation should be determined rather by the localizing symptoms than by the external scar, because the actual lesion may have been caused by a splinter of the bone or by injury of the brain by other means, at some distance from the seat of the injury and not directly under it. Moreover, excision of the scar itself, if one exists, has occasionally been followed by a cure, and in one unreported case of my own this seems to have been permanent. It would be right, therefore, as a pre- liminary minor operation, to first excise the scar. And also, if there be any other disease, such as necrosis of the tibia, this should be remedied first; in a case related by Briggs, the removal of necrosed bone was followed by a cure, which had persisted for five years when the case was reported. The injury may have been followed by splintering of the bone, by the formation of a clot, which is very apt to be followed by a cyst, by a brain scar, by adhesion between the brain and its membrane, or some- times by no apparent lesion. In the remarkable case of Mr. Miles just quoted there was no apparent lesion of the brain; and yet simple trephining had cured his patient three years and a quarter before the case was published. After opening the skull, the dura, in these cases, should always be incised. Should a scar exist in the dura, it must be removed. Should one exist in the brain, this must be removed down to the white sub- stance, and as much further as the scar goes. All of the damaged brain tissue must be removed. If any of the dura has been sacrificed, its place may be supplied by a piece of the pericranium, as described under technique. This is especially important in those cases in which the brain has been incised, in order that we may prevent a fungus cerebri. In other respects the treatment is that described in the section on tech- nique. Of course if the bone is diseased, or is irregular and would pro- duce irritation or pressure, it should not be replaced after removal. In those cases in which the lesion does not lie over well-known centres of motion or of special sense, but over latent zones, if excision of the scar does not effect a cure and there is distinct evidence of either 1 Brit. Med. Journal, 1887, vol. i., p. 864. 2 Lancet, 1891, vol. ii., p. 1159. trephining for headache. 621 fracture or irregularity of the bone, the skull should be opened and the dura also incised, further procedures being regulated by what is found. Any dural scar, brain scar, or diseased brain tissue or cyst should be treated by excision. If adhesions have formed, the proposition of Beach 1 to insert a piece of aseptic gold-foil between the brain and the dura may be adopted, as has been successfully done by Park. If there has been a prior trephining, at the time of the injury, removal of the thickened edges of the opening and of scar tissue, and possibly the in- sertion of gold-foil, will often be followed by great improvement, and in some cases will even effect a cure. Any such operation to be effective, however, must be thorough. The degeneration of the ganglion cells and the hyperplasia of the connective tissue have been shown by Van Gieson to be slow processes: and Sachs has especially insisted on the wide secondary sclerosis in the brain and the epileptic habit following it. Both of these observations render early rather than late operations imperative, if we would really cure our patients. Conclusions.—Perhaps the most difficult of all the diseases with which modern cerebral surgery has interfered, in which to give a fair and reasonable judgment, is epilepsy. The following, however, after con- siderable experience, seem to me to be just conclusions:— By far the vast majority of cases of epilepsy are wholly unsuited for operation, including in this class all those of general epilepsy and a very large number of other cases. In Jacksonian and in focal epilepsy, especially in the former, a considerable number of cases will probably be cured, a not inconsiderable number will be much benefited, and the remainder will be made neither better nor worse. In traumatic epilepsy a larger number will be cured, a larger number benefited than in the last two classes, leaving of course a smaller number unaffected by the operation. In all classes, it can be said that the danger is moderate, provided that the operation be absolutely aseptic in its technique. If simple trephining is done, the risk is very slight. If the brain be involved in the operation, then the danger will be increased in proportion to the de- gree of interference; but the mortality will rarely exceed ten per cent, even then, and will usually be less. Trephining for Headache. Occasionally, headache is of itself a serious ailment. When persist- ent, severe, and unconquerable, it may disable a man entirely from work, and be so serious an impediment to earning a living as to warrant interference. Horsley has advocated trephining for the relief of this condition, and has reported cases in which he has done the operation with excellent results. Warren2 has reported an excellent case in point. Weir has trephined in one traumatic case, in which the head- ache was the only symptom. Relapse followed temporary relief. I 1 Boston Med. and Surg. Journal, April 3, 1890. 2 Annals of Surgery, Sept., 1893, p. 259. 622 SURGICAL DISEASES OF THE HEAD. have operated in two cases. In the first, following trauma, the patient recovered entirely and was able to resume his occupation; but in the second case the operation failed entirely. From later developments I am inclined to believe the latter patient to have been neurasthenic. Nothing was done in any of these cases except simple trephining, which is better than using the chisel. The result apparently is due to a change in, or relief of, the intracranial pressure. At least, that is the only rational explanation which occurs to me in connection with the procedure. Hoffmann 1 has reported three cases of excessively severe headache, complicated, however, with other symptoms, such as paresis of various muscles, and in one case difficulty of speech; apoplexy with loss of con- sciousness for four days, severe headache, tottering gait, and suicidal impulses, in the second; and in the third, severe headache, vomiting, slow pulse, epilepsy, and hemiplegia. In the first two cases there was evidence of former ear disease on the same side. In all of them Hoffmann trephined the mastoid, exposed the lateral sinus, and opened it. Nothing wras found except sclerosed bone and thickened dura, and very dark blood in the sinus. Kecovery followed in all. It is evident of course that more than mere headache was present in these cases; but as they are obscure in their origin, and as the headache was the most prominent disabling symptom in all three, they find their place here better than elsewhere. The relief of the intense headache from tumor of the brain by trephin- ing already been alluded to. Trephining for Athetosis. This is a disease of the nervous system, characterized by irregular tremors or movements of the arms and legs; or sometimes, as in a case at present under my care, limited to a single member, as the arm. It is very often a result of the cerebral palsy of children, and is sometimes accompanied by epilepsy, and occasionally by contractures. In other respects the patient may be in good health and mentally sound. The advisability of operating in these cases is as yet doubtful. Mr. Horsley 2 regards athetosis as a form of cortical discharge, and has re- ported one case in which he operated without benefit. The patient’s movements began as a rule in the thumb, and hence he removed the thumb centre. In a fortnight, as the surrounding cortex resumed its activity, the spasms returned. He urges the removal of the entire area innervating the part involved (if, I suppose, the disease be limited to a single extremity; he would scarcely propose to remove both an arm and leg centre, producing an entire hemiplegia). Oppenheim3 records another somewhat more hopeful case, in a child of 12 who had had the cerebral palsy of childhood, and epilepsy beginning at 4 years of age. This was followed by right hemiplegia and contracture, the athetosis setting in subsequently. At the operation a cyst was found, and the final result was that the athetosis and contracture were both improved, while the epilepsy, although continuing, was less frequent 1 Centralbl. f. Chir., 1889, No. 29. 2 Brit. Med. Journal, 1890, vol. ii., p. 1291. 3 Deutsch. med. Wochenschr., 3 Juli, 1890, S. 595. TREPHINING FOR CONGENITAL CEREBRAL PALSIES. 623 and less severe. In a case under my own care, in which the athetosis is limited to the left arm, and in which the cause has probably been a small hemorrhage into the internal capsule, catching the fibres from the corpora quadrigemina and producing an irregular hemianopsia, I have not thus far thought it right to operate on the brain. The patient is an adult and still finds the arm somewhat useful. I stretched the brachial plexus above the clavicle, but the operation was not followed by any improvement. When the disease arises in childhood, especially in connection with the cerebral palsies of children, I should certainly advise against operation, with our present knowledge. It is, however, but just to say that our experience is as yet too limited for us to be dogmatic. Trephining for Arrested Development. Sometimes a case of arrested development is distinctly traumatic in origin. For these cases there is some hope of relief, but where the con- dition arises as a congenital defect it is very doubtful whether operation should be attempted. Dr. Felkin and Mr. Hare 1 report the case of a girl of IT who had had her skull fractured at the age of 10 months, fol- lowed by paralysis and imperfect development of the right arm and leg. At the operation a cyst was found, two inches in depth, with an osteo- phyte half an inch long. The lesion being extra-dural, the membrane was not opened. Marked improvement followed the operation. I have operated, much against my will, in a case of arrested development2 in which I found great atrophy of the central portion of the left hemi- sphere. The patient died immediately, after the operation. I had at first refused to interfere, but afterward unwisely yielded to the importu- nities of the parents. Certainly no operation whatever could have done this child, or any other similarly affected, any good. The cause of the qtrophy was a thrombus, or possibly an embolus, in the middle cerebral artery, and all the area supplied by this artery was wasted. Trephining for Congenital Cerebral Palsies. Two of the best recent non-surgical papers on the cerebral palsies of childhood are by Osier3 and by M. Allen Starr.4 The conclusions reached by both these authors are on the whole against operation, al- though Osier records a case operated on by Morton in which some im- provement followed, and Starr gives a qualified approval to occasional interference. In a few cases, especially those in which hemorrhage is the cause, an immediate operation might he of value; but in 343 cases Starr has only reported 18 of this character. The great majority, 239 cases, were due to porencephalus and sclerotic atrophy, in not a few of a very extensive character. The difficulties surrounding diagnosis are such that it is almost impossible in any given case to say just what the condition is. But as such chronic cases are incurable by medi- cine; as it is impossible without an exploratory operation to deter- 1 Manchester Med. Chron., Oct., 1891, p. 17. 2 Amer. Journal Med. Sciences, Sept., 1891, p. 235. 3 Med. News, 1888, vol. xxxiii., p. 29 et seq. 4 Med. Record, Jan. 23, 1892, p. 85. 624 SURGICAL DISEASES OF THE HEAD. mine absolutely what pathological condition exists; as the danger of operation, especially if it be conducted with great care not to go too far and to be as speedy as possible, is not very great; and as death itself is in most of these cases a boon, an operation may occasionally be proper. But the cases must be carefully selected, and should be limited to fa- vorable examples among those most likely to have been caused by clots, cysts, or tumors. When the brain is manifestly atrophied, as shown by a marked difference in the development of the two sides of the skull, I should advise against any operation. Linear Craniotomy for Microcephalus. In this disease the entire head is lacking in development. It may even be excessively small. There is sometimes a difficulty in deter- mining precisely the amount of the defect. The following table from Finlayson’s article1 may be of value:— No. of Cases. Age. Head, inches. Chest, inches. . Difference between Head and Chest. 100 One day 13.75 12.94 Head more than chest, 0.81 66 6 to 12 weeks 15.25 14.25 “ “ “ “ 1.00 75 6 to 8 months 16.68 15.58 “ “ “ “ 1.10 71 11 to 13 months 17.80 17.20 “ “ “ “ 0.60 67 21 to 24 months 18.38 17.85 “ “ “ “ 0.53 50 34 to 36 months 18.70 18.61 “ “ “ “ 0.09 60 4 to 44 years 19.20 19.72 Chest more than head, 0.52 46 6 to 64 years 19.51 20.76 “ “ “ “ 1.25 40 9 to 10 years 19.56 21.31 “ “ “ “ 1.75 31 11 to 12 years 20.00 23.46 “ “ “ “ 3.46 The pathology of this affection is very doubtful. Unquestionably, as a rule, the growth of the encasing hard parts is dominated lyy the growth of the contained soft parts, and the relative growth of the brain and skull is a resultant of the reciprocal pressure, centrifugal and cen- tripetal, which each exerts upon the other. In normal cases, in which ossification of the sutures takes place at the usual time, the skull yields before the growing brain; but it is very possible in a brain of feeble de- velopment, lacking the power of growth, that if early ossification of the sutures should take place, this slight added resistance might over- come and check the power of expansion and growth possessed by the brain. Sometimes this ossification of the sutures is noticed even at birth, and in most cases of microcephalus, at an early period after birth. It is undoubtedly true, however, that some cases of microcephalus do not show any evidence of such premature ossification. It is very prob- able that in these cases the rate of growth both of the skull and of the brain is lessened. In microcephalus, accordingly, Lannelongue 2 proposed to make by re- section a groove in the skull about a quarter of an inch wide, in order to allow of more rapid expansion and growth of the brain. This groove is more commonly made on one or both sides of the sagittal suture, ex- tending from low down on the forehead into the occipital bone. It 1 Keating’s Encyclopaedia of Diseases of Children, vol. i., p. 91, foot-note. * L’Union Med., 8 Juillet, 1890. LINEAR CRANIOTOMY FOR MICROCEPHALUS. 625 may have one or more lateral branches. Where the faulty develop- ment is chiefly in the frontal region, it would be best, as in one of Park’s cases, to make a groove transversely and a little in front of the biauric- ular line. The dura at the superior longitudinal sinus can with care be loosened from the bone without rupturing the walls of the sinus. Soon after the publication of Lannelongue’s first case I reported the first operated on in America.1 Since then a large number of other cases have been recorded, by Wyeth,2 Broca,3 Park,4 Lannelongue,5 myself,0 and others. The results have been very various. The mortality is large, averaging, even with Lannelongue’s favorable report, about 20 to 25 per cent. This would naturally be expected, inasmuch as these children are almost always feebly developed, and while the loss of blood is as a rule moderate, yet the shock of so extensive an operation must be very great. For this reason it is never advisable to operate on both sides at once. An interval of from two to four weeks should intervene be- tween the successive operations. Hence also the danger should be very fully explained to the parents, as otherwise they may justly blame the surgeon. The limits of age I should place at about 9 months for the mininum, as under that age the child would be too feeble, and about 8 or 9 years for the maximum; Park,7 however, has reported one of his best results in a boy 9 years of age, and older patients have been operated on. As to the effect on the mental development, the majority of the patients who recover from the operation show no improvement. Quite a number show a moderate degree of improvement, while in a few instances this has been very gratifying indeed. In one of my own cases, in which the mental state of the child has been comparatively little improved, the operation has been of the greatest value to the mother, inasmuch as before the operation the child demanded constant care, both day and night. Since the operation the mother is relieved very much during the day, and at night obtains a sound sleep in- stead of being wakened repeatedly at very short intervals. This to a working-woman with other children to care for is very important. As a general conclusidn, therefore, my own judgment is that the opera- tion is at present justifiable, in cases of decided microcephalus. In cases of simple idiocy without microcephalus, I should unquestionably be unwilling to perform an operation. I have refused a large number of cases, in some few of which I have had reason to believe that the parents sought it with a view to being relieved of the care of the child by death. In one of my cases, in which, at the Infirmary for Nervous Diseases, a year previously, Dr. Weir Mitchell had made measurements of the head, and in which I had made independent measurements at the time of operation, these measurements were identical, thus showing not the slightest increase in the size of the child’s head during the year. One year after the operation the circumference of the head had increased 1.5 centimetres. This would lend probability to the view that, whatever may be our theory as to the cause of microcephalus, 1 Med. News, Nov. 29, 1890. 3 Rev. de Chir., 1891, p. 37. 5 Rev. de Chir., Mai, 1891, p. 368. 1 Med. News, 1892, vol. lxi., p. 649. 2 Medical Record, Feb. 21, 1891. 4 Med. News, Dec. 3, 1892, p. 649. 6 Amer. Journal Med. Sciences, June, 1891. 626 SURGICAL DISEASES OF THE HEAD. linear craniotomy does allow of later expansion, both of the brain and of the skull. The operation is a simple one. After the usual preparation, the line of incision being chosen, the scalp is divided either from side to side, or from the border of the hair well back on the occipital bone. A lateral incision is then made just back of the anterior border of the hair, to al- low of the scalp over the forehead being drawn forward for making the groove in the frontal bone, and yet not to allow any visible scar on the forehead. Hemorrhage having been arrested by hemostatic forceps, the skull is perforated by a half-inch trephine, about half an inch from the median line, to avoid the superior longitudinal sinus. This was wounded by Halley.1 The best instrument for gnawing away the bone Fit;. 1691. Keen’s Rongeur Forceps. is I think the pair of forceps devised by myself (Fig. 1691), with which I have completed the entire operation in less than twenty minutes. I have very rarely been compelled to ligate any blood-vessels. The pres- sure of the haemostatic forceps, and afterward of the sutures, is sufficient to control it. The bone having been gnawed away, the pericranium is detached from the flap and cut away with the scissors, so as to prevent the formation of any new bony tissue in the groove. The edges of the scalp are then united by sutures, and the ordinary dressings applied. Occasionally I have drained by horsehair, laid from end to end, but more commonly I have done without drainage. Almost invariably the wound will unite by first intention within five or six days. What the ultimate results of the operation will be when we have been able to fol- low such cases for 10 or 20 years, is as yet, of course, very uncertain. Trephining for Psychoses. These may be divided into cases of (1) Traumatic Insanity, (2) Non- Traumatic insanity, and (3) General Paralysis of the Insane. I. Traumatic Insanity.—Although in many cases the treatment of this condition will be empirical, yet it holds out a very much better prospect of success than in the class of cases just considered. Fletcher2 refers to 9 previously reported cases, in which there were 1 Journal Amer. Med. Assoc., July 15, 1893. 2 Amer. Journal of Insanity, 1887, vol. xliv., p. 212. TREPHINING FOR PSYCHOSES. 627 6 of cure, 1 of transient improvement, and 2 of death. He himself re- cords 8 cases, with 3 of cure, 4 of improvement, and 1 with no good result. In another article1 he reports an additional case of melan- cholia with visual and auditory hallucinations, completely cured by operation. Often the mere elevation of depressed bone, or the loosen- ing of adhesions, will afford relief. Wade2 reports the case of a man who was operated on three times, each one of the three operations being followed by decided improve- ment, and the last by cure, lasting up to the time of the report, which was, however, very recent. Frank and Church 3 report a case of pre- sumed traumatic dementia, with personal uncleanliness. No deformity of the skull was observed, and the operation revealed no fracture. The membranes were in a state of jelly-like oedema, and four ounces of cere- bro-spinal fluid escaped in a gush. Great primary improvement was followed by a relapse. A year later a second operation was done, fol- lowed by a second improvement. The ultimate result has not yet been reported. Czerny4 records a very interesting case of hallucination of persecution, presumably brought about by an injury, as he refers to a scar. The only localizing symptoms of any value were slight paresis and hypersesthesia of the right brachial plexus. Under the scar, in- creased sub-arachnoid fluid and possibly some atrophy of the convolu- tions were found. The dura was sunken in and the bone was thickened. The operation was followed by great improvement, but a relapse oc- curred two months subsequently, after coitus, and was attended by spastic paralysis. The former flap was again reflected, and improve- ment was noted at the time of report, which, however, was too early to warrant the presumption that it would be permanent. Czerny sug- gests that the improvement caused may be due to the change in intra- cranial pressure, similar to that in intra-ocular pressure, the diminu- tion of which results in a cure in glaucoma. Park 6 has reported some excellent recoveries following trephining for traumatic epilepsy and in- sanity. In these cases of traumatic insanity, at a longer or shorter period after the injury to the head, not uncommonly after several years, there is usually maniacal excitement, followed by chronic irritability, sus- piciousness, and then homicidal impulses, with a marked tendency to dementia. The headache is often severe, and sometimes has induced the morphia habit. Generally there will have been unconsciousness after the injury, and very commonly a depressed area of bone will be found. The operation consists simply in elevating or removing the depressed bone and loosening adhesions. The prospect for cure in such cases is very fair; and where there is an obvious or even probable relation between the insan- ity and the injury, it would be eminently proper, in view of the present safety of trephining, to operate. The insanity cannot be made worse, and surely in the very few cases in which death would follow it would be an immense boon. 1 Journal of Nerv. and Mental Disease, May, 1892. 2 Ninety-fifth Annual Deport, Maryland Hosp. for the Insane. 3 Amer. Journal Med. Sciences, July, 1890, p. 1. 4 Verliand. Deutsch. Gesellsch. f. Chir., 1892. 5 Med. News, 1892, vol. lxi., p. 648. 628 SURGICAL DISEASES OF THE HEAD. In one case of epilepsy, with marked and growing tendency toward homicidal insanity, following a blow on the head, I operated five years ago, and removed a small portion of damaged brain tissue, containing a very small cyst, the size of a pea; ultimate recovery from the epilepsy ensued, and also entire and early recovery from the homicidal mania. A year ago the patient was entirely well.1 Macewen 2 relates a case which is not only of importance as regards the question of insanity, but is also of peculiar importance as showing how a very careful investigation of the minute symptoms of a case may lead to a brilliant diagnosis and successful treatment:— The patient was a man who, a year after the receipt of an injury, developed melancholia, with homicidal impulses, relieved, curiously enough, by excruciat- ing, indefinitely located paroxysms of pain in the head. The only symptom which pointed toward the seat of the lesion was discovered by minute and careful inquiry, as follows: For about two weeks after the injury, though his sight was not impaired, what he saw conveyed no impression to his mind (mind blindness). He could not recognize a person by the eye, but by speech could recognize him readily. Ilis New Testament was recognized readily by the sense of touch, especially its smooth leather covers and deeply indented letters; but when he opened it the words and letters were unknown symbols to him. On operation the angular gyrus was exposed, when a portion of the internal table was found detached, pressing on the posterior part of the supramarginal convolution, and a corner of it embedded in the angular gyrus. The bone was removed. Though still excitable, the patient after his recovery had no further homicidal tendency, and was at work. II. Non-Traumatic Insanity.—Czerny3 refers to a case of melan- cholia which he operated on, but he does not give the result. The most remarkable series of cases, and in fact the only ones, I believe, in which an attempt has been made to relieve idiopathic insanity by operation on the brain, are the six reported by Burckhardt.4 These were all cases of hallucination and delirium, chiefly verbal, though to some extent of sight and hearing. Burckliardt’s idea was that if he could intercept the paths of cortical association, which in his opinion transmitted the patho- logical impressions arising in the sensorial and ideogenous portions of the brain to the motor portion, he would be able to transform these victims of violent insanity, attended with homicidal impulses, into harmless dements. Accordingly he exposed the brain and removed a strip 2 centimetres wide from the frontal and parietal cortex, in front of and behind the Rolandic convolution, or else the centres for verbal hallucination, that is, the centres for word-deafness (first temporal convolution) and aphasia (triangular portion of Broca's convolution). His first case was typical of the others and the most remarkable of all. The patient had been insane for 16 years, with explosive outbreaks of a dangerous character both to herself and to others, so that she was necessarily put under restraint. She was exceedingly noisy, uncleanly in her habits, and so violent as to require constantly the attention of several nurses. At his first operation, December 29, 1888, he removed a 2-centimetre 1 Trans. N. Y. State Med. Assoc., vol. vii., 1890, p. 93. 2 Brit. Med. Journal, Aug., 1888, p. 172. 3 Verliand. Deutsch. Gesellscli. f. Cliir., 1892. 4 Allgem. Zeit. f. Psychiat. u. s. w., 1891, S. 463. TREPHINING FOR PSYCHOSES. 629 strip from the lateral part of the right upper parietal lobe and the supra- marginal gyrus, immediately behind the Kolandie convolution. The operation lasted four hours, and five grammes of cerebral tissue were removed. Paralysis of the left arm and paresis of the left leg super- vened on the tenth day, but spontaneous recovery took place in a few weeks. Although she still suffered from hallucinations, she was so much quieter that he was encouraged to do the second operation on March 8, 1889. On this occasion he removed a similar strip from the posterior part of the upper and middle temporal convolutions on the right side. The operation lasted two and a half hours, and two and a half grammes of brain tissue were removed. The patient was more cheerful after this operation, but still offensive to those about her. The third operation was done May 28, 1889. A strip of the upper and also of the lower left parietal lobe, involving the supramarginal and angular gyri behind the occipital end of the Sylvian fissure, was re- moved. This operation lasted four and a half hours, and five and a half grammes of brain tissue were sacrificed. She still had a few hal- lucinations of sight and hearing, but many of speech, and weeping and shouting were still practised, although less than before. The fourth operation was done Febuary 12, 1890, when the triangular part of Broca’s convolution was removed. The operation lasted two and a half hours, and involved one and a half grammes of brain tissue. It is especially noteworthy that no aphasia followed this partial removal of Broca’s centre. The four operations required thirteen and one half hours, and fourteen and one half grammes of brain tissue were re- moved. The result was that instead of being a dangerous lunatic the patient became harmless and mostly quiet. The operations on the other patients were much less extensive, al- though each required from two and a half to three and three-quarters hours for its performance. The removal of the centre for word-deafness apparently did not produce the expected effect. One of the six pa- tients died. The result in the first case was a satisfactory one, in view of the object sought, although it did not restore the reason. In three others the result may be said to have been fairly satisfactory. In a fifth case, after improvement to such a degree that she returned to her sister’s home, the patient was found drowned, whether by accident or, as seems most likely, by suicide, is uncertain. The general impression made upon my mind after studying these cases carefully is that the re- sults were scarcely such as to lead other surgeons to perform such operations, unless it should be in exceptionally bad cases, such as the first one. Moreover, it would surely seem that two hours should be as a rule sufficient, even for these extensive operations, and I cannot im- agine that many patients would survive operations between four and five hours long, especially four successive operations. On the other hand, we must remember that Luys, quoted by Burckhardt, says that of 130 patients who were subject to hallucinations only 20 recovered sufficiently to return to their homes, and that within three or four years 15 of these suffered relapses while the other 5 were lost sight of. There is no probability of cure, therefore, by medical means. Whether this fact should justify such extensive and repeated operations is a question which may give rise to a difference of opinion among surgeons. My own judgment would be against them. 630 surgical diseases of the head. In traumatic psychoses it is very clear that operation is justifiable’ and in a number of cases it has been followed by great amelioration, and in not a few by cure. The question of operation on cases of idio- pathic psychoses seems to be still unsolved. III. Trephining in General Paralysis of the Insane.—In 1889 Mr. Claye Shaw 1 reported the first case of trephining for this condition. The operation consisted in the removal on each side of a piece of bone an inch and a half by three-quarters of an inch in extent, and the evacua- tion of considerable fluid. The mental improvement was moderate, but the patient died six months subsequently, with no improvement in his physical condition, though with no mental relapse. In the same journal, for 1890,2 Mr. Shaw reports a second case, and in the reports of St. Bar- tholomew’s Hospital3 a third, both followed by some improvement. Batty Tuke4 reports a fourth case, with slight improvement. Rey3 reports another, with notable improvement, of the durability of which however, he expresses some doubt. Wagner6 reports a sixth case, with marked improvement for several weeks. Goodall7 reports another case without any noticeable improvement. McPherson and Wallace" re- port five others. In their cases bilateral trephining was done in two; the dura was cut away in four; in one, horsehair drainage was em- ployed. These 12 cases include, I believe, all that have been done for this condition up to the present time. The conclusion of McPherson and Wallace, that no improvement is to be expected from operation un- less possibly done at a much earlier period than in any of the reported cases, seems to be justified. The pathology of the condition, whether it be due to increased pressure from cerebro-spinal fluid or to a cor- tical degenerative cerebritis with atrophy of the convolutions, is uncer- tain. But in either case, especially in the latter, the encouragement to interfere is from present experience very slight. Trephining in Meningitis. For the diagnosis and symptoms of meningitis the reader is referred to Mr. Treves’s article9 in the fifth volume of this work. The question of operative interference, especially in view of the success and boldness of modern cerebral surgery, is one which has only recently arisen, and is not yet settled. Inflammation of the brain, as of other parts of the body, is followed by exudation and suppuration, and the serum or pus cannot escape from the bony skull and so relieve the pressure, as it can in the soft parts. As this exudate or pus, not being able to escape, produces rapid tissue changes and symptoms of pressure, it seems a priori reasonable that we should interfere surgically and offer it a means of escape by trephining, opening the dura, and draining. All surgeons are agreed on the propriety of this treatment when there is localized suppuration, but there is still much difference of opinion as to its pro- priety in the early stages, when the exudate is only serous, and when the 1 Brit. Med. Journal, 1889, vol. ii., p. 1090. 3 St. Barth. Hosp. Reports, 1892, p. 65. 5 Semaine Med., 12 Aout, 1891. 1 Brit. Med. Journal, 1893, vol. ii., p. 117. 9 Vol. V., p. Hetseq. 2 Ibid., 1890, vol. i., p. 1864. 4 Brit. Med. Journal, 1890, vol. i., p. 8. 6 Amer. Journal of Insanity, July, 1890. 8 Ibid., July 23, 1893, p. 167. TREPHINING IN HEMORRHAGE. 631 inflammation instead of being local is general. The fact is, however, that just as we incise the periosteum to give exit to serum or pus, as an iridectomy relieves increased intra-ocular pressure and saves the eye, or as in an orchitis an incision relieves the pain and saves the testicle; so in inflammation of the brain we have some slight experience to show that it is wise to trephine in order to drain off effused fluids before they have gone to the stage of suppuration and have inflicted irreparable damage on the brain. This mode of treatment would seem to be worthy of a fair trial, especially in that almost uniformly fatal disease, tuber- cular meningitis. If experience as it becomes larger is favorable, it will beget the hope that we may be able in the future to avert the dan- gers of cerebral inflammation far better than we have done in the past. Naturally those cases afford the greatest probabilities of cure in which there is evidence of localized rather than diffused, and especially of basilar, inflammation, and in which there is only a local production of serum or of pus. One remarkable case has been reported by Mr. Barker,1 in which it is probable that he evacuated an ounce of odorless pus from the fissure of Sylvius, with a successful result. Sawtelle2 records the case of a sailor who after a blow on the head developed severe head- ache and afterward fell into a stupor. . When operated on no fracture was found, but the dura was thickened and opaque. The evacuation of five drachms of fluid was followed by complete recovery and cure. McArdle6 relates one case in which he saved life by trephining three weeks after injury, and another in which he might have done so. Tobin4 also has reported a successful case after trephining and draining away a considerable amount of subdural fluid, and urges early operation, even in tubercular meningitis. Mr. Parkin5 has recorded a case of what he terms “cortical drainage,” in the frontal region, for meningitis following a blow in which there were marked psychical disturbances and epilepsy. He evacuated about an ounce of clear fluid, and the boy was apparently entirely cured after seven months. Mr. Horsley has also urged this course of treatment, but as yet there is not experience enough to warrant us in saying more than that in a favorable case it would not be improper to operate. The point at which the trephining should be done should be determined, as in Mr. Barker’s notable case, by localizing symptoms if these exist. Whether in general encephalitis any good result can be obtained by operative interference, is as yet very doubtful. (See Surgery of the Ventricles, p. 639.) Trephining in Hemorrhage from Pachymeningitis Interna Hemor- rhagica. In a number of cases, especially of alcoholism, a considerable amount of blood accumulates under the dura from that form of meningitis known as pachymeningitis interna hcemorrhagica. The best collection of cases with which I am familiar is given by Dennis.6 Occasionally, as in the case of Ceci,7 the condition is owing to accident, but much 1 Brit. Med. Journal, 1888, vol. i., p. 777. 2 Occidental Med. Times, Feb., 1892, p. 76. 3 Dublin Journal Med. Sciences, 1892, vol. xciv., p. 17. 4 Brit. Med. Journal, 1892, vol. ii., p. 21. 5 Lancet, July 1, 1898, p. 21. 6 New York Med. Journal, Dec. 24, 1892, p. 701. 7 Yon Bergmann, Cbir. Beliand. d. Hirnkrank., 2 Aufl., S. 179-180. 632 surgical diseases of the head. more commonly it is the result of disease. In such cases Dennis has re- cently urged that an operation should be undertaken. Ceci was able, even two months after the accident—which had produced palsy, incon- tinence of urine, and coma—to evacuate a clot, and his patient recov- ered and regained all the motor functions except for slight paresis of the left hand. Stewart and Annandale1 have reported a similar case, in which, however, the result was unfavorable, probably due to the de- lay before trephining. Tassi2 has reported a case which proved fatal on the seventh day from hemorrhage from the middle meningeal artery. Buchanan3 has reported a successful case operated on two months after the accident. Four ounces of bloody serum were evacuated from the opposite side to that of the injury. Harris4 also reports a suc- cessful traumatic case in which the symptoms were late in appearing. Certainly all would agree that the traumatic cases should be submitted to operation. Even the alcoholic cases of subdural hemorrhage would not be made worse by trephining, and the prospect of improvement would be very great. Usually the alcoholic cases are first seen by the physician, and the surgeon is not called until it is too late to do any operation. The symptoms in such cases, as Dennis lias pointed out, are first an ill-defined, dull headache, most commonly in the vertex. As the clot accumulates paralysis will supervene. The position of the clot must be determined by the doctrines of cerebral localization. The pupils will be contracted and immobile, but will dilate as soon as the clot has increased to a sufficient size. This contraction of the pupil be- fore unconsciousness is of great diagnostic value. Optic neuritis will ordinarily supervene after a certain length of time. One of the most valuable symptoms is the final coma. The rapidity with which this sets in will depend upon the rapidity and extent of the hemorrhage. If then headache, drowsiness, paralysis, contracted and afterward dilated pupils, and optic neuritis are present, and the patient becomes comatose, with a previous history of alcoholism and without traumatism, the pre- sumption is very strongly in favor of pachymeningitis hasmorrhagica, and as an operation could do no harm and might be followed by suc- cess, it would be proper to trephine or do an osteoplastic resection, followed by removal of the clot and probably by drainage. Operations for Meningocele, Encephalocele, and Hydrencephalo- cele. These three deformities of development are fortunately not very com- mon. The etymology of the names is equivalent to a statement of the malformations. Meningocele is a tumor caused by the protrusion of the membranes of the brain only, through an aperture in the bones of the skull, the sac being filled with cerebro-spinal fluid. Encephalocele is a tumor caused by the protrusion of a portion of the brain itself as well as of the membranes. The fluid in both these malformations is outside the brain substance. Hydrencephalocele is a tumor caused by protrusion, as in encephalocele, of a portion of the brain as well as of its membranes, but in this case the interior of the mass communicates directly with the 1 Brit. Med. Journal, 1887, vol. i., p. 877. 3 Pittsburgh Med. Rev., Sept., 1894. 2 Centralbl. f. Cliir., 1898, S. 675. 4 Brit. Mod. Journ., 1892, vol. i., p. 503. OPEKATIOXS FOK MENIXGOCELE. 633 ventricles and is distended with a large amount of ventricular fluid. Sometimes the brain substance enclosing the fluid is reduced to a very thin film. Treatment.—Until very recently the treatment of these conditions has consisted practically in electrolysis, pressure, or the injection of Morton’s fluid; hut the success of operations on the brain has led re- cently to a number of attempts to cure them by operative measures. In the “Annual of the Universal Medical Sciences” for 1889,’four cases of meningocele are collected, wTith one death. MazzucchelliJ reports an- other successful case, and Lea 3 reports two more—one of meningocele as large as a walnut (Fig. 1692), operated on at six weeks of age, the other of encephalocele operated on at eight months of age, after the Fig. 1693. Excision of a Meningocele. (Lea.) Excision of an Encephalocele Containing Part of t Cerebellum. (Lea.) failure of Morton’s fluid. The tumor (Fig. 1693) was as large as a hen’s egg, and on examination a large part of the cerebellum was found to have been removed. The patient’s temperature rose to 104° F., with vomit- ing and twitching of the arms, but by the third day became normal, and primary union was obtained. At the end of three weeks, however, hydrocephalus was beginning. I have myself reported a case 4 of menin- gocele in which recovery was uninterrupted. Powell5 narrates a case of encephalocele about the size of a tennis ball which he mistook for a sebaceous cyst. During the excision, when pulling on the presumed sac, violent spasms of the right arm and leg drew his attention to the real condition. Removal of the tumor was followed by recovery with out paralysis. Berger 6 has referred to a large number of cases re- corded by Perrier, Jessup, Marshall, Picque, and others. Cabot7 also reports a case of recovery after operation. Horsley and Marshall have reported deaths. Even hydrencephalocele, which is as a rule entirely unamenable to treatment, has been operated on at least three times with success: first, by Picque,8 who operated on a child 14 days old, the tumor being as large as a child’s head, and portions of the cerebrum and cerebellum being removed; secondly, by Fagen,9 who removed a tumor as large as as medium-sized orange three weeks after birth, when gangrene of the tumor had set in, tying the pedicle with four strong catgut ligatures 1 Vol. iii., A, 53. 2 Armais of Surg., 1892, vol. xv., p. 79. 3 Brit. Med. Journal, May 6, 1893, p. 949. 4 International Clinics, Oct., 1891. 5 Brit. Med. Journal, Feb. 4, 1893, p. 232. 6 L’Union Med., 16 Avril, 1891; Rev. de Cliir., 1890, p. 269. 1 Trans. Arner. Surg. Assoc., 1892, p. 168. 8 Bull, et Mem. Soc. Cbir, Paris, t. xvii., p. 258. 9 Lancet, June 4, 1892, p. 1240. 634 surgical diseases of the head. and removing a considerable amount of brain substance; thirdly by Mayo,1 who operated on a child a 37ear and a half old with an occipital tumor as large as a small orange, the child recovering in two weeks. It is not to be expected, of course, that the majority of such chil- dren will recover, yet the cases to which I have called attention above are quite numerous enough to authorize the statement that in suitable cases the operation should be done. Rarely advisable in hy- drencephalocele, though the examples quoted show its possibility, in the other two conditions the operation will presumably be proper in a con- siderable proportion of cases. Of course it should be done only in those instances in which the aperture in the skull is relatively small, so that the pedicle may either be included in a single ligature or be ligated in three or four sections. Moreover, great feebleness of the child and the presence of other malformations as complications would be contra- indications. The method is the same in all cases. The thick scalp at the base of the pedicle should be dissected away by two semilunar incisions. When the pedicle has been disclosed, if this is small enough, a single ligature may be cast around it, as close as possible to the opening in the skull. Where the pedicle is too large for a single ligature it may be ligated in several sections. The flaps of scalp should then be united over the ped- icle and the wound dressed in the ordinary manner. Great care should be taken that the dressings do not become displaced, lest infection should follow, as happened in one of my recent cases with a fatal result. Removal of the Gasserian Ganglion for Tic Douloureux. The Gasserian ganglion, as is well known, lies in a fossa on the an- terior surface of the petrous bone, near its apex. It lies between two layers of the dura, the upper layer being the dura proper, the lower layer lining the fossa in which the ganglion lies and serving as the periosteum. The first, as far as I know, who suggested operation on the ganglion was Dr. J. Ewing Mears, of Philadelphia, who expressly men- tioned it as a possible necessity in cases of trigeminal neuralgia, in a paper read before American Surgical Association as long ago as 1884. To Mr. Rose, of King's College Hospital, London, belongs, how- ever, the credit of first actually performing the operation. His paper was published in the “ British Medical Journal,”2 and thus far he has re- corded seven cases, the first six of which may be found in his Lectures on the Surgery of Trigeminal Neuralgia,3 and in his republished mono- graph. The first operation was done April 2, 1890. In this case he removed the upper jaw, but took no especial care to protect the eye, which unfortunately had to he enucleated in consequence of pan- ophthalmitis following. His second and later cases have been done by a better method, which is practically as follows: The eyelids are first stitched together, the stitches being removed on the fourth day. (My own experience confirms that of other operators, that it is not necessary thus to pro- tect the eyeball.) An almost semicircular incision is made, extend - 1 Annals of Surg., July, 1893, p. 26. 2 Brit. Med. Journal, 1890, vol. i., p. 1012. 3 Ibid., 1892, vol. i., pp. 33, 157, 261. REMOVAL OE THE GASSERIAN GANGLION FOR TIC DOULOUREUX. 635 ing from near the outer eanthus about an inch below the external angular process, backward along the upper border of the zygoma to its posterior extremity. It is then carried down over the parotid region just in front of the ear to the angle of the jaw, and then forward along the lower border of the horizontal ramus as far as the facial artery. The flap of skin thus marked out is dissected forward. Two holes are then drilled at each end of the zygoma to facilitate later wiring, and the zygoma is divided and displaced downward along with the masseter muscle. The coronoid process is similarly drilled, divided, and turned upward with the tendon of the temporal muscle. In Mr. Bose’s latest cases this portion of the bone was entirely removed as useless, and doing this dispenses with the need of drilling it. The external pterygoid muscle is next scraped loose from the sphenoid bone, and the foramen ovale is found. At first Mr. Bose put the blunt end of the centre-pin of his long-handled half-inch trephine through the foramen ovale, but afterward, on account of the danger of encroaching on the Eustachian tube and the possibility of infection from this tube (his fifth case died from meningitis probably due to such infection), he placed the sharp end of the centre-pin a little external and anterior to the foramen, so that the edge of the trephine opening should be at the foramen itself. The thin lining of the fossa in which the ganglion lies (the lower layer of the dura mater) is then divided, and the ganglion as far as possible removed. If the internal maxillary artery or vein is in the way, it is double- ligated and divided. Care must be taken not to divide the upper layer of the dura above the ganglion (the true dura itself), for by so doing the subdural cavity would be opened. On the inner side the carotid artery and the cavernous sinus must also be avoided. An electric light is almost a necessity.1 The second and third divisions of the fifth nerve are readily found and removed, with as much of the ganglion as can be taken away by Bose’s special hooks, or by a small sharp spoon. Fowler has proposed to attempt the removal of the sensory portion of the ganglion, leaving the motor root intact. Whether this is feasible has not yet been demonstrated. It is certainly desirable, but there is a possible danger that the attempt to preserve the motor root might cause imperfect removal of the sensory portion of the ganglion, and so nullify the whole operation. Of Mr. Bose’s 7 patients, 6 recovered, and of these, 5 at the time of the last report were entirely free from pain, the first having been so for nearly two years. One very nervous patient had slight recurrence. Andrews,2 of Chicago, has also devised several operative methods which differ but little from Bose’s. Mr. Horsley8 proposed an intra- dural method and has operated once. He made a large opening through the squamous portion of the temporal bone, opened the dura, lifted the temporal lobe so as to see the roots of the fifth nerve emerg- ing from the pons, from which they were removed by avulsion. His patient unfortunately died in seven hours from shock. Bichardson has 1 The best light is that of W. A. Hirschmann, of Berlin. It is very bright, and the light can be thrown in any direction, thus making it useful in all other surgical work requiring such illumination. Otto Flemming, of Philadelphia, has made me a very satisfactory storage battery to work the lamp. 2 Journal Amer. Med. Assoc., 1891, vol. ii., p. 168; and 1898, vol. i., p. 180. 3 Brit. Med. Journal, 1891, vol. ii., p. 1191. 636 SURGICAL DISEASES OF THE HEAD. done one operation by this method successfully. The roots of the fifth nerve were not torn from the pons, but were cut by scissors. Hartley, of New York,1 has published still another extradural method, as follows. (Figs. 1694, 1695.) A large osteoplastic flap of scalp, muscle, and bone is made* in the region of the temple. This flap should Fig. 1694. Hartley’s Operation for Removal of the Gasserian Ganglion; Separating the Flap. begin just in front of the auricle, a little above the zygoma, the base being about two inches antero-posteriorly, and the height of the flap three inches. It is best made with Hartley’s or Pyle’s chisels. By two or three elevators placed under the circumference of the bone the flap is raised and its base fractured; the flap is then turned down, ex- posing the dura. The middle meningeal artery may if necessary be ligated, either now or subsequently, just above the foramen spinosum. By the finger the dura is next stripped from the floor of the middle fossa. Care must be taken during this separation that the middle meningeal is not torn at the foramen spinosum. In one of my cases the artery was torn so close to the foramen that it could not be tied. The hemorrhage was gradually controlled, first by the finger and then by packing with iodoform gauze. The dura is separated until the second and third divisions of the nerve are seen. These are divided at their foramina, their distal ends pushed through the latter, and their proximal ends or stumps traced hack to the ganglion. The nerves should be ex- sected together with the ganglion, or the ganglion itself may be destroyed as before. The ganglion in a very few cases has been removed as a rec- ognizable mass. In Stewart’s case (see Table) the first division was re- moved with the ganglion, and yet, strange to say, no trophic changes took place in the eye. Krause2 has described a precisely similar operation, 1 New York Med. Journal, March 19, 1892, and Annals of Surgery, May, 1898, p. 512. 2 Archiv f. klin. Chir., 1892, Bd. xliv., S. 821. REMOVAL OF THE GASSERIAN GANGLION FOR TIC DOULOUREUX. independently of Hartley, by whom, however, he was anticipated both in its performance on the living subject and in publication of the method. In Krause’s case, to check hemorrhage the space between the dura and the bone was packed with iodoform gauze, and under ansestliesia on the fifth day the nerves were divided. I have found this method of performing the operation in two stages very useful, and have adopted it in two out of the three cases I have operated on. In one of them I packed the cavity with a piece of gauze thirty-seven inches long and six inches wide, to arrest the hemorrhage, and left it in the cavity of the skull for three days. No mischief resulted from it. In removing the ganglion care must be exercised not to injure the carotid artery, which can, however, easily be felt and identified by the finger. But more especially must the surgeon be careful of the cavernous sinus, as it cannot be recognized with any certainty, its walls being tense and there being no pulsation. It is an encouragement to know that in Stewart’s case, though the cavernous sinus was opened, yet packing with sponges wrung out of hot water arrested the bleeding, and the operation was successfully terminated, the patient recovering. Fig. 1695. Hartley's Operation for Removal of the Gasserian Ganglion; the Flap Turned Down. In the following table I have collected all the cases which I have found thus far reported. They include cases operated on by every method, and of the 62 cases only 12 have ended fatally, 19.3 per cent., a small mortality, considering the character and newness of the operation. Thus far there has been a moderate recurrence of the neuralgia in one case of Rose’s and in one of my own. It must be remembered, however, that the operations have been reported after a comparatively brief period. It is therefore too early to give a definitive opinion as to the permanency of the cure. It is thus far, however, apparently both a very successful operation and a not very dangerous one. Should a longer experience prove it to be efficacious, it may possibly become the operation of first 638 SURGICAL DISEASES OF THE HEAD. choice in very severe cases of tic douloureux. Should it, however, prove unsuccessful as a permanent means of arresting the pain, it should then be our last resort, and a wise surgeon would begin by the most peripheral operation, and gradually approach the ganglion from time to time, as forced to do so after various recurrences. Even then it would hold apparently an important place as a final means of relief. Operations for the Removal of the Gasserian Ganglion. Author. Reference. Recov. Died. Total. (c) Horsley Brit. Med. Jour., 1891, vol. ii.. p. 1191 1 1 (b) Rose Brit. Med. Jour., 1892, vol. i., p. 261 5 5 (,b) Id Lancet, 1892, vol. ii., p.953 i i 2 (e) Fernandez Siglo Med., Madrid, 1892, pp. 804, 819 ; 1893, pp. 4, l 18, 36 1 (a) Roberts Proc. Pliila. Co. Med. Soc., 1892, p. 490 i 1 (i) Kerr Jour. Amer. Med. Assoc., Feb. 18, 1893, p. 181.. i 1 (b) Lanpliear Pacific Med. Jour., vol. xxxv., 1892, p. 637 i 1 (b) Park Med. News, Feb. 18, 1893, p. 183 o ■2 (b) Andrews Jour. Amer. Med. Assoc., Feb. 18, 1893, p. 180.. 3 l 4 (a) Hartley Annals of Surgery, May, 1893, p. 511 1 1 (b) Parkhill Med. News, Sept. 16, 1893, p. 319 1 1 (a) Krause Annals of Surgery, Sept., 1893, p. 362 5 5 (a) Finney Johns Hopkins Bulletin, Oct., 1893 2 l 3 (a) O’Hara Austral. Med. Jour., Oct. 15, 1893 1 1 (b) D’Antona Brit. Med. Jour., 1893, vol. i., p. 81 1 1 (b) Doyen Rev. de Chir., 1893, p. 391 2 i 3 0b) Camponotto Brit. Med. Jour., Epitome, 1893, p. 102 l 1 (a) McBurney Annals of Surgerv, 1893, vol. i., pp. 516, 519 2 2 (a) Keen & Mitchell . Trans. Pliila. Co. Med. Soc., 1894 1 i (a) Tiffany Annals of Surgery, Jan., 1894, p. 47 4 4 (b) Eskridge & Baker Amer. Jour. Med. Sciences, March, 1894, p. 291 . . l 1 (a) Fowler ... Med. Record June 16, 1894, p. 745. . 1 i 2 (b) Stewart Med. News, Aug. 11, 1894 1 1 (c) Richardson and Walton Boston Med. and Surgical Jour., Nov., 1894 1 1 (b) Dennetieres.... Rev. de Chir., 1894, p. 970 1 1 (d) Quen u Gaz. des Hop., 1894. No. 5 1 1 (a) Thorn Annals of Surgery, March, 1895, p. 296 1 1 (b) Lanphear Jour. Amer. Med. Assoc., April 6, 1895, p. 507... 1 1 (a) Griffith*'.... Ibid., p. 508 l 1 (a) Buchanan . . Med. News, April 27, 1895 .’ i 1 (a) Tiffany... Annals of Surgery, May, 1895 3 3 (b) Eskridge A Rogers Amer. Jour. Med. Sciences, June. 1895 1 1 (b) Camponotto f... Brit. Med. Jour., Epitome, 1895, vol. i., p. 37... l 1 (b) Dandridge Boston Med. and Surg. Jour., 1895, vol. i.-, p. 397 1 1 (a) Mixter Ibid , p. 412 1 1 (a) Keen Unpublished 1 U 2 (b) Cheever. . Personal communication 1 1 ~12 62 Summary. Total No. Recov. Died. Mortality Per Cent. (a) Hartley’s method 29 25 4 13 8 (b) Rose’s “ 29 23 6 20.7 (c) Horsley’s “ 2 1 1 50.0 (d) Combined “ of Hartley and Rose 1 1 (e) Unknown “ Reference could not be verified 1 1 100.0 62 50 12 19.3 * Ganglion not removed on account of hemorrhage. Death from meningitis on third day. t This is said to be Camponotto’s third case. I have not seen a reference to his second. X This patient died from an infection by an assistant. SURGERY OF THE VENTRICLES. 639 Of all the methods proposed, that of Hartley and Krause seems to he the best. Rose’s operation has the disadvantages that the muscles of mastication on one side are paralyzed, and that the lower jaw may be dis- placed so that the teeth are no longer opposed. The parotid has been wounded and the seventh nerve paralyzed. The im- mediate proximity of the trephine opening to that of the Eustachian tube has twice induced death from septic meningitis. In the small number of cases thus far reported, the mortality by Rose’s method is some- what greater than by Hart- ley’s. Fig. 1696 shows the result in one of my cases. Surgery of the Lateral and Fourth Ventricles IN RELATION TO INCREASED Intracranial Pressure. Puncture of the lateral ventricles through the an- terior fontanelle for hydro- cephalus is an old opera- tion, but in 1881 Wernicke first proposed trephining and puncture of the ven- tricles in completely ossi- fied skulls, and again Zenner, of Cincinnati, in 1886 made a similar suggestion. The first publication, however, in which the steps of the operation were distinctly formulated was a paper which I read before the College of Physicians of Philadelphia, on Nov. 7, 1888.1 In Au- gust, 1890, before the Tenth International Medical Congress in Berlin, I presented an elaborate paper, covering the whole surgery of the lateral ventricles up to that time.2 The earliest case in which the operation was done, though not re- ported till after my paper was published, was that of von Bergmann,3 on July 15, 1887, and the second operation was by Ayres and Hers- man on Dec. 4, 1888.4 The third case operated on was my own, on Jan. 11, 1889, and the fourth was that of Mr. Mayo Robson, on Feb. 7 of the same year.5 Since then a considerable number of cases have been operated on, some of which will be referred to hereafter. Fig. 1696. Successful Removal of Gasserian Ganglion by Hartley’s Method. The last of fourteen operations for tic douloureux. 1 Med. News, Dec. 1, 1888. 2 Unfortunately the MS. of this paper, of which I had no copy, wras lost by the authorities of the Congress, and only a resume wTas printed in the Med. News, Sept. 20, 1890, Lancet, Sept. 13, 1890, and Rev. de Chir., 1891, p. 45. 3 Chir. Behand. d. Hirnkrank., 1889. 4 Pittsburg Med. Review, March, 1889. 6 Brit. Med. Journal, Dec. 6, 1890. 640 SURGICAL DISEASES OF THE HEAD. In my first paper I described three different routes by which the lateral ventricles could be reached; the frontal, the occipital, and the lateral. The lateral is decidedly the best route (Fig. 1697), inasmuch as it passes through no important brain centres, and by it the ventricles can be reached with accuracy. A trephine opening half an inch in diameter is made an inch and a quarter behind and the same distance above the meatus. The brain is then punctured by a tube, No. 5 of the French catheter scale, or by any other suitable instrument, directed to- ward a point (A) inches vertically above the opposite meatus. At a depth of about If or inches, or less, according to the distention of the ventricle, its cavity will be reached. This can almost always be deter- mined by a sudden diminution of pressure, and by the immediate es- cape of the cerehro-spinal fluid. Continuous drain- age may be kept up, in small amount, by three or four stout, doubled horsehairs, introduced through a canula, or by a rubber or other drain- age tube. In my first case, on the 32d day, by a fountain syringe, the bag of which was raised 6 inches above the head, after tapping the opposite ventricle, the cavities of the two ventricles were irrigated from side to side by a warm boric-acid solu- tion, gr. iv. — f 3 i., with not a little comfort to the child. Boiled water, which was used two days subsequently, gave less relief, but produced no ill effects. The child died on the 45th day, the wound remaining absolutely aseptic. Finding the drainage too sudden, and that the withdrawal of the fluid produced convulsions, in my second case I siphoned from a height of 8 inches, 8 times in succession, from half an ounce to an ounce of warm boiled water, each siphonage being followed by an arrest of the convulsions. The object to be attained by this operation may be the relief or cure of hydrocephalus or porencephalus, the relief of intracranial pressure, or possibly the evacuation of an abscess or of a collection of blood in the ventricles. The conditions of chronic hydrocephalus and porencephalus may be considered together, as they are not unlike. It is probable that only a very small number of cases of hydrocephalus can thus be cured, but the disease is so distressing and fatal that an attempt to give relief in reasonably favorable cases seems proper, especially as there are on record several instances in which benefit has been obtained. Among those ter- minating fatally were my own second and third cases, and several re* Fig. 1697. Puncture of Lateral Ventricles by Lateral Method. SURGERY OF TIIE VENTRICLES. 641 corded by Thiriar,' Andry,2 Phocas,3 Mayo Eobson,4 Manny,6 Walker,15 and others. But on the other hand Broca 7 reports a case with con- tracture of the left arm in which the right ventricle was drained for two weeks, and in which the operation was followed by entire relief of the contracture, so that the child could use its arm; by the disap- pearance of the strabismus; and by the beginning of the ability to walk at the time the case was last seen, six weeks after the operation. In a case recorded by7 Phocas there was improvement, and the child was liv- ing four months afterward. In addition to this, Kocher8 has reported two cases of recovery after operation for porenceplialus, which are es- pecially worthy of notice. The first patient, a child of 15, had a fall at one and a half years of age. At four, attacks of unconsciousness developed, and subsequently epileptic attacks, begin- ning in the left arm, which became paretic. At the operation, Feb. 26, 1889, the skull was trephined in the occipital region, and a large porencephalic cavity was opened, laying open the lateral ventricle, so that the choroid plexus was seen. Drainage, with copious flow of cerebro-spinal fluid, was kept up for four weeks. The flow altered greatly with the position of the child, and it is remarkable that as an aid to evacuation of the fluid the head was bent forward, so that the air was sucked into the sac, and on replacing the head in the vertical position the fluid escaped freely, yet no infection seems to have followed. At first arrest of drain- age caused renewed attacks, but finally the fistulous track of the drainage tube healed, and the child entirely recovered. The second patient, a girl of 17, had her head injured by forceps at her birth. Her epileptic attacks set in at 3 years of age, as many as two to three in a day. A large porencephalic cavity was found in the anterior part of the brain, leading into the lateral ventricle, and the corpus striatum was seen. Two hundred cubic centimetres of fluid were evacuated, and three months afterward the drain had closed and the girl had recovered. I have seen but a single case operated on,9 one with athetoid move- ments, in which the patient died after the operation, of scarlet fever. The porencephalic condition of the brain was not recognized until the operation revealed it. In acute hydrocephalus, the case of Mayo Eobson 10 is the first one which has ended in recovery after operation. Hahn 11 reports a still more noteworthy case, of a butcher 35 years of age, who suffered from entire blindness in one eye, with impairment of hearing and smell, loss of memory, and headache. Cysticercus was suspected, and he was tre- phined in the frontal region. The conclusion was reached that the very marked increasing bulging of the brain through the opening was due to intraventricular pressure, whereupon the ventricle was punc- tured with a hypodermic needle, and 120 cubic centimetres of watery fluid were withdrawn. The brain substance receded at once, and re- covery was complete, except for monocular blindness. Soderbaum 12 has reported the case of a girl, almost in a comatose condition, with facial palsy, convulsions, and vomiting, whom he trephined, making I Broca, Rev. de Chir., 1891, p. 87. 2 Progres Med., 1892, No. 9. 3 Rev. Mens, des Malad. de l’Enfance, Fev., 1892. 4 Loc. cit. 6 Rev. de Chir., 1893, p. 388. 6 Med. and Surg. Reporter, vol. lxiii., p. 216. 7 Loc. cit. 8 Deutsche Zeitschr. f. Chir., Bd. xxxvi., 1893, S. 72. 9 Willard and Lloyd, Amer. Journal Med. Sciences, April. 1892. 10 Loc. cit. II Twenty-second Cong, of German Surgeons, 1893; Med. News, May 6, 1893, p. 500. 12 Annals of Surgery, 1892, vol. xv., p. 467. 642 SUKGICAL DISEASES OF THE HEAD. several deep punctures and evacuating “ an unusual quantity of serum.” Entire recovery followed. The author suggests that either a cyst or the ventricle was punctured. It would seem probable that the latter was the more likely conclusion. McCosh 1 narrates a case in which there was doubtful prior epilepsy. Sub- sequently, at 29 years of age, the patient fell downstairs. This was followed by partial and temporary paralysis of the left arm. Epileptic convulsions ensued, as many as five in the 24 hours, with rapidly increasing weakness and headache. A quarter-inch button of bone was removed over the lateral sinus; no clot was found, but there were evidences of great intracranial pressure, and there was marked bulging of the brain. Punctures in different directions gave no result. Finally, by puncturing the right lateral ventricle fluid was found. An ounce of fluid was drained off in 48 hours, when the canula was removed. At the end of two weeks the patient was out of bed, and in five weeks there was en- tire recovery, with no headache. Markedly increased, acute, intracranial pressure is due commonly to an accumulation of cerebro-spinal fluid in the ventricles, not only from hydrocephalus, hut especially from pressure on the aqueduct of Sylvius, chiefly by tumors of the pons or cerebellum. It is of course impossible to expect any cure from the mere evacuation of the pent-up cerebro- spinal fluid, but the relief which was obtained in a case reported by Mills and Hearn2 was so noticeable that, as a palliative measure, it seems en- tirely justifiable. In this case the patient was blind and deaf, and the only means of communicating with him was by tracing German letters on the palm of his hand. His headache was atrocious, so that life was absolutely a burden. At the operation Dr. Hearn tapped the lateral ventricle, withdrawing a large amount of fluid; and though the patient died on the fifth day, yet the relief which he obtained from his intense headache was as justifiably procured by this surgical procedure as it would have been by a hypodermic injection or other medical means. The lessened suffering in my first case, in which a tumor of the cere- bellum was found, was quite marked. Diller3 records also a case of tumor of the pons in which he tapped the ventricle, with relief of pres- sure, although there is no especial statement as to the influence on the suffering of the patient. Instead of draining the cerebro-spinal fluid directly from the ven- tricles by tapping them, Wynter4 proposed to drain it away indirectly by puncturing the membranes of the cord in the lumbar region. He has reported four cases, with temporary improvement, but ending fatally. Quincke 6 has reported ten similar operations for hydroceph- alus, the treatment being combined with pressure on the skull at the same time. One patient was cured. In two cases the result was prob- ably due to the other means employed. In three there was temporary improvement. None of the patients died. Ziemssen 6 has also operated on some cases. • Quincke calls attention to the fact that in infants the cord extends to the third lumbar vertebra, and that hence the puncture should be 1 Med. Record, Sept. 16, 1893, p. 376. 2 Phila. Hosp. Reports, vol. i., p. 270, and Proc. Phila. Co. Med. Soc., Dec. 11, 1890. 3 Amer. Journal Med. Sciences, 1892, vol. ii., p. 509. 4 Lancet, 1891, vol. i., p. 931. 5 Berl. klin. Woch., 1891, Nos. 38, 39. 6 Verliandl. d. 12ten Kongress. f. inner. Med., 1893, S. 197. SURGERY OF THE VEXTRICLES. 643 made in the third or fourth intervertebral space. This measures 18 to 20 millimetres transversely and 10 to 15 millimetres longitudinally, the cauda equina being in two lateral bundles with an interspace of 5 milli- metres. The depth of the puncture to reach the cord in infants is about 2 centimetres, and in adults from 4 to 6 centimetres. Parkin 1 has proposed and practised still another method. (Fig. 1698.) He trephined three-quarters of an inch below the superior curved line of the occipital bone, just to the right of the middle line, and enlarged the open- ing downward by a rongeur forceps. After opening the dura he inserted a probe into the fourth ventricle, lifting the cerebellum to a slight extent, when two to three ounces of fluid “ gushed out. ” Temporary improvement was followed by death in 16 hours after the operation. Morton,2 commenting on this proced- ure, calls attention to the fact pointed out by him3 that the opening between the fourth ventricle and the subarachnoid space of the cord is always patent in tubercular meningitis, but he doubts whether Parkin’s operation will do any good, and objects to it as involving a dangerous locality. Parkin 1 has reported four cases with two recoveries, and Ord and Waterhouse5 have recorded another recovery. Fig. 1698. Vertical Section of Base of Skull immediately to Right of Median Line, a, Basal subarachnoid cavity and its relation to cerebellum; b, fourth ventricle; c, site of trephine opening. (Parkin.) Abscess Bursting into the Lateral Ventricle.—It is of course very rare that it would be possible to save life in so fatal an affection as abscess of the brain bursting into the lateral ventricle. I know of no recorded case in which this has been accomplished. Sheen,6 how- ever, reports the case of a patient who received a blow on the head, fol- lowed by an abscess which was evacuated and drained for three weeks. The autopsy revealed the fact that the tube was in the lateral ventricle. Certainly in so fatal a disease the resort to a desperate remedy seems justifiable, unless experience shall show that it will be of no value. In case of rupture of an abscess into the ventricle, I should propose instant bilateral trephining and washing out of the ventricles with a boric-acid solution. It must not be forgotten, however, that the foramen of Monro is sometimes closed, when only one ventricle could thus be washed out. Usually, however, in that case only one side would be involved in the disease. Such closure has been reported by me in my third case, and also by Pott.7 1 Lancet, 1893, vol. ii., p. 21. 3 Brit. Med. Journal, 1893, vol. i., p. 741. 4 Lancet, 1893, vol. ii., pp. 23, 1244. 6 Brit. Med. Journal, 1890, vol. i., p. 236. 1 Med. News, Sept. 20, 1890, p. 290. 2 Ibid., p. 194. 5 Ibid., p. 878. 644 SUROICAL DISEASES OF THE HEAD. Hemorrhage into the Lateral Ventricle.—Dennis1 removed a clot in a patient aged 36 years, who had received a blow on the head and was trephined six hours after the accident. No clot being found, either outside or under the dura or in the brain substance, an incision was made directly into the ventricle, when a clot about the size of a pullet’s egg shot out with such force as to fall several feet away from the patient’s head. Death followed, however, in. three days, as a result of the great laceration of the cerebral substance. The ventricles have also been ruptured in cases of compound fracture, two such cases at least having been recorded, both ending in recoverey. Of secondary rupture of the ventricles quite a large number of cases are now on record, and in over one-half recovery has followed surgical treatment. In my paper before the International Congress I called at- tention to five cases of rupture of the lateral ventricles from simple fracture, all in young children, and three terminating favorably. In such cases as a rule no operative interference should be attempted un- less threatening symptoms supervene. 1 New York Med. Journal, 1892, vol. lxvi., p. 701, INJURIES OF THE BACK. BY LEWIS A. STIMSON, M.D., PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF THE CITY OF NEW YORK. Dislocations, Fractures, and Fracture-Dislocations of the Vertebra. It seems desirable, in view of the increasing frequency of resort to operation in spinal injuries, to call attention to the possibility of com- plete, irremediable, instantaneous destruction of the spinal cord with- out permanent displacement or recognizable deformity of the column. The injury appears to be produced in some cases by overstretching of the cord in forced flexion of the column, especially in the cervical re- gion, aided sometimes by fracture of one or both laminae; when the flex- ion ceases the parts are at once restored to place, and no deformity remains to indicate what has occurred. The following case, reported by Dr. Edward 0. Otis,1 is quoted in illustration: A lad, 17 years old, fell about five feet, head-foremost, upon a mattress in a gymnasium, striking in such a way that his head was bent so far forward that his face must almost have rested upon his breast. Complete paralysis from a little below the clavicles. He survived until the sixth day. The autopsy showed a fracture of the laminae of the fifth and sixth cervical vertebrae, but no displace- ment, and no rupture of any of the ligaments of the spinal column. At the point corresponding to the fracture the dura was moderately injected, and the cord was soft and diffluent. A somewhat similar case was reported by Dr. McBurney to the New York Surgical Society in 1892; the patient, an elderly man, fell down- stairs and was completely paralyzed below the neck, except the dia- phragm. He survived a week in perfect bodily comfort and died sud- denly. The autopsy showed a transverse horizontal fracture of the body of one of the cervical vertebrie without displacement, and a com- plete division of the cord. Treatment of Fractures and Fracture-Dislocations.—It is not easy at the present time to la}T down positive rules for the treatment of these injuries, for various modifications of, or additions to, those that have heretofore seemed proper and sufficient are now undergoing trial. The tendency is decidedly toward more active interference; attempts 1 Boston Med. and Surg. Journal, Sept. 15, 1892. 645 646 INJURIES OF THE BACK. are made to correct displacements by traction, by direct pressure, and by bending the spine, usually backward ; the latter may be effected by passing a stout bandage under the patient as he lies on his back, so that it rests against the projecting spinous process—for example, at the lower dorsal or lumbar region—and then lifting the body by means of this bandage. Traction is made by fixing the head, or the head and shoulders, and then raising the end of the bed or the plank dpon which the patient rests so that the body shall tend to slide gently downward away from the head. Immediate fixation to secure such gain as has been thus obtained may be effected by a plaster-of-Paris jacket. A more convenient method than the use of the ordinary roller bandage is to prepare a pad of about a dozen thicknesses of crinoline of suitable length and breadth, and saturated with plaster cream; this is passed under the patient, and the ends are brought up on either side to overlap in front. A smoother fit can sometimes be got by splitting the ends so as to make a “ many-tailed” or Scultetus bandage. Dr. Woodbury, of New York, has adopted the ingenious plan sug- gested in cases of Pott's disease by E. Davy, of suspending the patient horizontally upon a strip, or sort of hammock, of stout muslin, and then including it in the turns of a plaster roller. After the plaster has set, the muslm is cut off at the upper and lower edges of the jacket. In some cases the application of a plaster jacket, without any attempt to rectify any displacement that has been present, has been promptly followed by marked amelioration of the symptoms and an ultimate cure. On the other hand, traction by partial suspension, as just described, has occasionally given rise to unfavorable, and even to alarming, symptoms. On the whole, it seems proper to say that we have, in cautiously made partial suspension by the head, or head and shoulders, a safe means for correcting or diminishing certain displacements after fracture, and in immobilization of the trunk by a plaster-of - Paris jacket a means of avoiding secondary or recurrent displace- ment during repair. Operative Treatment.—The experience gained during the last few years has shown that under the protection of modern methods of operat- ing and dressing, the dangers of cutting down upon the spinal column and opening the spinal canal are much less than they formerly were, or were supposed to he. Unfortunately an affirmative gain, the proof of its ability to relieve, has not been so fully established. This experience has been collected and thoroughly studied by Dr. J. William White in a paper read before the American Surgical Association in 1891, and published in its Transactions for that year. To it the reader is referred for details that cannot be repeated here. In order to determine as far as possible the present risk of such oper- ative interference, Dr. White has collated only those cases in which the wound was treated antiseptically; there are 37 operations for fracture, with 6 complete recoveries, 6 recoveries from the operation with benefit, 11 recoveries unimproved, and Id deaths, a mortality of thirty-eight per cent. In how many of these cases the fatal result was occasioned or hastened by the interference cannot, of course, be positively deter - DISLOCATIONS, FRACTURES, AND FRACTURE-DISLOCATIONS. 647 mined, but a review of the histories indicates that asepsis is as potent to prevent inflammation of the cord and its membranes, as well as sup- puration of the wound, as it is to prevent similar complications of wounds of other regions; that serious hemorrhage is not to he feared, although one of the deaths appears to have been caused by it; and that the loss of cerebro-spinal liquid is without important consequences. Moreover, the removal of the spinous processes and laminae of even sev- eral adjoining vertebrae does not appear seriously to weaken the spinal column. This seems satisfactorily to remove the objection against in- terference based upon the theory that in itself it seriously endangers the patient’s life, and relieves its advocates from the necessity of show- ing great gains to compensate for great risks. Even small gains may be a sufficient justification. The indications for operation are to relieve pressure upon the cord by fragments, by the displaced vertebrae, or by extravasated blood, and, if necessary and practicable, to correct deformity. The relief of pressure upon the cord in order to favor the re-establishment of function and oppose secondary ascending degeneration, is the chief, and practically the only, indication. The question before us, then, is: to what extent are we justified in believing that this indication can be met by opera- tion? Until within a few years it was very generally believed that, in almost all cases of fracture, the pressure was made upon the front of the cord by the upper edge of the body of the vertebra across which it was stretched by the bodily displacement forward of the next upper ver- tebra, and the inaccessibility of this projecting edge was one of the reasons urged against operation. Later investigations have shown that the proportion of cases in which the fracture is limited to the laminae, and in which the pressure is made by a depressed portion of the posterior arch, is very much larger than was supposed, and several operations have shown that even in the other and commoner form the resection of the posterior arch of the upper vertebra, the one that has been displaced forward, will sometimes relieve the pressure upon the cord, which is pinched between this arch and the underlying verte- bral body rather than stretched across the latter. In such cases the operation is fully competent to relieve. When the pressure is made by. blood extravasated within the canal, or within the dura, the operation is also competent to relieve, but it is powerless against hemorrhage into the central canal or into the substance of the cord. In respect of the degenerative changes in the cord set up by the traumatism, it can only be said that in some cases they begin promptly, advance rapidly, and do not disappear on the removal of pressure, while in others marked improvement has set in after the lapse of many weeks. Possibly in the first group the original injury has been a crush or laceration of the cord, not simply its compression. Examination of the results according to the region involved shows that the proportion of successes is very much greater in injuries of the lumbar and lower dorsal vertebrae than in those at higher points. In- juries of the cauda equina resemble those of peripheral nerves rather than those of the cord, and the hope of restoration of function after the relief of pressure is much greater. So, too, in injuries of the lower por- tion of the cord, while the cord itself may be permanently disabled, the enveloping nerves originating at higher points may regain their function. 648 INJURIES OF THE BACK. Probably the recognition of a condition of the cord that may be benefited by operation will not often be possible, and the operation, if undertaken, will almost always begin as an exploration, so that in most cases the question that the surgeon has to ask himself is, whether or not an exploration is likely to furnish information the importance of which will outweigh the dangers of the exploration itself. In certain groups of cases this question, according to our present knowledge, must be answered in the negative. In recent cases of fracture by forcible flexion (indirect violence) of the cervical or upper dorsal spine, in which there is paraplegia but little or no displacement, operation seems unjustifiable because of the probability that the cord has been completely divided or pulpifled; and the same argument and conclusion will apply in fractures at any point, effected by great violence and accompanied by marked displacement. In recent cases of fracture by direct violence, cases in which depres- sion of a portion of a posterior arch can be made out or reasonably sus- pected, operation is justifiable, especially if the injury is in the lower dorsal or lumbar region. Other cases in which operation is deemed justifiable are those in which degenerative changes appear promptly and rapidly increase, those in which the cauda equina alone is compressed, those in which it is believed that the cord is compressed between the posterior arch of one vertebra and the body of the adjoining one, and those cases in which after the lapse of eight or ten weeks improvement in function has re- mained wholly absent or has ceased, bed-sores have formed, and there is incontinence of urine or faeces. In short, in the present state of our knowledge, the immediate risks connected with an exploratory incision into the spinal canal are so small that such an exploration may properly be undertaken when- ever there is a reasonable expectation that it will disclose a condition of the cord that can be relieved. The details of the operation, as described by White, are in the main as follows: The patient lies face downward. An incision, from four to six inches long, is made in the median line along the spinous processes, its centre opposite the seat of the fracture; the muscles on each side are separated from the spines and laminae, and the periosteum is stripped from the latter. Hemorrhage must then be completely stopped by ligatures, clamps, and sponge-pressure. The muscles on each side are drawn aside with sharp retractors, and one or two spinous processes cut away close to their bases with strong forceps. This greatly facili- tates approach to the laminae. The laminae are next cut through as close as possible to the transverse processes with bone forceps, rongeur, saw, chisel, or small trephine, and after removal of the central portion the opening may be enlarged laterally by cutting away the stump with the rongeur. Some surgeons, such as Dr. Abbe, have sought to expedite the opera- tion, and to diminish the amount of bleeding and interference with the solidity of the spine, by making the incision close beside the spinous processes and stripping the muscles away on one side only; then three or four spinous processes are isolated by cutting through the inter- spinous ligaments above and below them, and they are next cut away from the laminae with forceps or rongeur; they can then be retracted GUNSHOT WOUNDS OF THE SPINE. 649 en bloc toward the other side, so as thoroughly to expose the whole of the posterior arch, when the laminae are cut away piecemeal with the rongeur. If the presence of blood or pus respectively within the dura is indi- cated by a dark purplish or yellowish color, it will be proper to open into the subdural space, which is best done by picking up the dura in the median line with fine forceps and cutting through it with scissors. This incision may be closed with fine sutures. Gunshot Wounds of the Spine. Further experience has shown that the prognosis under antiseptic treatment is rather better than it was thought to be ten years ago, and even that operative interference is not to be quite so absolutely re- jected. Vincent1 has collected thirty-three cases, many of them of re- cent date, and has carefully reviewed the subject. Bacteriological ex- amination of the bullets of fixed ammunition has shown that they are remarkably free from infective microbes, and the natural inference that the wound inflicted by them would be likely to heal kindly if pro- tected from subsequent infection, has been confirmed by experience. It is no longer deemed essential that a bullet should be removed from a wound in order to avoid suppuration; the necessity for its removal arises from other conditions, such as its mechanical interference with the integrity or the function of important structures. This principle, which has been amply demonstrated in respect of other tissues and organs, has also been proved for bullet-wounds of the vertebral column, and even when the bullet has penetrated to the spinal canal. In a case under my care at the Chambers Street Hospital in 1890, the patient sur- vived the injury a week, and died apparently of causes not connected with the wound ; the autopsy showed the bullet lodged within the spinal canal at the twelfth dorsal vertebra, but without perforation of the dura, and its track showed only the evidence of advancing repair. The first impact of the bullet had caused a temporary paraplegia, which had disappeared by the second day. In respect to the propriety of operative interference, the statement of Dr. Lidell that “ the operation of resection or trephining the vertebrae is unjustifiable, because it does not offer a reasonable prospect of im- proving the patient’s condition in any case, while, on the other hand, there is always reason to fear that it may increase the chances of a fatal termination,” is certainly too sweeping; not only have several patients recovered after such interference, under circumstances which indicated that the operation had favorably influenced the course of the case, but the experience of the last few years in the operative surgery of the spine has shown that the removal of considerable portions of a vertebra, and even of several adjoining vertebrae, may be effected with safety if proper precautions are taken to secure and maintain surgical cleanliness of the wound. The plan of treatment that now seems best for these rare injuries is simple disinfection of the wound by irrigation, in recent cases without important nerve-symptoms, and the use of a protective dressing in the 1 Revue cle Chirurgie, Fevrier, 1892. 650 INJURIES OF THE BACK. hope of obtaining primary union. That failing, or in cases in which there is reason to think that the bullet or fragments of the vertebrae have lodged in the spinal canal and are pressing upon the cord, the wound should be freely enlarged to give ready access to the bone and permit the removal of such fragments or of the bullet if present. Such treatment may not lead to the repair of a divided or crushed cord, but it may save one that has only been compressed from permanent degenera- tion, and it will diminish the risks incident to the period of repair. Concussion of the Spine, and Remote Effects of Spinal Injuries —“Railway Spine.” As was stated in the note added by the editor to Dr. Lidell’s article in Vol. IV., that article was written before the publication of Mr. Page’s important book upon the same subjects, and consequently be- fore the marked change in current professional opinion concerning them which followed that publication. The reaction from Mr. Ericli- sen’s extreme views, which was anticipated from the beginning by many who appreciated the speculative character of the basis upon which they rested, has gone on to an almost total overthrow, and has practically removed the subject from the domain of the surgeon to that of the neurologist. Among the earliest of those who suggested the hysterical or neurasthenic character of the symptoms attributed to structural injuries of the cord, may be mentioned Drs. Putnam and Walton, who published papers in the Boston Medical and Surgical Jour- nal and in the Archives of Medicine, in 1883. Of the work done by surgeons, by far the most important is to be found in Page’s book already mentioned, and in Thorburn’s “Contribution to the Surgery of the Spinal Cord,” published in 1889. Of late many neurologists have studied the subject, with more or less detail and with more or less dif- ference of opinion—Charcot, Oppenheim, Thomsen, Klein, Brissaud, and Grasset. Those who are interested in the subject will find a full bibliography up to date in Thorburn’s book, and some later references in the writings of Charcot1 and Brissaud.2 The belief in the alleged nosological entity termed “concussion of the spinal cord” appears to have little or no other support than an argu- ment by analogy from “concussion of the brain,” and on examination it is evident that the analogy is not close. It is now very generally held that in concussion of the brain there are recognizable structural lesions which may properly be regarded as slight forms of contusion, lesions consisting mainly in rupture of small vessels, with consequent extravasation of blood, and apparently produced sudden movement of the cerebro-spinal liquid occasioned by abrupt temporary change in the shape of the skull, or by shifting of the cerebral mass within it. The physical conditions which favor the production of such lesions in such a manner within the skull, are not found in the spine. The cord is much more perfectly protected than the brain against movements within its bony case, and the waves of the liquid within the skull have no counterpart within the spine. In cases of extreme violence to the skull and brain, the wave has sometimes been traced down the central 1 CEuvres, tome iii., 1890. 2 Gaz. des Hopitaux, 23 Nov., 1889. CONCUSSION OF THE SPINE AND REMOTE EFFECTS OF SPINAL INJURIES. 651 canal of the cord, but such an effect is only a relatively unimportant addition to the cerebral lesions. The slighter lesions found in the cord after injury of the spine are probably the effect of direct pressure by a temporarily displaced verte- bra (contusion), or of forcible elongation of the cord during a momen- tary diastasis of the corresponding portion of the spine. In Mr. Page’s summary of his analysis of cases of alleged concus- sion,1 he says: “ We have thus been able to briug together a considerable number of cases of so-called concussion-injury of the spinal cord, and among them we have seen how few there are in which there has not been damage likewise to the spinal column. . . . We have endeavored upon anatomical grounds to show that the spinal cord shares but little of the risk of the brain to suffer lesion from blows directly inflicted upon its bony covering; and we have appealed to the unwritten experience of surgeons as to the rarity of lesions of the spinal cord in the absence of injury to the form, structure, and integrity of the spinal column. . . . And this fact is very prominent, that there is no evidence to show that the spinal cord can receive concussion-injury without the manifestation of undoubted symptoms, or that the cord itself can meet with structural traumatic lesion without the appearance of those symptoms immediately upon the injury.” As the result of such study and of such advance in our knowledge of the subject, it is not singular that the theory that the spinal cord is peculiarly liable to injury in railway accidents has ceased to be re- garded with favor. The “ railway-spine” of Mr. Erichsen had a bril- liant but brief career, and soon gave place to the “railway brain,” because the symptoms marking the condition were in the main cere- bral, not spinal. But as Mr. Tliorburn says, this change is but one step toward the truth; we still need more knowledge of the conditions grouped under that term. Study of the subject has tended steadily to bring the cases into the class of functional disturbances of the nervous system, neuroses or psychoses, and authors now use the terms “trau matic neurasthenia,” “traumatic hysteria,” “traumatic neuroses,” and “traumatic neuropsychoses.” The paralysis, the anaesthesia, the limi- tation of the field of vision, the long and varied group of symptoms formerly thought to indicate chronic inflammatory changes in the spinal meninges or in the cord, are now seen to be identical in character and, behavior with the similar symptoms observed in cases of undoubted hysteria, and Charcot has shown that similar conditions can be pro- duced by suggestion during hypnotic sleep. This latter fact has sug- gested an explanation of some of the symptoms on the theory of “ auto- suggestion.” The symptoms vary greatly in degree, character, and duration. Mr. Tliorburn groups them as those of acute and chronic hysteria. In the first he places those explosive “hysterical” manifestations with which all are familiar—screaming, crying, laughter—which soon pass away and leave no trace; also a second form, a condition of temporary oblivion in which the patient is not unconscious in the usual sense of the term, walks and talks, but remembers nothing of what he has said or done. Mr. Tliorburn compares it to somnambulism. Such persons, too, often have extraordinary ideas as to what occurred at the time of the acci- dent. and give circumstantial accounts of purely imaginary occur- 1 Injuries of the Spine and Spinal Cord, etc., p. 49. 652 INJURIES OF THE BACK. rences. The symptoms of the chronic form (following Thorburn) may be: (1) psychical, including epileptiform attacks and hysterical insanity, (2) motor, including paralysis and contractures of the limbs, and spe- cial effects upon such organs as the larynx and the bladder; (3) sen- sory anaesthesia, hyperesthesia, and paresthesia of the general or special sensory nerves; and (4) vasomotor, secretory, and trophic changes. In most cases there are also symptoms which are rather to be regarded as the effects of combined neurasthenia. With reference to the prognosis, Thorburn says that if there is no pecuniary complication, that is, if the patient has no claim for dam- ages because of the accident, and if proper treatment is promptly insti- tuted, complete recovery within a few weeks may be confidently expected; if, in the same absence of pecuniary complications, treatment has been delayed, recovery will require more time. If, on the other hand, the patient has a claim for compensation, the symptoms will be markedly aggravated and recovery will be delayed until after the set- tlement of the claim; everything, in such a case, tends to fix the idea and to rivet the suggestion on a mind weakened by the worry of legal proceedings, and by the fear of the popularly accepted fate of the vic- tim of “railway spine.” In the male the symptoms appear to be more fixed than in the female. A neurotic tendency, hereditary or acquired, and chronic alco- holism make the prognosis worse. Marked fluctuation in the symp- toms, in degree or place, is highly favorable. The indications for treatment are to improve the general condition and diminish the neurasthenic prostration, and as far as possible to avoid all that tends to fix the morbid ideas. Separation from friends and relatives is advisable, cold bathing, over-feeding, massage and faradism of the paralyzed parts. The bromides are to be avoided, be- cause of their tendency to increase the neurasthenia. It is said that good results have been obtained by hypnotism. DISEASES OF THE SPINE. BY DE FOREST WILLARD, M.D., CLINICAL PROFESSOR OF ORTHOPAEDIC SURGERY IN THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PRESBYTERIAN HOSPITAL, PHILADELPHIA. Spina Bifida. It would be an advantage if the old name of “spina bifida” could be dropped, and a term adopted which would more accurately describe the actual pathological condition, since the spine is not really bifid. The defect actually consists in the absence of a portion of the vertebral arch, with a protrusion of the contents of the canal, either meninges or cord. Rachischisis posterior, Schistorachis (cleft spine), or Atelora- chidia (defective spine), would more correctly designate the condi- tion. When the meninges alone protrude through the opening, the tumor is a meningocele; when the cord contents also emerge, it is a myelomeningocele. The terms hydro-meningocele, myelo-cystocele, etc., are also employed. Spina bifida anterior occasionally occurs from a defective vertebral body. These tumors occurring in the pelvis may present themselves in the vagina or rectum, and have been operated upon with fatal results, as instanced by Doughty, Thomas, Emmet, and others. Spina bifida oceulta is caused by a defect in the lumbar region. The tumor is covered with skin and with an excessive growth of hair.1 Koch,2 Dareste, Lebedev,3 and others do not assign to hydrops as great an influence in the etiology of spina bifida as do earlier authors. Koch believes that the bony defect is rather due to the failure of separation between the cutaneous and medullary layers after the formation of the medullary canal. The consequent septum between the neural tube and the skin prevents the osseous and muscular tissues from uniting at the median line, thus permitting hernia of the contents. The report of the London Clinical Society’s Committee gives the pro- portion of cases in which the spinal cord enters the sac as sixty-three per cent, and while this may not be true as regards the cord, yet there is no doubt that nerve elements enter the sac in even a much larger proportion of cases. Thorburn reports a peculiar case of cicatrization of a spina bifida which compressed the cauda equina, producing anaesthesia and ulcera- tion of the legs, while the walk was tabetic. 1 Keating’s Encyclop. Dis. Children, vol. iv., p. 733. 2 Beitriige zur Lehre der Spina Bifida. 3 Virchow’s Archiv, 13, Bd. lxxxvi., S. 263. 653 654 diseases of the spine. In a case now under my care, there is total loss of both motor and sen- sory power from below the line of the tumor in the lumbar region, and the trophic changes are so great that large bedsores almost constantly form beneath the buttocks and on the posterior parts of the thighs. When the serous accumulation is contained in the dilated central cavity of the cord, the condition is known as syringo-myelia (y'W’, a tube, and marrow), hydromyelia, or hydrorachis interior, a con- dition which is followed by a peculiar train of s}Tmptoms, recently closely studied and well described by Sinkler,1 Lloyd,2 and others. In only a few cases has the condition been diagnosed during life. Lloyd 3 has recently shown that injury of the cervical cord may produce simi- lar symptoms in certain cases. The principal symptoms are loss of power, muscular atrophy espe- cially in the upper extremities, and loss of thermal sense together with great alterations in both tactile and pain sensation. When there is ex- treme loss of sensibility in the arms and marked trophic changes, the condition is known as Morvan’s disease. Symptoms and Diagnosis of Spina Bifida.—The skin covering the tumor is at birth frequently in an unhealthy state of ulceration, but has a tendency to heal if friction is avoided. In well-formed cases there is no difficulty in diagnosis, but in cases where the communica- tion with the canal has been severed, the differentiation from congeni- tal cystic and other tumors will often be difficult. In several instances I have noted marked dimples and depressions over the sacrum, which were apparently the result of an incomplete but cured spinal defect. The depression so frequently found upon the tumor of spina bifida indi- cates either the point of attachment of the membranes or that of termi- nation of the spinal cord. Tumors containing foetal remains are sometimes found in a central dorsal position. Perforative ulcer is not infrequently associated with anaesthesia and paralysis. Treatment of Spina Bifida.—As a protective measure I have found a wide pad of close-fitting leather most effective. An asbestos cloth which can he purified by fire when soiled with urine, lined with linen, is also advantageous. Gutta-percha and celluloid have also been used. Paracentesis.—When tapping is performed the needle should he very small, and should enter the sac by a long route through healthy skin so as to prevent subsequent leakage and consequent infection. The utmost care must be exercised as to scrupulous cleanliness and asepsis. The puncture should he closed at once by iodoform collodion. Haley 4 holds that the continual leakage of cerebro-spinal fluid results in pro- found anaemia. Injections.—Iodine injections are still in favor. The success of any form of treatment, whether injection, ligature, or excision, will depend largely upon the degree of communication which exists between the sac and the spinal cord, and secondly upon the elements contained in the sac. In pedunculated tumors, and in those of narrow base, an operation is much more hopeful than in sessile growths with large bony openings. 1 International Clinics, Philadelphia, vol. iii., third series. 2 Univ. Med. Magazine, 1892-3, vol. v., p. 393. 4Journ. Amer. Med. Assoc., July, 1893. 3 Ibid., 1894. SPINA BIFIDA. 655 Unfortunately, sessile spinal tumors ar.e most common. The presence of the cord elements in the sac renders operative interference much more serious, and the resultant nervous symptoms are far more dangerous and fatal. Whenever the inferior extremities are paralzyed, or poorly nourished, the existence of cord structures in the sac is almost certain, and opera- tion then offers far less hope of success. Morton's fluid is superior to Brainard’s, as sterilized glycerin is less diffusible than water. Unfortunately, Morton’s eighty per cent, of successful cases do not seem to be continued by the report of the Lon- don Clinical Society, which gives only fifty per cent; but even one-half of selected cases cured is not a bad showing for so serious a condition. It can be set down as a universal rule that successful operations are more liable to be reported than fatal ones. It should not be forgotten that speedy death has followed these injections. The most scrupulous cleanliness must be enforced, and leakage should be prevented, if neces- ' sary, by finger pressure for hours after the operation. This form of treatment is not hopeful in paraplegic cases. Contraction and solidifi- cation of the sac will warrant repetition of the injection. Ligation, either with an elastic rubber cord, or with silk or catgut, is now but seldom practised, having been largely superseded by injection or excision. The use of the seton has been entirely discarded. Occasion- ally, but very rarely, a cure follows spontaneous rupture.1 Excision. — Within the past decade operative attempts having in view the removal of the sac and the closing of the abnormal opening in the bony canal have been renewed. These operations have been chiefly modificacions of old plans, but have been rendered more hopeful in their results by strict attention to antiseptic precautions. These results, as indicated in an elaborate table made for me by Dr. John H. Rhein, show that of 103 patients with spina bifida operated upon by various methods of dissection and excision, 31 died, 63 were cured, and 9 im- proved; of these cases 18 were in the lumbar region, Id in the sacro-lum- bar, 31 in the sacral, d in the dorsal, and 6 in the cervical; 27 of the pa- tients were operated upon in the first wreek of life, d2 in the first month, 6d within the first six months, and 75 within the first year. The opera- tions under one week gave 9 deaths and 18 cures. One child was only two days old, and nine months afterward was reported as well, with no palsy; yet, it seems unjustifiable to submit so young a child to so serious an operation, especially when but little harm could result from delay. The first reported operation which I have discovered was done by Sherwood, in 1811. The patient was six days old and recovered. In 13 operations reported in Hildebrand’s clinic, 10 were for meningocele and 3 for myelocystocele. Three patients died from the operation and one subsequently. Ten were discharged cured; one was reported well twelve years afterward, and the remaining eight were living and well. Among these were two with myelocystocele. The third with myelo- cystocele lived three months, when the tumor recurred and the child also became hydrocephalic.2 In cases accompanied by paraplegia, or when hydrocephalus exists, an operation is rarely of benefit. 1 Knox, Lancet, 1894, vol. i., p. 472. 2 Trans German Surg. Congress, 1898; Amer. Med.-Surg. Bulletin, June, 1893; Archiv f. klin. Chirurgie, Berlin, 1893, Bd. xlv., S. 200. 656 DISEASES OF THE SPIXE. Since removal of the sac in severe cases necessitates removal of a portion of the cord, operative cases to be hopeful must be those in which the bony opening is small, and those in which there are but few cord elements. When the integumentary covering is thin and ulcerated it should be removed, and a flap of healthy skin from the loin should be turned inward to give a solid covering to the opening. This flap may be cut from good tissue and be turned upon its base as in ordinary plastic work. Recognizable cord structures and meninges may be replaced in the spinal canal, and the tissues sutured in separate layers and levels, so that the lines of union shall not be superimposed. If the cauda equina, or other distinct nerve filaments, are found run- ning across the sac after it is opened, they should be carefully dissected out (the incision running around the vasculo-medullary area) and should be replaced in the spinal canal. If the nerves run into the wall of the sac, this should be dissected free and replaced in the canal. In one of my cases the sac was cut away. The child did well for five days, when the temperature suddenly rose to 105° F., and he died in convulsions. In a recent case in which 1 excised the sac, a tumor presented itself opposite the sacrum, and so much to the left of the median line that it appeared to be in the upper part of the buttock. This peculiarity of position was found on operation to have been due to the fact that the cleft was in the left laminal region, between the second and third seg- ments, while the spinous processes were perfect; this carried the tumor decidedly out of its usual central position, and it protruded in the upper part of the left buttock. The tumor was covered with perfectly nor- mal skin and with a thick layer of adipose tissue, the boy being over a year old. The neck of the sac was narrow, and a to-and-fro running stitch of catgut was put in before the sac was cut away. The stump was then sewn with an overhand stitch, such as is used in closing a uterine pedicle; this completely closed the opening. Recovery was un- eventful. There was no leakage. There had been no paralysis, and no convulsions. At birth the tumor was small, but enlarged when- ever the child cried, and was steadily increasing in size. Osteoplastic Operations.—The greatest advance in operative work is found in osteoplastic operations, in which attempt is made, by raising a bony flap around the margins of the opening, to secure an osseous closure. Parings can be made and the flaps united so as to form a solid bridge across the gap. In the sacral or lumbar re- gions a half-thickness of the innominate may be split off and turned into the gap, periosteum .inward, without separating it from its liga- mentous and muscular attachments, thus insuring its life. The trans- plantation of periosteum or of bone from other animals has been prac- tised both experimentally and in the human subject by Jaksch, Barth, and others, the former transplanting bone from the head of a gosling with success. It is better to select a young animal rather than a fowl for the graft. A trephined button of bone from an animal has also been used, but the experiments of Wolff and others 1 show that while detached pieces of bone almost invariably die by transplantation, yet if they have the support of the muscles and fascial tissue they will live. A flap taken from the body of a vertebra, or portions of the articular process, attached to the soft parts, may be employed. When bone chips 1 German Surgical Congress, 1893; American Med.-Surgical Bulletin, June, 1893. SPINAL CAEIES. 657 are introduced they become vitalized and frequently waken a process of connective-tissue growth. Osteoblasts grow directly into the old bone as the constituents of the dead bone are re-absorbed and gradually be- come converted into the new; this seems to take place either with or without periosteum. Spinal Caries. The term antero-posterior curvature of the spine is certainly defec- tive, since a curve may have its convexity either forward, or back- ward, and the title is just as applicable to lordosis as to kyphosis. The term kyphosis is applicable also to either abrupt bending of the spine or the long, even, backward curve which is commonly seen in rickets, rheumatism, and feeble spine. We can hardly speak of an “angular curvature,” although the term is frequently used to indicate the abrupt- ness of the deformity caused by loss of vertebral bone substance. I cannot agree with Mr. Treves in his remarks in Yol. IV., in regard to the term caries of the spine, since the name is very accurately de- scriptive of the actual process which occurs in so large a proportion of cases that the few minor ones need not be considered. Even though the bone may be exempt and the caries confined (as is rarely the case) to the intervertebral fibro-cartilages, yet these cartilages are just as much a portion of the spine are the vertebrae, and the process is still distinctly a caries. Since the publication of Mr. Treves’s article the continued advance in pathology and bacteriology has been so marked, as was then clearly outlined, that there is no longer any hesitanc}7 in regard to the term vertebral tuberculosis, since in the large majority of cases the disease is a local tubercular affection. The term “ Pott’s Disease,” while honoring the name of an individual justly distinguished, is not descriptive of any pathological process. To attach the name of any one to a definite process is inadvisable. If, therefore, we use the term caries of the spine, and even if we add the term tuberculous, we shall in nearly every case be both pathologically and clinically accurate. Etiology of Spinal Caries.—In regard to the effect of heredity and the question of traumatism as factors in producing this condition, it still seems difficult for the ordinary practitioner to realize that local tuberculosis may exist without general evidence of the disease, or with- out any history of heredity. Local tuberculous processes are exceed- ingly common, and in the large majority of cases systemic infection does not take place. This process develops in the vertebrae with greater ease than in other parts of the body, the spongy nature of the bones and their rather complicated articulations favoring the invasion. Whether we term it tuberculous, strumous, or inflammatory, the tendency of this process is to degeneration rather than to organization. The effect of injury as a causative agent, formerly the subject of much discussion, is now plain. It is evident that traumatism is most positively a cause of local tuberculosis from the fact that inflammation following upon injury destroys the resisting power of a particular region 658 DISEASES OF THE SPINE. against the inroads of the tubercle bacilli, the result being that the dis- ease gains a foothold in the tissues. Phagocytosis is constantly active in the body, and thus the bacilli are ordinarily overpowered. The re- sisting power of tissues may also be destroyed by poor food, bad air, low fevers, exhaustive diseases, etc.; or the individual may inherit non- resisting cells. In earlier days, when the statement that a patient was tuberculous meant that he was afflicted with a necessaril}7 fatal lung disease, opposition was more violent to the theory that traumatism was a potent factor in the production of the condition. With our more thorough present knowledge of the process involved in local tuberculosis, it is easy to understand that even a slight traumatism may be produc- tive of evil results, and that any tissue with vitality lowered by inflam- mation readily becomes the prey of the invading bacillus. Spinal tuberculosis, therefore, may either be hereditary, or may be acquired in the manner above mentioned. The existence of local tubercular bone disease is frequently over- looked by physicians, simply because they are unable to trace any pre- vious history of tubercular disease in the parents of the individual. But for the frequent errors of this kind it would seem hardly necessary at this day to refer to the great frequency of local tuberculosis, or even to the enormous amount of both known and unintentional deception which is constantly practised in regard to hereditary diseases. Again, many patients say truly that they know of no tubercular disease, and yet it may exist to a very large degree. When positive evidence of tubercular disease is present it should be recognized as such, no matter what the antecedents. There is no rea- son that the same rule should not hold good in regard to a group of symptoms positively indicative of local tuberculosis that is accepted in regard to local sarcoma, fibroma, lipoma, or any other disease. The effect of heredity is easily explained. One individual is born with cells already tainted, and possessing but feeble resisting power against the inroads of the tubercle bacillus, and he quickly yields to a local or general infection; another individual enters the world with a limited amount of repelling force sufficient to ward off an attack until a local injury with its consequent inflammation lessens the defensive power in that particular region, and vertebral, joint, or other local de- generation occurs; a third maintains the fight until some depressing disease or non-hygienic surrounding lowers his powers of defense, when his tissues yield; while a fourth, with every cell especially fortified by ancestral and personal purity of habits and surroundings, successfully repulses every onslaught of the deadly foe even through traumatism, sickness, and filth. The frequency of the existence of the tuberculous process is evidenced in the fact that its presence was demonstrated in sixty-six out of one hundred cadavers examined by Schlenker.1 The spine is affected in nearly twenty per cent of the cases of local tuberculosis. Taylor2 in 845 cases of spinal caries found that scrofu- lous or tubercular disease could be distinctly traced in at least thirty- four per cent., and Gibney 3 says that he finds either an hereditary or an acquired diathesis in nearly every case. 1 Archiv f. path. Anat., Phys., und klin. Med., Bd. cxxxiv., S. 145; Univ. Med. Mag., Dec., 1893, p. 208. 2 Lovett, Diseases of the Hip, p. 64. Boston, 1891. s Gibney, New York Med. Jour., July, 1877. SPINAL CARIES. 659 Following the hypersemia produced by traumatism 1 or by disease, infection occurs through the blood-vessel system; bacilli aggregate in the capillaries of the Haversian canals, endarteritis is set up, and in the centre appears a small grayish spot. Rarefying osteitis follows, the trabeculae are absorbed, and fatty degeneration of the bone cells soon occurs, with the formation of embryonal or granulation tissue in which giant and epithelioid cells are readily found. The gray spots slowly become }fellowish, and speedily caseate or break down into pus. There is but little reason to doubt that this process is tuberculous, as it corresponds histologically with tuberculous changes in other re- gions. Inoculation experiments, such as those of Schiller, Parllovski2 and others prove that bone tuberculosis and general tuberculosis are interchangeable. Bacteriologically it is not easy to demonstrate the presence of the tubercle bacillus,3 as it is only found in a small pro- portion of cases,4 but patient search by Ehrlicher’s or other method will demonstrate its presence, and inoculation or culture tests will ordi- narily establish the nature of the process.5 Rare Forms of Spinal Abscess.—Abscesses from spinal caries in the dorsal region occasionally discharge into the pleural cavity and from thence into the lungs. I have seen several cures take place, even when pus lias taken this route. The diagnosis between this process and lung tuberculosis is often difficult, unless the history and progress of the case are thoroughly considered. I have in a number of instances seen abscesses opening into the bladder, rectum, or vagina. In another case a tumor diagnosed as “ fatty” had formed just above the knee; careful palpation discovered induration extending up the thigh and into the pelvis. There was no deformity, but diligent inquiry revealed the existence of a “ weak back” for nine years, and subsequent post-mortem examination disclosed a carious lumbar vertebra. I have also seen a pelvic accumulation of pus burst rapidly through the ischiatic foramen, when compressed anteriorly by the application of a plaster jacket. Process of Repair after Spinal Caries.—It is absolutely true that loss of tissue from vertebral tuberculosis is never thoroughly re- paired ; hence the resultant deformity will depend largely upon such loss of tissue. When once angulation has occurred, deformity is perma- nent ; but of course if the spine is held rigidly straight from the incep- tion of the disease, the amount of new tissue formed between the dis- eased bodies will be greater, and hence the deformity will he markedly less. The Spinal Deformity.—Lateral deviation may occur not only in the cervical region, as noted in Mr. Treves’s article, but also in the dorsal and lumbar regions. It is due either to the unequal yielding of the sides of the bodies of the vertebrae, or to excessive muscular action of one side, or to muscular relaxation to relieve pain. 1 Centralblatt f. Chir., 1878, Bel. v. ; Lovett, op. cit., p. 60. 2 Ilueter; Arcbiv f. Chirurgie, 1879, Bd. xl., S. 817. Lovett, op. cit., p. 68. 3 Park, Mutter Lectures on Surg. Pathology, p. 215. St. Louis, 1892. 4 Kanzlen, Berlin, klin. Wochenschrift, 2 Jan., 1884, S. 14. 5 Park, Med. Press of Western New York, Jan., 1887. 660 DISEASES OF THE SPINE. Lovett1 has pointed out that it is an early symptom of spinal caries, largely due to muscular irritation, and advises that it should be looked upon as a diagnostic symptom. It differs widely from ordinary lateral curvature of the spine, from the fact that it is an abrupt tilting to one side, not a long rounded curve with rotation, as commonly seen in the latter condition; moreover, the symptoms of the diseases are usually entirely different. Disturbance of the Motor Nervous System in Spinal Caries.— Paraplegia is most common when the caries is situated in the dorsal region, since the cord at this point nearly fills the canal. Paralysis is usually produced, not by direct bone pressure from angulation, but by pachymeningitis with tuberculous or inflammatory deposit en- croaching upon the cord. Cases of even right-angled deformity may escape, while those of slight deformity may be of severe grade, espe- cially when the deposit is pressing upon the anterior column of the cord. This was well illustrated in one of my recent laminectomies, when there was found a tuberculous nodule upon the antero-lateral column, while in front of the cord was a large mass of tubercular tissue. Paraplegia had existed for more than a year. Lloyd2 describes a section of cord from a case of paraplegia in which the patient died from septic infec- tion due to bed-sores over the sacrum, the seventh dorsal vertebra having been previously diseased. He agrees, in common with Sinkler3 and others,4 that the deposit is nearly always the result of pachy- meningitis or lepto-meningitis, and that if transverse myelitis results it is a later condition. Schwenkel gives the result of 52 post-mortem examinations, in 32 of which compression existed, and Karskel6 gives 70 cases in which inflammatory or caseous products were present. Diagnosis of Spinal Caries.—Lateral deviation in spinal caries is usually abrupt, and is widely different from the long arch of lateral cur- vature. An occasional error may be made at the first examination of a resisting, crying child, when apparent rigidity of the spine may be found, and yet the complaint may be really a lateral curvature. In young children with torticollis, several examinations are sometimes necessary to exclude the non-existence of caries of the spine, if there is no deformity and if the rigidity is slight. Rigidity is the most reliable sign of caries; but even rigidity requires to be differentiated from vol- untary muscular resistance. Suppurative spinal caries is not infrequently confused with hip dis- ease. Open sinuses in the groin below Poupart’s ligament, or behind the great trochanter, or at some other point in the thigh or in the but- tock, frequently exist, together with marked rigidity at the hip. Flex- ion may also be present to the extent of 30 or 40 degrees, with resistance to motion in any direction at the hip, on account of pain, and from con- traction of the irritated psoas muscle. Especially when no history is attainable, and without careful examination, or when the back is with- out deformity, the true condition may be overlooked, and the error may not be corrected until kyphosis subsequently appears. Very frequently 1 Trans. Am. Orthopaedic Assoc., vol. iii., p. 186. 2 Univ. Med. Mag., Dec., 1893, p. 143. 4 Elliot, New York Med. Journal, June 2, 1888. 6 Schmidt’s Jahrbiicher, Leipzig, Apr., 1892. 3 Med. News, Nov. 18, 1893. SPINAL CARIES. 661 also, both hip disease and spinal caries may be present from multiple tubercular foci. Deep palpation in the iliac fossae will often reveal a deposit of pus even when there is but slight deformity of the spine. Treatment of Spinal Caries.—Treatment by prolonged recumbency yields such superior results that it is largely adopted by those who have tested its merits. It inflicts no pain upon the patient, it lessens deformity, and its irksomeness is largely mitigated by the use of a suit- able bed frame, or tray, or stretcher, which permits the patient to live in the open air. This frame may be made of wood, or gas-pipe, flat iron, brass rods, or other metal. Canvas, linen, or other material is stretched across the frame. Defecation in young children can be readily managed. If the canvas is smooth and in one piece the child need not be removed from it, since the frame can be placed in any bed. The child, carried easily upon the tray, may be placed on supports in the open air, in a long baby coach, or upon a set of wheels, and may thus live out-of-doors nearly all the time. An awning may be erected over the carriage, and toys may be suspended at convenient places for the amusement even of an infant. A two-inch mattress placed upon such a stretcher in winter will protect the child from cold. When head or foot extension is desirable, the pulleys may be attached directly to the frame and extension maintained either by weight or by elastic bands. Counter-extension may be made by elevating one end of the stretcher. Cervical and upper dorsal cases necessarily require a long period of recumbency. Three months after the acute stage has passed the child maybe fitted with an apparatus and permitted to move about. Extension and Suspension.—Extension either in the horizontal or in the erect position has a most beneficial effect not only on the bones themselves but on the nutrition of the cord. Its employment in bed has already been described. In the sitting position it is best employed by fitting a strong, curved davit-arm to a chair,1 from the projection of which above the head of the patient a pulley may be rigged to attach to a well-fitting head-piece.2 The amount and the time of the extension must be regulated by the feelings of the patient. Additional extension from the armpits and thorax may be secured by shoulder-straps incor- porated in a plaster jacket. Mitchell says that a patient will bear a pull of from twenty to seventy pounds for five or six hours a day. Mechanical Appliances.—The immense variety of apparatus em- ployed shows that the inherent difficulties are many. One class of appliances, represented by plaster, felt, leather, wood, aluminium and other metal jackets, attempts to secure fixation or limitation of motion in the vertebrae. This is accomplished much in the same manner as in the treatment of fractures by the application of an encircling splint. The support given to the ribs by the outside casing is also a factor in se- curing fixation. In young children with small pelves this method is very helpful, since a steel appliance readily slips down on the hips. In the application of a plaster jacket in painful cases it should not be forgotten that the most comfortable position for the patient is lying upon the abdomen in a narrow, plain muslin hammock, the muslin itself to be included in the turns of the plaster bandage as it is applied. 1 Bradford and Lovett, Orthopaedic Surgery, 1890, p. 70. 2 Mitchell, Trans. Pliila. College of Physicians, 1889, vol. xii., p. 82. 662 DISEASES OF THE SPINE. The best representative of a steel spinal support which acts upon the principle of antero-posterior leverage, is the Taylor brace with its various modifications.1 It consists of two steel bars placed in the gutters on either side of the spinous processes, the bars following the pathological curves. At the upper end are two arms which pass over the shoulders at the root of the neck. Below, the uprights are secured to an inverted U-shaped frame, the lower pads of which are fitted into the post- troclianteric sulci on either side. To give anterior support to the shoulders, chest pieces are applied below the clavicle to the anterior portion of the thorax, being firmly secured to the posterior uprights. This posterior splint is firmly fastened in position by an anterior apron with straps passing round the body. Perineal straps also serve to fix the apparatus. The uprights are hinged to permit of motion back- ward but not forward.2 Whitman 3 describes a modification of this form of apparatus, which even more thoroughly fixes and rigidly holds the shoulders. Another class of appliances is represented by the lateral crutch, which is expected to maintain the erect position, not with the expecta- tion of relieving the spinal column of its superabundant weight, but by supporting the shoulders and thus preventing the bending forward of the body. Still another class of apparatus, represented by Stillman’s, attempts by spring or elastic force to straighten the existing kyphosis. No one form of apparatus is sufficient for all cases, and adaptations must be made for each particular patient. As a rule the encasing ap- paratus is the most comfortable and permits of the least motion of the the diseased vertebrae. Plaster of Paris is the cheapest and gives the most support, but has the disadvantage of weight. The objections to non-removable jackets are avoided by cutting open the plaster jacket along its front and having it bound and laced. Wood and paper jack- ets4 are serviceable, but aluminium 5 will doubtless come into use when its alloys are better known. The objections which have been urged against the use of the partiall}7 tanned leather jacket recommended by Agnew, and largely used in America, have arisen from a want of practical acquaintance with it. Taking a plaster cast does not require long suspension, seldom more than a few minutes, and the patient is quickly placed in a recumbent posture, after which the cast is at once cut open and removed. When made of proper leather and well fitted over a mould, Agnew’s apparatus is a most satisfactory and comfortable support, and yields excellent results. The leather is only partially tanned, and is stiffened at a few points by steel strips.6 The use of poro-plastic felt, even in the temperate climate of America, is unsatisfactory, as the heat of the body soon softens and renders it useless. When the location of caries is above the seventh dorsal vertebra, any form of encircling splint becomes more and more ineffective as a 1 This is thoroughly described in the Transactions of the American Orthopaedic Associa- tion, vol. i., 1889, p. 15. 2 See illustration in Trans. Am. Orthop. Assoc., vol. i., p. 15. 3 Trans. Am. Orthop. Assoc., vol. v., p. 44. 4 Young, Orthop. Surgery, pp. 45-49, Phila., 1894; also Annals of Gynaecology and Psediatry, August, 1891. 6 Phelps, Transactions of the American Orthopaedic Association, 1893. 6 Agnew, Principles and Practice of Surgery, 2d edition, Philadelphia, 1889, vol. ii., p. 881 SPINAL CARIES. 663 higher level is reached, and a head support is needed to restrict the movements of the upper portion of the spine. This head fixation may be accomplished by the jury-mast attachment (Sayre'); or by chin cup and occipital plate (Taylor2); or by a prolongation to the vertex of the posterior bars,3 properly curved, with forehead and chin straps; or by postero-lateral U-shaped supports.4 Operative Measures for Spinal Caries.—Treatment of Abscess by Aspiration and Injection. — While antiseptic measures render the opening of a spinal abscess a perfectly safe procedure, yet unfortunately the results obtained by operation are not brilliant, since it is seldom possible to remove all sources of suppuration. Abscesses that are small require injections of iodoform, 10 per cent., in boiled olive oil or in glycerin. One drachm or more may be permitted to remain after the contents have been drained off. This process may be repeated in two weeks. The procedure not only permits the inhibitory action of iodoform upon the tubercle bacilli, but it also strengthens and thickens the walls of the sac so that systemic infection is less likely to occur when an opening is made. This procedure will frequently prevent the formation of abscess when only the liquefaction of caseation is present in the sac; caseation, absorption, or encapsulation subsequently taking place, and a permanent cure resulting, provided traumatism does not reawaken the focus. Mechanical fixation is always to be associated with any form of treatment. Drainage.—W7hen the sero-purulent material reaccumulates, or when pus is evident, an incision should be made, after very careful cleansing of the patient, and with strict precautions against the entrance of infection. The pus should be thoroughly washed out with hot boracic acid or bichloride solution in order to destroy the bacilli. No pressure should be made upon the walls of the abscess lest a fissure should ensue and infection of the system should occur. WTien an abscess wall can be thoroughly curetted or excised, injections with iodoform-oil may be used and immediate closure practised. When the abscess wall cannot be excised or curetted, then it is advi- sable to make a counter opening either in the loin or through the os in- nominatum, by trephining or by notching the edge of the bone, and to institute through-and-through drainage, after which washing with cor- rosive sublimate or with peroxide of hydrogen, and the employment of iodoform-oil injections together with strict antiseptic dressings, will usually greatly shorten the suppurative process. At a discussion on Spinal Caries at the American Orthopaedic Asso- ciation,5 the conclusion reached was that operative treatment of abscess, while not materially affecting the course of the disease, yet, when prop- erly combined with thorough and prolonged mechanical fixation of the diseased area, tended to shorten the period of cure, and to lower the destructive temperature of confined purulent accumulations.6 Ercisionof the Vertebrce.—When it is possible to reach the diseased por- tions of the vertebrae in the lumbar region, erasion should be attempted, 1 Bradford and Lovett, Orthopaedic Surgery, 1890, p. 59. 2 Ibid., p. 79. 3 Ibid., p. 82. 4 Davis, Trans. College of Physicians, Philadelphia, 1891, vol. xiii., p. 123. 5 Trans. Amer. Ortho. Assoc., 1891. 6 Townsend, Phila. Med. News, 1891; Trans. Am. Orthopaedic Assoc., 1891. 664 DISEASES OF THE SPIHE. although it is still a problem whether the entire process of separation of carious bone is hastened by this procedure, as the curette necessarily destroys a superficial layer of bone cells. Chipault1 gives the history of the attempts made by Treves, Lannelongue, Reclus, and others for the removal of carious bone, and concludes that it is possible to curette the body of a vertebra even in front of the cord.2 The incision should be outside the border of the erector spinse muscle, say two and one-half inches from the median line, until the transversalis fascia is reached, when this membrane should be followed to the transverse process. The attachments to the transverse process must be removed, and the quadratus separated from the psoas. The ab- dominal branches of the lumbar arteries may be followed. Removing the transverse process by rongeur forceps the front of the vertebral body can be reached, and the diseased area should then be thoroughly cu- retted. After this the diseased surface should be mopped with pure carbolic acid to prevent absorption of septic material, and the parts thoroughly drained. Unfortunately it is not possible to determine whether the entire extent of caries is reached; hence, -while the process of suppuration may be shortened, it may not be entirely prevented. Shim well3 advises an incision from the middle of Poupart’s ligament, curved upward nearly to the ribs, with the convexity outward. When the transverse fascia is reached its layers are separated until the pro- montory of the sacrum is exposed. Another incision is made on the outer side of the erector spinse down to the posterior leaflet of the trans- versalis fascia, having passed through which it is easy to work back to the body of the vertebra. Through these openings the body may be readily examined, curetted, and drained. In the dorsal region the operation becomes more difficult, since the articulating processes and the heads and necks of the ribs must be re- moved in order to reach the anterior part of the vertebrae. Vincent4 reports that he has been able not only to remove the carious body of the vertebra after resection of the ribs, but also to carry a drainage tube in front of the cord. I have been able to accomplish this in one instance where the body had been largely eroded and its place occupied by a large caseous cavity, but in all other cases, and in some twenty-five experiments upon living dogs, I have not been able to reach the front of the vertebral body without opening the pleura, which lies in close proximity to the articular process. It is scarcely possible to avoid this accident unless the pleura has been pushed forward by the disease. The articular processes and the ribs are to be resected subperiosteally. The intercostal muscles are to be separated, the pleura detached, and the fungosity followed to the site of flexion of the spinal column, or within the premeduliary triangle caused by the destruction of the vertebral bodies. An incision upon the opposite side and the use of a long probe will permit the passage of a drainage tube through the caseating or suppurating mass which occupies the original position of the body of the vertebra. By this method thorough drainage is secured, and iodoform or other local remedies may be introduced. Vincent also practises lateral trephining of the body of even a 1 Revue de Cliirurgie, 7 Nov., 1891. 3 Med. News, Oct. 21, 1893. 2 Cliipault, Dublin Med. Journal, June 1, 1892. 4 Revue de Cliirurgie, 1892-93, p. 273. SPINAL CARIES. 665 dorsal vertebra, a “ trans-somatique” operation, with curetting and drainage, after resecting the head of the rib. Chipault has proposed to trephine or gnaw away the lamina, and then carry a drainage tube across the canal to the body of the bone. This procedure exposes the cord to danger from septic infection and is not justifiable. It is seldom possible to remove the diseased bone, and free drainage seems to be the only benefit to be derived from this operation. Schaeffer1 advises reaching the vertebral bodies behind the psoas muscle in the lumbar region, and in the dorsal region resects the transverse processes and heads of the ribs. The risk of infecting the pleural cavity with tubercular material is certainly a matter for grave consideration. LaMNECTOMY, FORMERLY CALLED TREPHINING OF THE SPINE.—Re- moval of the.laminae for the relief of pressure paraplegia has become an established operation in spinal caries since Macewen published his successful series of cases,'2 although it is limited in its beneficial results. The majority of cases of paraplegia yield to long-continued extension, rest, and fixation of the spine, but when the carious process is limited to the posterior arches of the vertebrae the operation is undoubtedly indicated. In cases of exaggerated reflex, ankle clonus, etc., where paraplegia has persisted in spite of treatment, it is a procedure to be re- commended in a limited number of cases. Lane3 speaks most hopefully of the results; but in my experience4 it is an operation accompanied with great shock. An incision is made a little to one side of the spinous processes. The arches are cleared from muscular tissue. During this stage of the opera- tion free venous hemorrhage may be expected, but it may usually be controlled by the use of hot water and packing. In the dorsal region the cord is comparatively accessible, but in the lumbar region, in mus- cular subjects, the operation is a tedious and difficult procedure. Abbe separates the muscles on one side only, and by cutting off the spinous processes at their bases permits them to slip over in a block. The ligamentum subflavum first appears in view, and may easily be mis- taken for the cord, but the error is soon corrected. Removal of the first lamina is the most troublesome part of the operation. It is best gnawed through with sharp rongeur forceps, or divided with a saw. After the removal of the first arch, the others may easily be taken away with rongeur forceps with flat lower blade. The base of the lower blade must be narrow so as not to become wedged. These forceps as modified by Hopkins and Keen are very serviceable.5 Frequently tuberculous deposits will be found pressing upon the cord, or there may be pus or other inflammatory deposit from pachy- meningitis, all of which should be removed as thoroughly as possible. 1 Trans. Illinois State Med. Soc., 1891. 2 Brit. Med. Journ., 1888, vol. ii., p. 1808; Glasgow Med. Jour., 1884, vol. xxii., p. 55; Ibid., 1885-86, vol. xxv., p. 210; Ibid., 1888, p. 11; Brit. Med. Journ., Aug. 11, 1888; Lancet, July 14, 1888. 3 Brit. Med. Journ., 1891, vol. ii., p. 949; Ibid., 1892, vol. ii., p. 1495; Ibid., 1889, and June 6, 1892; Ibid., Oct. 31, 1892; Trans. Clinical Society, London, 1892, vol. xxv., p. 30; xirchives of Paediatrics, March, 1893, p. 285. 4 Trans. College Physicians, Philadelphia, 1891 ; Mutter Lectures, 1893. 5 Buck’s Reference Handbook of the Medical Sciences, vol. ix., p. 824, Fig. 591. 666 DISEASES OF THE SEINE. When the extra-dural tuberculous deposit is large in amount, it is better not to open the membrane lest infection ensue. With a curved probe the anterior region of the cord may be ex- plored, and by sacrificing one spinal root it is possible even to remove the anterior .deposits. Manipulation of the cord should be carefully avoided, as it adds markedly to the shock of operation. Bone frag- ments, if found, may be removed. Hot boracic acid solution should be used for washing, and drainage should be thorough, both by rubber tubing and catgut. The muscles above and below should be sutured in separate layers, and the wound should be packed with iodoform or aristol gauze. In cases where the posterior arches are the seat of caries, as in cases reported by Dr. John B. Roberts1 and by myself,2 considerable portions of the bone may be removed, but, unfortunately, complete removal is seldom possible, as the disease commonly extends to the bodies. Urban3 lifts a large mass of muscle with the laminae, and replaces the trap-door flap; Chipault and A^incent,4 and Israel5 are in favor of very radical and complete removal, not only of the deposit, but of the diseased bone in front of the canal. Lane0 and Horsley 7 are favorable to early operative interference; but Thorburn 8 declares that we do not lose by waiting. A study of the literature of lamnectomy shows that, save the two attempts of Maisonneuve in 1860, there were no operations of this char- acter until about fifteen years ago, when Lannelongue removed the detached spine of the second dorsal, an operation which should more properly be classed under the head of removal of carious bone. Jack- son’s operation in 1882 was probably the first deliberately planned attempt to remove pressure and relieve the paraplegia. Temporary improvement is frequently noted immediately after the operation, undoubtedly from the relief of pressure, but as the tubercular and inflammatory deposits reform, relapses are frequent and death has fol- lowed in a number of instances. In 134 recorded cases (or 130, omitting 4 that are incomplete in detail), the total deaths within a year after the operation were 58, making a percentage of 44.6. Thirty-two patients died of shock, or within the first week, and their deaths may be fairly attributed to the operation, 24.6 per cent. Forty-seven, or 36 per cent., died within the first month; and the lives of all these may be said to have been short- ened by the surgical interference. Of the 75 cases in which the patients survived, 11 are recorded as “unsuccessful,” or “not improved,” and 15 more as only “slightly im- proved,” while only 46 cases can really be set down as decidedly and permanently benefited, a percentage of 35.4. It is of course impossible to judge of the possibilities of these forty- six cases had they been treated by rest and extension, but the results of lamnectomy are certainly far from satisfactory, and prove that 1 Trans. Phila. Co. Med. Soc., 1893. 2 Mutter Lectures, College of Physicians, Phila., 1893-94. 3 Yerhand. d. Deutscli. Gesellsch. f. Chirurg., 1892, No. 21. 4 Revue de Chirurgie, 1892-93, p. 273. 6 Yerhand. d. Deutscli. Gesellsch. f. Chirurgie, 1892, No. 21, Bd. ii., S. 211. 6 Trans. Clin. Soc., London, 1892, vol. xxv., p. 30; Brit. Med. Journal, 1891. ’Brit. Med. Journal, 1890, vol. ii., p. 1286. 8 Surgery of the Spinal Cord, p. 800. 1891. CONGENITAL SACRO-COCCYGEAL TUMORS—LORDOSIS. 667 thorough hygienic, mechanical, and fixation methods should be insti- tuted for a long time before operative interference is attempted, since it is a well-known fact that a large proportion of patients with pres- sure paraplegia recover. It is to be presumed, however, that these cases were of the most helpless class, and that all other means had been exhausted without benefit. As far as recorded, 70 of these cases were in males and 35 in females* while the respective numbers of children and adults were 75 and 43. The dorsal region was the seat of disease in ninety-eight cases, the cer- vical in twelve, and the lumbar in six. Wiring of the Spinous Processes.—Hadra1 has proposed to wire together the spinous processes of the diseased vertebrae, thus preventing the approximation of the anterior portions of the column, and compel- ling Nature to bridge the chasm. He gives no cases in which this operation has been practised, but simply suggests it. Wilkins2 has modified this plan by passing a figure-of-eight wire suture through the intervertebral foramina. Puncture of the Spinal Canal.—Wynter3 and Quincke advise puncture of the canal to relieve pressure in cases of tubercular menin- gitis. The trunk being flexed, a small trocar may be driven into the space between the second and third lumbar arches. Salil and Naunyn4 have also performed the operation a number of times. Congenital Sacro-Coccygeal Tumors. Mr. Treves’s article in Vol. IV. leaves but little to be said of these tumors. In the majority of cases complete excision and non-interference are the only methods of treatment to be employed. Borges successfully removed a congenital lipoma from the meninges in the lumbo-sacral region of a child eight years old. The only similar case is reported by Johnson. Lordosis. The most common causes of lordosis are rickets and infantile paraly- sis, with the resultant deformity of the lower limbs and atrophy of the muscles in the latter disease. Curvature of the spine and extreme lordosis are not uncommon, especially in the contractions of the rectus and tensor vaginse femoris, with secondary shortening of the psoas and iliacus. This condition, if of long standing, can only be relieved, after myotomy of the contracted muscles, by long-continued extension in bed. 1 Trans. Am. Orthop. Asso., 1891, p. 206. 1 St. Louis Med. and Surg. Jour., 1888, p. 341. 3 Lancet, 1891. 4 Univ. Med. Mag., Aug., 1893; Wiener med. Presse, No. xix., 1893. INJURIES AND DISEASES OF THE EYE. BY CHARLES W. KOLLOCK, M.D., LECTURER ON DISEASES OF THE EYE AND EAR IN THE CHARLESTON MEDICAL SCHOOL AND OPH- THALMIC SURGEON TO THE CHARLESTON CITY HOSPITAL AND SHIRRAS DISPENSARY, CHARLESTON, SOUTH CAROLINA. Anesthetics in Eye Surgery. The discovery of the property which cocaine possesses of causing local anesthesia, and of the wonderful effects produced by the practice of asepsis and antisepsis, have given ophthalmology an impetus that has kept it abreast of all the special branches of medicine, and allowed it to be surpassed by none. Ether and chloroform are rarely used in ophthalmic practice except in the performance of operations that re- quire considerable time, for enucleation and evisceration, resection of the optic nerve, and in cases of children who on account of their ner- vous temperaments fear any kind of operation. Bromide of ethyl, which has long been known as an anaesthetic suitable for operations that require but a short time, has of late come more into notice, and is now being used for such operations as enucleation and strabotomy. Tropacocaine is a substitute for cocaine, but as yet is rather too expen- sive for general use, especially as cocaine fills almost every want. An- aesthesia by tropacocaine is said to last longer and to be more readily produced upon inflamed surfaces than that caused by cocaine. It may be employed in solutions of two per cent, for ordinary purposes, and of five per cent, for deep-seated operations. It has no haemostatic or my- driatic effect (Ferdinand). Asepsis and Antisepsis in Eye Surgery. In the treatment of all ocular diseases and in the performance of all operations, absolute cleanliness should be the first rule learned and carried out. Boiled distilled water should he used for making all solu- tions, and the antiseptics employed should be those possessing the strong- est germicidal and the least irritating effects. It is scarcely safe to use bichloride of mercury for the conjunctiva in solutions stronger than 1 in 8000 or 1 in 10,000, for severe conjunctivitis has been produced by a solution of 1 in 5000 parts. For cleansing the parts surrounding the eye, solutions of 1 in 2000 or 1 in 3000 may be employed with- out fear. Solutions of bichloride of mercurv are of course not suita- 669 670 INJURIES AND DISEASES OF THE EYE. ble for instruments, but cyanide of mercury (Chibret), from 1 in 200 to 1 in 1500, may be used for cleansing both the instruments and the surface of the patient. Bourgeoise recommends boric acid in an aqueous solution of borax. After an operation has been commenced, there is perhaps no better preparation for cleansing than a four-per- cent. solution of boric acid freshly made in boiling water. It is neces- sary that the water should boil after the acid has been added in order that any impurity contained in the latter shall be destroyed by the heat. Nuel also recommends the physiological salt solution for the same purposes. According to G. E. and A. E. de Schweinitz the solu- tions of boric acid and cocaine contain many poisonous germs when not fresh, and it is therefore necessary that care should be exercised, for these preparations are perhaps more constantly employed in dis- eases and operations than any others. For the same reason pipettes, cotton, gauze, and bandages should be thoroughly sterilized. For sterilizing instruments boiling water is probably the most effective, simple, and easily obtained material. They may also be placed in a bath of cyanide of mercury (1 in 1500), in absolute alcohol, or in a saturated solution of boric acid after they have been sterilized. Dressings may be sterilized by steam, or may be dipped in strong solu- tions of bichloride of mercury. Iodoform and aristol, which have been highly recommended, are less suitable for the conjunctiva, which they irritate by acting as foreign bodies; but they may be used with advantage by dusting over the lids and along the commissure. Diseased conditions of the lids and lachrymal apparatus should be cured before any operations are performed on the ball. WTheu there is disease of the lachrymal sac it has been advised (Haab) to occlude the canaliculi by cauterization. Injuries of the Eyeball. Foreign Bodies in the Eye.—In no operation on the eye are the effects of cocaine more useful and more appreciated by both patient and surgeon than in removing foreign bodies. A few drops of a four- per-cent. solution soon quiets the most irritable eye, so that it may be handled with impunity and without pain. Minute particles are at times overlooked by the most careful operator, and in order that there may be no doubt as to the presence of a foreign body, a drop or two of a solution of fluorescine may be dropped into the eye. When there is a break in the epithelium of the cornea the spot immediately becomes green, and if a foreign body is present it is surrounded by the green spot. Foreign bodies that penetrate the eye require prompt attention. When lodged in the cornea they should be removed through the point of entrance. Bodies that have penetrated the cornea and entered the anterior chamber should be removed at the most convenient point that will interfere least with vision. No exact rules can be laid down for their removal, but generally a peripheral opening should be made with a lance or Graefe knife, and if the body can be grasped by a small for- ceps this will be the readiest instrument; but when it is difficult to seize, it may (if steel or iron) be brought to the opening by the electro-magnet, INJURIES OF THE EYEBALL. 671 and then withdrawn by forceps. Bodies that have lodged in the iris are very difficult to remove without excising a portion of that membrane. When bleeding follows the iridectomy, removal may be complicated by the introduction of the magnet, which at times coagulates the blood. Foreign bodies that have penetrated the lens are very difficult to handle. When they have but partially penetrated, and project also into the anterior chamber, no effort should be spared for their removal, and the greatest care should be exercised in order that the lens should be disturbed as little as possible, for though these injuries are generally followed by the formation of cataract, still, in a small number of re- corded cases, the resulting opacities have either cleared or have not increased. Bodies that have passed wholly into the lens substance usu- ally cause rapid loss of vision, but in rare instances have remained in the lens for a considerable time without producing general opacity. It is at times difficult to decide how such cases shall be treated. The removal of a traumatic cataract, when vision in the other eye is good, has little to recommend it beyond the cosmetic effect. Usually foreign bodies are found at the bottom of the capsule (unless recently intro- duced), and move with every motion of the eye. Evacuation of the lens-substance does not insure removal of the foreign body, and should it by any accident escape into the vitreous, the condition would be far worse than before. Therefore, unless it is solidly imbedded in the lens substance and can be extracted with it, or can be taken out in the capsule, it is far better to allow it to remain undisturbed. Foreign Bodies in the Vitreous.—The electro-magnet has worked wonders among these cases, and many eyes are now saved for good and useful vision that were formerly either removed at once or left only to become blind. When possible, the foreign body should be located by the aid of the ophthalmoscope, but when this is impossible then the general direction of its course, its probable size, and its velocity must be taken into consideration. When the case is seen soon after the ac- cident, the point of the magnet may be introduced through the opening made by the foreign body; but if important tissues are likely to be injured by this proceeding, another opening may be made close to its position as well as this can be determined, and where there is least like- lihood of doing permanent injury. When the exact position of the foreign body is unknown, the opening may be made through the con- junctiva and sclera, about the equator, and near the lower edge of the external rectus muscle. For this purpose a Graefe knife may be used, and care must be taken that the opening in the conjunctiva is not di- rectly over that in the sclera. The opening should be large enough for the easy withdrawal of the foreign body when its size can be approxi- mately determined. The point of the magnet is gently introduced and held for a short time just within the globe, so that if the foreign body is near it may be attracted without further disturbance of the vitreous; but should this fail, the point is carefully moved in different directions until the foreign body is found, or until it is demonstrated that the magnet is useless. The failure to remove these bodies with the magnet is generally caused by their having become encapsulated, or by their having 672 INJURIES AND DISEASES OF THE EYE. passed through into the orbit; but it is not safe to depend upon the latter supposition, and the injured eye should be enucleated, unless vision is still good, when it should be kept under strict surveillance. Perfect cleanliness must be observed in all operations for the removal of foreign bodies from any portion of the eye, and the suggestions under the head of asepsis and antisepsis should be carefully followed. The conjunctival wound, if large, may be closed with aseptic sutures, and the eye should then be protected by a light dressing. Wounds of the Eyeball.—But little need be said in addition to what is contained in the article of Dr. Williams, except perhaps as to the manner of treatment. Perfect cleanliness of wounds and of surround- ing parts has done much toward saving many eyes that were thought to be irreparably injured. Sutures are rarely necessary except in wounds involving the conjunctiva and sclera, and then onhT in the former. The danger of infection is always greater when the vitreous chamber is opened, and the greatest care should be taken in cleansing such wounds and thoroughly disinfecting them. Before closing the wound a few drops of a solution of bichloride of mercury (1 in 1000) may be instilled. Injuries and Diseases of the Eyelids. Symblepharon.—In addition to the methods by sliding flaps of con- junctiva which have long been practised in the treatment of sym- blepharon, the methods of Harlan and Hotz are often of use when there is extensive attachment between the lid and ball. Harlan’s operation is especially useful wThen the entire lower lid is adherent. The attach- ment is dissected through until the ball has free movement in every direction. Then an incision is made through the lower lid into the conjunctival cul-de-sac along the margin of the orbit, leaving the lid attached only at its ends. Next a thin curved flap of skin is dissected below the incision in the lid, and large enough to cover the denuded conjunctival surface. This flap is turned on itself and tucked through the incision into the cul-de-sac, and attached by sutures to the lid, thus bringing the fresh surface in contact with denuded portions of the lid, and the skin surface against the ball. Hotz’s mode of operating for extensive symblepharon is by Thiersch's method of skin grafting. The eye is first thoroughly cleansed and the part for receiving the graft is prepared by dissecting through its attachment, or by carefully denud- ing its surface of cicatricial tissue. The inner surface of the forearm is washed with soap and water, and then with a solution of bichloride of mercury. A sharp razor which has been rendered aseptic by being dipped in boiling water is then laid flat against the arm, and by a gentle sawing motion a thin layer of skin is shaved off. This is trimmed to the proper size and laid on the denuded surface. No harm is done if the graft is larger than the denuded part. The lid is gently closed over the graft and the eye is dressed aseptically. The new sur- face will be lighter in color than the surrounding mucous membrane, and will remain so for a long time, but the flap rapidly grows to the part, and soon takes on the nature of the conjunctiva. THE LACHRYMAL APPARATUS. 673 Transplantation of the conjunctiva of the rabbit has been successfully accomplished in several cases when extensive adhesions have existed. The flap should be larger than the denuded surface and free from subcu- taneous tissue, and the sutures should be inserted before its removal from the rabbit. It should be kept warm and moist. Flaps of mucous membrane may also be taken from the lip of the patient. All bleeding must be stopped before the flaps are applied. Blepharitis.—This disease is at times very obstinate, and the remedies commonly used may fail to produce any change for the better. It is well to remember that the cause may be constitutional, and other than scrofulous, and therefore it is necessary to study closely the general condition of the patient. Syphilis is not an infrequent cause of the inflammation, and especially in this form are the roots of the ciliae diseased. The diseased cilise are readily recognized by their bulbs being black instead of white, which is due to the diseased condition of the lid margin. The inflammation at times causes swelling of the entire lid, and may extend to the ocular conjunctiva. The inflammation in some cases partakes of the nature of eczema or other skin disease, and is then very difficult to manage. The general treatment of blepharitis is thoroughly outlined in the article of Dr. Williams. In obstinate cases we should always suspect syphilis, and they may be treated accordingly with mercury and iodide of potassium. It may be necessary to give the latter in large and in- creasing doses, especially when the condition has lasted a long time and the lids are very much thickened by infiltration. In those cases that partake of the nature of skin disease the internal use of arsenic may be followed by good results, and much benefit may be derived from the use of an ointment of aristol (gr. xv. to vaseline gr. lxxviii.). This should be applied to the margins of the lids, once or twice a day, after the usual cleansing of the parts. Some cases of blepharitis are due to refractive errors and are cured by the use of proper glasses. The Lachrymal Apparatus. Inflammation of the Lachrymal Gland.—This is rather rare, but occurs in both an acute and a chronic form. The acute is more fre- quent among children and is generally caused by trauma. The chronic form is at times bilateral and then is usually of syphilitic origin. The symptoms of inflammation of the lachrymal gland are swelling of the lid, partial ptosis, displacement of the ball downward and inward, and pain. Sometimes an abscess forms and breaks through the lid, leav- ing a fistula that is difficult to close. This condition may be con- genital. The gland in some cases is simply hypertrophied. Abscesses are of course treated according to general principles. Malignant Tumors of the Lachrymal Gland.—These are sar- comata and "carcinomata, and they cannot always be distinguished in the beginning from simple hypertrophy. The treatment for malignant growths is early and thorough excision, care being taken not to cut the levator palpebrse muscle. 674 INJURIES AND DISEASES OF THE EYE. The Tear Passages.—It is now admitted that the most frequent cause of obstruction of the tear passages is swelling of the nasal mucous membrane, which closes the nasal end of the duct and causes a dam- ming of the tears in the sac, epiphora, dacryocystitis, or abscess. A case is reported by Malgat where a piece of lettuce which was forced into the duct during the act of sneezing caused an abscess. Syphilis is a frequent primary cause of obstruction of the tear passages, usually beginning in the nose. Lachrymal abscess sometimes occurs in women during the early months of pregnane}7, and, according to Mr. Powers, is caused by the congestion of the nasal mucous membrane following vomiting. Sometimes epiphora is caused by papillomatous growths obstructing the canaliculi, but this is rare. Treatment.—When cases of epijihora are seen in the beginning it is generally easy to prevent serious consequences, but unfortunately, when the case is seen by the surgeon, the mischief often has already been done. For the slighter cases caused by catarrhal inflammation of the conjunctiva and adjoining mucous membranes it will be sufficient to wash out the sac with a weak solution of bichloride of mercury (1 in 10,000), boric acid and salt, or peroxide of hydrogen properly diluted with boiled water. At the same time the nasal mucous membrane should receive appropriate treatment by spraying, douching, insuffla- tion of powders, or stronger applications, according to the condition of the parts. It is difficult to abort an abscess after it has once begun to form, and it should therefore be poulticed and opened early by a longitudinal incision at the most prominent part. The sac and infil- trated tissues may now be carefully cleansed by injecting an aseptic solution through the opening. As soon as the inflammation has suffi- ciently subsided treatment of the sac should be commenced through the canaliculus, either being used. Ophthalmic surgeons are becoming more conservative in dealing with the tear passages, and though there are still a considerable number who slit up the canaliculi for prepara- tory treatment, many are coming to the conclusion that it is far better to treat these affections with as little mutilation of the parts as possible. Therefore they dilate the canaliculus until sufficiently large to admit the small nozzle of a syringe, and by this means the sac is cleansed, for if the liquid fails to pass through the duct it will escape by the other canaliculus. Generally it will be found that a variable quantity passes through into the nose, and that is reason enough for not cutting strictures by specially devised knives, or using large- sized probes that make gutters of capillary tubes. It must be ad- mitted that in cases of lachrymal abscess when the tissues of the face have become infiltrated, and the bones of the orbit and nose are in- volved, it may be necessary to slit a canaliculus in order that the parts may be more thoroughly cleansed. Dividing strictures only causes the formation of cicatricial tissue which will prove a future menace to the lumen of the duct. The employment of large probes seems unneces- sary, for in reality the probe should only be of sufficient size to give an outlet to the fluids, and should be used only as long as may be needed for the parts to recover their normal condition, which is now more readily accomplished than formerly, by strictly aseptic measures. When the duct becomes occluded bv bone at the nasal end, the treat- ment advocated by Caldwell is probably the best. He uses an electri- DISEASES OF THE CONJUNCTIVA. 675 -cal trephine on the turbinated bone until the duct is reached, and then cuts out the sides of the duct until the probe, which has been entered from above, is exposed. This gives a free outlet for the fluids and the case is then easily treated. However, the progress of cases of lach- rymal obstruction is frequently unsatisfactory, partly because they are not seen by the surgeon until considerable mischief has been done, and again because the treatment is necessarily protracted and many patients become discouraged. Therefore, when the patient lives at a distance, or is unable to continue treatment, or when for any other cause this can- not be followed systematically, it is better to slit the lower canaliculus and teach him to use a probe on himself. In such cases a No. 3 Bow- man probe should be selected. When the conservative plan of treat- ment is adopted, the canaliculus should first be cocainized, and a small silver probe should then be introduced into the sac and followed by the small nozzle of a syringe through which cocaine may be injected into the sac and duct. It will generally be found that the probe now passes easily into the nose. The waste ways being open, the cleansing fluid (solutions of bichloride of mercury 1 in 8000 or 1 in 10,000, boric acid and salt, peroxide of hydrogen, or simple salt) may be syringed through. The peroxide of hydrogen has the advantage of hunting out all the pus, and especially when infiltration has occurred. These cleansings should be continued daily until all discharge ceases. At the same time the patient may supplement the treatment by using at home any of the above-named solutions in the cul-de-sac, or mildly astringent washes, among which may be mentioned alum in the distilled infusion of witch-hazel. Pyoktanin (1-1000) has been advised, but it is only in chronic cases that any good can be expected from its use, and even then it is uncertain. In cases where no benefit results from treatment, the sac may be excised or destroyed by the actual cautery. For excision a cut should be made directly down upon the sac, which is then seized by forceps and dissected out. Syphilitic cases are treated by mercury and iodide of potassium, and usually respond promptly. Diseases of the Conjunctiva. Conjunctivitis.—For the milder forms of conjunctivitis which are caused by the irritating influences of cold, dust, or light, non-irritating washes are by far the most useful, and are followed by the best results. Bathing the conjunctiva with boiled water, or spraying and douching with the same, either cold or warm according to circumstances, will often afford much relief and be all the treatment that is necessary. For catarrhal inflammation and blepharitis, thorough cleansing with boiled water and castile soap several times a day, with the alternate use of the boric acid and salt solution, usually quells the inflammation. Th,e stronger astringent solutions of nitrate of silver, zinc, alum, copper, and tannin are apt to increase the irritation in acute cases and are therefore contra-indicated, but for chronic cases they are very useful. The solutions of nitrate of silver are still the most highly prized, and are used in varying strengths, gr. x. to f 1 i. Only in the very severe cases will the stronger solutions be necessary. At times acute 676 injuries and diseases oe the eye. attacks of catarrhal conjunctivitis with profuse muco-purulent dis- charge may be cut short by the thorough application of nitrate of silver, gr. iv.-x. to f 3 i., but the cases for such treatment should always be carefully chosen. Solutions of bichloride of mercury do not seem to be indicated in the treatment of acute conjunctivitis, as a solution of only 1 in 5000 has caused serious irritation in these cases. Ophthalmia Neonatorum.—This is probably caused oftener by the gonococcus than by any other germ, but there are undoubted cases in which its presence cannot be demonstrated. Crede's method of instil- ling one or two drops of a two-per-cent, solution of nitrate of silver into the eyes of infants immediately after birth, is still the recognized preventive treatment, and this precaution has caused a vast reduction in the number and severity of cases. Certain states have adopted laws requiring all midwives to report to a physician every case of eye in- flammation occurring in new-born children under their care, and the penalty for failing to make such report is fine, or imprisonment, or both. Laws of this kind, if properly enforced, would go far toward stamping out the greatest cause of blindness, and should be uni- versally adopted. Gonoerhceal Ophthalmia.—This inflammation is caused by the gonococcus getting into the conjunctiva, and its presence may always he proved by the microscope even when the source of infection is un- known. The symptoms are too well known to be repeated here, and the diagnosis is easy. If seen in the first stage, when the entire con- junctival area is reddened and the eye is weeping, the attack may be aborted, or the severity lessened, by prompt and energetic treatment. This consists in perfect cleanliness and the use of nitrate of silver, which is the most important remedy for this disease. Usualty it is not necessary to use solutions stronger than two per cent., but when the discharge is very profuse and the cornea is threatened, the strength may be increased to twenty or thirty grains to the ounce, or even more. Unless accustomed to treating these cases it will be more prudent to employ the weaker solutions. The strictest attention must be paid to the cornea, and a critical examination should be made several times a day when possible. Softening, which is indicated by haziness, shows that the microbe has made its way through the epithelium. Atropine to allay the irritation is at once indicated, and the efforts to secure cleanliness must be redoubled. It has been advised (Hinde) to apply strong solutions (1 in 500) of bichloride of mercury to the infected spot, but the use of this remedy requires caution. French surgeons have advocated the use of the actual cautery, and report cases as saved by this treatment. Ice-cold cloths should be applied continuously to the lids until all active symptoms have subsided, for by the use of cold multiplication of the gonococci is restricted. The sound e}Te must always be sealed and every care taken to prevent it from becoming ;n- fected. Bandages and dressings to the inflamed eye are unnecessary unless perforation of the cornea is threatened, or has occurred. Finally, when possible, a nurse should be in constant attendance upon these cases, and too much care cannot be exercised by the surgeon and attendants that they themselves do not become infected. The pus will DISEASES OF THE CONJUNCTIVA. 677 at times spurt from between the swollen lids when opened, and the danger to those around is imminent. The hands of all in attendance should be carefully washed with soap and water, and then in a solution of bichloride of mercury (1 in 1000). Trachoma; Chronic Granular Conjunctivitis.—Muttermilch says that the microbe of trachoma has not been found because it does not exist. According to Fuchs, “there is but one kind of trachoma, which, however, appears under various forms.” He thinks that the disease can be traced back to gonorrhoeal infection which lias caused acute blen- norrhcea, and that, this becoming chronic, its secretion has produced in the healthy eye trachoma, which has continued to spread itself as such. The numerous descriptions which have been given of the disease have caused no little confusion, but it may be briefly said to have in the beginning distinct papillary elevations with hypertrophied conjunctiva and purulent secretion. These elevations coalesce and form large, ir- regularly shaped elevations, flat or rough, and finally absorption sets in, connective and cicatricial tissues form, and the lid shrinks, becom- ing dry and curving upon itself, when entropion follows. The eye irritated by the rasping of the lid becomes rough, pannus forms, grow- ing from the upper corneal margin, and this formation of connective tissue and blood-vessels gradually forces itself down between the conjunctival covering and Bowman’s membrane, until the entire cornea may he covered and blindness follows. Follicular Conjunctivitis.—This is regarded by Fuchs as separate and distinct from trachoma, while others are equally positive that it is but a form of that disease. Follicular conjunctivitis occurs quite fre- quently among children, while trachoma is rare among them. The follicles of the former are smaller, more sharply formed, and are com- monly arranged in parallel rows on the conjunctiva, especially of the lower lid. There is little or no pain, and no formation of pannus con- nected with the presence of these follicles, and they may exist for months without the patient suffering any inconvenience. At times follicular conjunctivitis follows the prolonged use of atropine, and it may possibly he due to the presence of some germ in stale solutions. The simple eye washes are sufficient treatment for the lighter cases, while for the severer cases more heroic measures are necessary, such as pressing out the contents of the follicles by the finger nails, or by specially devised forceps. In some cases recover}r takes place without any treatment, and without the conjunctiva becoming impaired. Treatment of Trachoma.— The acute stage of trachoma must be treated by soothing washes (boric acid and salt), ice-cold cloths should be applied to the lids, and upon any threat of corneal invasion atropine should be instilled. Weak solutions of nitrate of silver (gr. i.-iv. to f Si.) may be carefully employed at this period, provided no serious re- action follows. As soon as the acute stage has passed and the eye is less irritable, stronger applications are indicated. One of the most efficient, in that the results are excellent and that the patient may if necessary apply it himself, is the solution of bichloride of mercury in varying proportions (1 in 300, 500, or 1000). Several drops may be placed on the inflamed conjunctiva once or twice a day, according to the effects produced. The pain after the first applications will be in- 678 INJURIES AND DISEASES OF THE EYE. tense, and will often continue for an hour or longer, but gradually the parts become more tolerant and the pain less severe, and the applica- tions may then be made twice a day. The crystal of copper sulphate, strong solutions of tannin and glycerin (gr. x.- xxx. to f 3 i. or stronger), and boroglyceride (fifty per cent) may all be used during this stage. The copper, though an effective and highly prized remedy, is severe, the pain from a single application not unusually lasting for several hours, and at times all day, and it should therefore only be used by Fig. 1699. Noyes's Trachoma Forceps. skilful hands. The popular treatment for this stage is the surgical, which consists in expressing the contents of the follicles by means of the finger nails or specially devised forceps, or in incising the con- junctiva in lines parallel to the lid margin with a special instrument, and then, with a nail-brush or tooth-brush that has been dipped in a solution of bichloride of mercury (1 in 100, 200, or 300), brushing out their contents. This method is known as “grattage,” and has been recommended by Darier and other French surgeons. The forceps de- signed by Noyes and by Knapp (Figs. 1699, 1699 bis) are among the best for the treatment by expression. Patients are placed under the influence of an anaesthetic, or perhaps strong solutions (ten per cent.) of cocaine may answer. Noyes uses two pairs of forceps, and with one grasps and everts the lid, while with the other the folds of the con- junctiva are caught, and by pulling against the first pair the contents of the follicles are pressed out. Knapp’s is a roller-forceps, and by its use the conjunctiva is milked, as it were, both arms being at times Fig. 1699 bis. Knapp’s Roller-Forceps for Trachoma. within the cul-de-sac, though when the edges of the lid are reached one be placed outside. Considerable reaction follows these operations: but beyond washing with a solution of boric acid, and applying iced cloths externally, no immediate treatment is necessary. Adhesions between the torn and mangled conjunctival folds may be prevented by breaking them up daily with a probe. As soon as the reactive symp- toms have subsided the treatment may be supplemented by the use of astringent washes, careful applications of the crystal of copper, boro- glyceride, and solutions of nitrate of silver. No exact rules can he laid down for this stage, hut the case must be treated according to cir- DISEASES OF THE CONJUNCTIVA. 679 cumstances. Pannus is still treated by performing peritomy, but in those cases where there are thick pannus and rough, tough excres- cences on the conjunctiva, no remedy can accomplish more than jequirity. This may be employed in a three-per-cent, infusion, or as a powder sprinkled upon the pannus and lids. Two or three applications of the infusion are sufficient to produce the desired inflammation, which begins usually within twelve hours, and at the end of twenty-four is well under way. When the pannus is old. tough, and thick, the inflamma- tion should continue two or three days, and then be gradually checked by frequent cleansing with boric-acid solution. It is better to accomplish too little than to run the risk of destroying the cornea, for the process may be repeated as often as is necessary. The pannus has been seen to slough away in large pieces. Jequirity is contra-indicated in cases of ulcerated cornea, when there is much discharge, and in all acute cases. Phlyctenular Ophthalmia.—This form of inflammation of the conjunctiva and cornea, on account of the intimate connection between the parts, will be considered under the above heading. The appearance and symptoms are well known and need not be dwelt upon here. The phlyctenula is a collection of round cells situated beneath the epithelium in the conjunctiva, and between the epithelium and Bowman's mem- brane in the cornea. When the cells pass through this membrane and penetrate the cornea a hazy spot is always left. The primary cause of phlyctenular inflammation is undoubtedly constitutional, but some writers contend that nasal complications are always present and that treatment of the nose cures the eye. The nasal affections are hyper- trophy of the turbinated bones, and polypi and other growths that are found upon the mucous membrane of the nose and naso-pharynx. The nasal hypertrophies frequently cause obstruction of the duct, and it is quite likely that poisonous germs from the sac find their way along the canaliculi and finally infect the conjunctiva and cornea. The predis- posing constitutional diseases are syphilis and scrofula, and at times it may occur when the system is run down, as while teething, and con- junctival phlyctenulae are at times seen even in apparently healthy children, though doubtless due to some latent hut slight disorder of nutrition. Befractive errors, and astigmatism especially, are said to be causes. Undoubtedly constitutional weakness and dyscrasiae have much to do with the disease, and it is not unlikely that the same cause produces that of both eye and nose, and that the treatment of one organ is incomplete without that of the other, both being improved by constitutional remedies. Therefore it must he concluded that phlyc- tenular ophthalmia occurs most frequently in strumous and syphilitic children, in whom all mucous membranes are prone to inflammation and hypertrophy; that malarial, unsanitary, and bad hygienic sur- roundings are usually the direct causes of attacks; and that not only the membranes of the eye and nose are involved, but frequently that of the alimentary tract also. Treatment.—The patient’s surroundings when bad should he im- proved, change of climate is beneficial, good and nourishing food is .essential, and out-of-door life is not to be restricted. The condition of the general health should receive careful investigation, and indigestion 680 injuries and diseases of the eye. or mal-assimilation should be corrected. All throat and nose compli- cations should receive appropriate treatment, and as soon as the irrita- tion of the eyes has sufficiently subsided they should be examined, while under the influence of a mydriatic (preferably atropine), for refractive errors. When found, these should be corrected by the proper glasses. When the conjunctiva'alone is affected, calomel dusted on the eye and the simple washes are all that is necessary, unless the ulcer should prove obstinate, when it may be touched daily with a five-grain solution of nitrate of silver. Corneal invasion will be treated of under the next heading. Affections of the Cornea. The three principal layers of the cornea, viz., the epithelium, Bow- man’s membrane and the cornea proper, and Descemet’s membrane, correspond to the three coats against which they abut, viz., the con- junctiva, sclera, and uvea (iris and ciliary body), and in fact the micro- scope does not show any sharp line of demarcation between the cornea and sclera, the fibres of each passing imperceptibly into the other. The cornea is therefore from its intimate connection with these parts most likely to sympathize, or by contiguity and continuity to be infected or affected, by any abnormality existing in them. Keratitis.—Inflammation of the cornea may be suppurative or non- suppurative. The first stage is infiltration, and in the non-suppurative form resorption takes place. In suppurative keratitis there are three stages, viz., infiltration, sup- puration, and cicatrization. Fuchs says: “ We must first examine the corneal reflex. If the surface is dull, we are dealing with a recent af- fection, and in that case, if there is no loss of substance, with an infil- trate or with an abscess; hut if a loss of substance is present, with a foul ulcer. If the surface is lustrous, the affection is an old one; if a loss of substance is present, it is a clean ulcer that we have before us; but if no loss of substance is visible, we are dealing with a cicatrix.” An easy and positive way of diagnosing corneal inflammation or injury is by the use of the solution of fluorescine, which stains all breaks and softened spots in the epithelium a green color. In suppurative keratitis there is always a loss of tissue when the ulcer extends below Bowman’s membrane. True corneal tissue is never reproduced when once de- stroyed, and healing takes place by cicatrization which begins from the sides and bottom of the ulcer. Non-suppurative keratitis may result in perfect recovery of vision, hut if the cellular elements are not entirely resorbed, then haziness remains. This haziness may be in the corneal layers or on the membrane of Descemet, and accompanying iritis with synechiae may be a strong factor in causing dimmed vision. Treatment of Suppurative Keratitis.—Cleanliness is of prime impor- tance, and when the ulceration has been caused by disease of the lids, this should be vigorously treated. The solutions of boric acid and salt, bichloride of mercury (1 -1000), and chlorine water are sufficient for cleansing. Atropine is most important for allaying irritation and pre-. venting iritis, though it is hardly possible to do this. For chronic AFFECTIONS OF THE CORNEA. 681 ulcers with little discharge, and for those of traumatic origin, the ban- dage may work wonders. When ulcers show a tendency to extend, with the formation of hypopyon, nothing avails but the use of the actual cautery, and this must be boldly applied to every point. Ab- scesses and ulcers accompanied \)y large deposits of pus in the cornea or anterior chamber should at once be treated by Saemiscli’s method of incision and evacuation. After this the wound and anterior chamber must be carefully washed out with the solution of boric acid. Ulcers that tend to extend gradually over the cornea, such as have been called serpiginous and dendritic, are often difficult to control and are very chronic. When the pupillary area is likely to be involved the actual cautery renders valuable assistance. Eserine is useful at times, but is generally found to do most good in old and chronic ulcers that perhaps have been caused by some lid affection. Rarely is eserine useful in acute ulceration, but in one rapidly progressing case which had been caused by the injudicious use of jequirity in an acute attack of granular lids, eserine at once changed the condition and saved the eye. Threatened perforation of the cornea must be guarded against by bandaging, and occasional paracentesis may be required until the corneal tissues have regained their strength. This of course renders infection of the an- terior chamber more liable to occur if there is much discharge, but this procedure is preferable to having the cornea burst, leaving a ragged opening and prolapse of the iris. The opening in the cornea should be in the healthy portion and as far from the ulcer as possible, in order that there may be less danger of infection. The employment of eserine and atropine to prevent prolapse of the iris is not practically useful, for when the break occurs the iris goes in, and besides, in those cases in which eserine has been used there is greater danger of the formation of synechiae. Should perforation have occurred before the patient is seen, nothing can be done toward reduction, and on no ac- count should the iris be interfered with, for, acting as a plug in the wound, it prevents further infection of the anterior chamber, and keeps the aqueous humor from escaping and thus causing obliteration of the chamber. Absolute cleanliness is essential, and beyond this little treatment will be necessary. At times weak solutions of atropine will aid very much in allaying the irritation, but at other times they in- crease it, so that it is only by trial that their effect can be known. Gentle pressure should be kept up by a bandage to prevent further bulging of the iris in the wound, and in time the inflammation will subside, the projecting portion will become flattened, and nothing but the hazy spot and distorted pupil will remain. Finally, constitu- tional treatment is of paramount importance, and the digestive func- tions should receive careful supervision and regulation when necessary. The scrofulous cases are generally very tedious, and it will often tax the skill of the surgeon to meet the many complications that arise. Those cases which are due to malarial poison are benefited by large doses of quinine, repeated at short intervals for several days and then gradually diminished. For obstinate cases of malarial or other origin, arsenic in the form of Fowler’s solution, and given in ascending doses, is of decided benefit. Keratitis is at times caused by delayed or irreg- ular menstruation, and then usually disappears when that function is established. 682 INJURIES AND DISEASES OF THE EYE. Hazy cornese are often much benefited by massage with the oint- ment of the yellow oxide of mercury (gr. ss.-i. to 3i- vaseline).1 The rubbing should be systematically performed in every direction with the lid and finger. The improvement is very gradual. Electrolysis has been employed by Alleman and others for leucoma, and they claim with gratifying results. While the cornea is still irritable atropine should be continued, and in not a few cases it will aid greatly in clearing away slight nebulae. For the dense central leucomata, iridectomy when practicable will of course be necessary. The sequelce of ulcerated cornea are hazy spots (nebula and leucoma), synecliiae, staphyloma, cataract, panophthalmitis, and destruction of the globe. Small staphylomata are sometimes reduced by bandaging and supporting the weakened parts until they have thoroughly healed. Again the performance of iridectomy will at times cause a subsidence of the swelling. Large staphylomata may be treated by posterior sclerotomy, as advocated by de Wecker. This is performed by drawing the eye downward and inward with the fixation forceps, and with a Graefe knife making an incision through the conjunctiva and sclera, back of the ciliary body, and between the superior and external recti muscles. The opening may be a little greater than the breadth of the knife, care being taken not to make the incision in the sclera directly under that in the conjunctiva. Immediate improvement must not be expected, as a year or more may elapse before the good effects are seen, and in some cases the operation is of no benefit. Other operators ex- cise the staphyloma in various ways and draw the edges of the wound together with a continuous or interrupted suture. Enucleation is necessary when the protrusion is very great, or evisceration may be preferred. This operation can be done with the eye under the influ- ence of cocaine. For its performance a speculum, fixation forceps, scissors, knife, and scoop are necessary. The conjunctiva is loosened about the cornea and with the knife an incision is made through the sclera. The cornea is excised by the scissors or knife, the contents of the globe evacuated, and the inner surface of the sclera is scraped in order that the choroid may be entirely removed. The cavity is cleansed with any antiseptic solution, or, as Prince has suggested, may be wiped out with a solution of carbolic acid to prevent the pain which is usually severe. The edges of the conjunctiva are drawn to- gether by the continuous suture. Considerable reaction follows the operation, and healing is slow. It is claimed that a better stump for an artificial eye is gained in this way, and that hence the operation is preferable to enucleation. Mules has introduced a glass ball into the scleral cavity and closes the sclera over it. This makes a good resting place for the artificial eye, and Mules, with others, speaks highly of the results. Conical Cornea.—This change in shape is due to a thinning at the centre of the cornea, the pathology of which is not understood. It occurs in both eyes, in males and females, at times affects several members of the same family, and in some instances has seemed to be hereditary. The process is slow and can rarely be controlled. Several 1 This ointment is less irritating when the mercury is lirst rubbed up with a few drops of olive oil, and the ointment then made with vaseline or albolene. AFFECTIONS OF THE CORNEA. 683 modes of treatment have been tried, such as trephining the apex and removing a plug, and cauterizing with lunar caustic, but the results have not been satisfactory. The operation described by Knapp1 has probably been followed by the best results and seems most rational. He employs with the galvanic cautery an electrode with an oval plate,, 3 by 2 mm. This is applied cold a little below the centre of the cornea, and is removed as soon as it is brought to a red heat. He is careful not to allow the instrument to penetrate the anterior chamber, and thereby prevents the formation of synechige. A second operation may be necessary, but this is preferable to causing too much reaction by the first. It may be necessary to perform a subsequent iridectomy for optical purposes. Tumors of the Cornea.—These may be dermoid cysts, which are congenital and are attached at any portion of the margin, or fibromata, which are very rare, while in one or two instances corneal polypi have been reported. The malignant tumors which at times attack the cornea do so by extension from the iris, choroid, or ciliary body. Pterygium.—Ophthalmic surgeons still differ as to the origin of this growth, or overgrowth, of the conjunctiva. Contrary to many opinions, Fuchs claims that pterygium has its starting-point in a pinguecula, which during the degenerative process extends upon the cornea and then draws the conjunctiva after it. True pterygia occur only at the inner and outer margins of the cornea, those found at other points having their origin in corneal ulcers to which the conjunctiva becomes attached. This variety rarely if ever shows any tendency to extend. Pterygium, while it may occur more frequently in elderly persons, is by no means uncommon among young men, but is much less common among women of any age. Several methods of removal have been described, but that advocated by Prince seems the most satisfactory and thorough. It consists in grasping the growth at or near its corneal attachment and gently tugging until it is entirely detached. With the eye under the influence of cocaine there is no pain, and the removal, as far as the cornea is concerned, is absolute. Bowman’s membrane is usually sepa- rated from the cornea proper, and a white and glistening area, caused by the partial separation of the corneal layers, is temporarily seen, hut soon disappears, the cornea healing without any opacity, which is not always the case when the dissection method is employed. After re- moval of the pterygium the edges of the conjunctiva are dissected back, and are then drawn together by sutures. It has been advised to make two vertical slits in the conjunctiva near the cornea, above and below, which prevent the conjunctiva being folded over the cornea when the sutures are tightened. When large pterygia are removed Hotz has advised skin grafting by Thiersch’s method to fill the gap. After the operation has been performed the eye should be thoroughly cleansed, as has been directed, and a light dressing applied to keep if closed, for healing takes place faster than if it be left open. The sutures may be removed on the fourth or fifth day, and smoked glasses may be worn to protect the eye from light and dust. The part is likely to be sensitive for several weeks. 1 Archives of Ophthalmology, vol. xxi., No. 4. 684 INJURIES AND DISEASES OF THE EYE. Affections of the Iris and Ciliary Body. Iritis and Cyclitis.—Inflammation of the iris and ciliary body usually coexist, on account of their very intimate connection. Iritis begins with a hypersemic condition of the iris which causes congestion of the blood-vessels and contraction of the pupil, the latter being aided by spasm of the sphincter from irritation. An exudation from the over-distended blood-vessels covers the surface of the iris, gives it a dull appearance, and changes its color. This exudation also produces a cloudiness of the aqueous humor, and when present in any quantity is precipitated in the anterior chamber, forming hypopyon. At times hemorrhages occur from the bursting of a vessel in the iris, the blood (hypohcema) occupying the anterior chamber. Exudation into the posterior chamber causes posterior synecliise. These are best seen by reflected light as small projections from the pupillary margin into the pupillary space. Atropine at once proves their existence by producing irregular dilatation, unless the entire margin is adherent, when no dila- tation occurs. The exudation may fill the pupillary space and interfere seriously with vision, while the seclusion caused by total posterior synechia does not at first necessarily impair the sight, though it usually causes increase of tension which may eventually produce blindness. Cyclitis.—The exudation from the ciliary body covers that body itself, and passes into the posterior and anterior chambers and into the vitre- ous. In the anterior chamber it is seen as minute dots and specks cov- ering the membrane of Descemet, and the situation of these spots in the same plane distinguishes them from corneal disease with which they have no connection. The exudation into the posterior chamber pro- duces total posterior synechia, and exudation into the vitreous causes opacities which are readily seen with the ophthalmoscope. Tension is not increased in simple iritis, but may be so in the beginning of cyclitis, though in the end it is reduced. Pain, photophobia, ciliary injection, lachrymation and impaired vision are prominent symptoms of iridocyclitis. Duration.—Acute attacks, when properly treated, last from two to six weeks, and the eye remains sensitive for several months afterward. Iritis cannot be aborted; when taken in time it can be cured, but when not treated and allowed to become chronic it never tends to recovery. There is often a tendency to relapse, especially in chronic cases, which is probably due to a continuance of the cause. Usually but one eye is attacked, though both may be simultaneously affected, or one may be involved before the other by one or two weeks. When seen before synechia© have formed or have become firm, iritis may be cured, and vision will then be as good as before the attack, but when synechiae re- main vision will be impaired. Sequelae.—Atrophy of the iris rarely follows acute, but is common after chronic iritis. Posterior synechice, when few and slight, do not interfere much with vision, but when there is seclusion of the pupil increased tension may follow, and sight fails as in glaucoma. Pupil- lary occlusion shuts off light and prevents vision, while exudation covering the ciliary body, filling the posterior chamber, and causing a general matting together of the iris, ciliary body, and lens, by organiz- AFFECTIOHS OF THE IRIS AND CILIARY BODY. 685 ing and shrinking gradually detaches the retina from the choroid, and produces blindness. The eye loses its elasticity and becomes soft, the ball is smaller, the cornea is battened and the anterior chamber ob- literated, the iris is atrophied, and the positions of the recti muscles are apparent by their indentations in the sclerotic coat. The development of atrophy is slow and painless, except perhaps in cases where ossifica- tion occurs in the choroid. Etiology of Iritis and Cyclitis.—The causes are primary and secon- dary, and Fuchs classifies them as follows:— 1. Iritis syphilitica. 2. “ scrofulosa. 3. “ tuberculosa. 4. “ rheumatica. 5. “ gonorrhoeica. 6. “ in acute infectious diseases. 7. “ diabetica. 8. “ idiopathica. 9. “ traumatica. 10. “ sympathetica. Iritis in consequence of general disease A—Primary iritis Iritis as a local affection B—Secondary iritis. Syphilitic iritis is present in at least fifty per cent, of all cases. Be- sides constitutional symptoms there are usually nodules at the pupillary margin, but at times these are absent and, as far as the iris is concerned, there are no pathognomonic signs of syphilis. It usually follows the first eruption in the skin, but occasionally comes much later. When due to hereditary syphilis it is not so severe as in the acquired disease; the former is more commonly seen in children and young persons, whereas the latter occurs in adults. Syphilitic iritis is frequently associated with inflammation of the choroid, retina, and optic nerve. Scrofulous iritis in appearance is somewhat like that due to syphilis. It is seen in children, young persons, and at times in the anaemic. Tuberculous iritis is frequently seen in children. There are small nodules and at times larger growths. These eyes are usually lost, though occasionally they recover. Rheumatic iritis occurs in persons of rheumatic diathesis. A simi- lar form occurs in those who have gout. Gonorrhoeal Iritis.—This form is seen when the general system has become infected by the poison. It is liable to recurrence, especially in * connection with fresh outbreaks of the urethral discharge and swelling of the joints. The iritis of acute and infectious diseases occurs in relapsing fever, and at times in variola, typhus, etc. Diabetic iritis is frequently associated with hypopyon, hut its course is generally favorable. Idiopathic Iritis.—The etiology of these cases cannot he traced, but it is probable that some of, the above-mentioned causes are present though not recognized. Traumatic iritis is produced by any traumatism, especially by blows, the presence of foreign bodies, injuries during operations, etc. Sympathetic Irido-cyclitis; Sympathetic Ophthalmia.—The inflam- mation passes from the injured eye to its fellow. A sharp line must be drawn between sympathetic ophthalmia and sympathetic irritation. The latter, according to Schirmer, is a variable condition, but has two prominent characteristics, viz., no true inflammatory changes, and de- 686 injuries and diseases of the eye. pendence upon continued inflammation in the exciting eye; for as soon as this eye is removed all irritation disappears from the other. In order that there may be no mistake in recognizing sympathetic inflam- mation, three points must be considered: (1) the nature of the injury in the exciting eye, (2) the nature of the affection in the sympathizing eye, and (3) the length of time between the injury of the first and the implication of the second. Irido-cyclitis must exist in the exciting eye, and this has generally followed perforation of the coats allowing the entrance of microbes, which, not the wound as was at one time sup- posed, are the cause of the inflammation. The affection in the sym- pathizing eye is generally a uveitis, a papillo-retinitis, or a combination of both. The time that may elapse between an injury to one eye and sympathetic inflammation in the second is usually about three weeks, rarely shorter, though it may be a much greater period. Various causes have been suggested for the sympathetic inflammation, and among these are nerve irritation and the migration of bacteria. Irido- cyclitis is an essential condition in the exciting eye, and is caused by germ infection. Mechanical irritation of the ciliary nerves does not cause disease, and therefore cannot account for disease in the fellow- eye. Again the affection may continue or even return after the ex- citing eye has been removed, whereas had it been caused by nerve irritation it would have immediately subsided. The bacterial theory accounts more satisfactorily for the inflammation, but as to the path by which the germs pass from one eye to the other, or as to the real nature of the organism, observers are still in ignorance. Treatment of Sympathetic Ophthalmia.—A blind eye that is capable of exciting inflammation should be at once excised. An eye containing a foreign body that cannot be extracted should be excised, unless it retains vision while the other eye is blind. An exciting eye that retains vision should not be removed when the other eye is affected, for in tlmend it may prove the better of the two. The removal of the exciting eye when the second has not been affected is a matter of grave importance, especially when good vision remains, and the case must be judged by a consideration of all the conditions. When inflammation has com- menced, a blind exciting eye should be excised at once. When the patient refuses to have enucleation performed, a large portion of the optic nerve may be excised as a substitute, but the responsibility should be thrown upon the patient or friends. Sympathetic inflammation should be treated by atropine, pilocarpine, and mercury (by inunction if possible). The patient should remain in a darkened room and all use of the eyes should be prohibited. No operation should be performed on the sympathizing eye until all symptoms of inflammation have en- tirely subsided. Secondary Iritis and Irido-Cyclitis.—This usually follows kera- titis, scleritis, retinitis, or choroiditis, and the iritis is generally severe, but chronic and sluggish. Treatment of Iritis in General.—Full dilatation of the pupil by atropine is of prime importance. This should be used freely and fear- lessly, and the intense pain that is frequently caused by the tugging at the adhesions must not deter the surgeon from continuing its use until affections of the iris and ciliary body. 687 sufficient time has elapsed to prove that the attachments cannot be broken. At times the iris is so engorged with blood that the mydriatic is powerless to affect it until blood has been taken from the temple by leeches, or by Heurteloup’s instrument. The free use of mercury by inunction may greatly assist in causing the adhesions to give way, and therefore these two remedies—sometimes with the addition of iodide of potassium—should be pushed until the object has been accomplished. Diaphoresis also may be followed by beneficial effects, and in all but traumatic cases of recent occurrence, hot applications not only help to draw the blood from the parts but greatly alleviate the.pain. This being worse at night, a dose (gr. x.) of antipyrine, or phenacetin, given one or two hours before bed-time and repeated, often relieves pain and thereby induces sleep. At times morphine will be necessary. Para- centesis of the cornea may also be performed in extreme cases. For traumatic iritis ice-cold cloths are at first of most use in subduing in- flammation, but afterward hot applications are preferable. Syphilitic iritis probably responds more promptly to treatment than the other forms, all of which should be treated according to their causes. Iodide of potassium is a safe and useful remedy in all. Synechise unless extensive may not cause much trouble, though some surgeons believe that they excite recurrent attacks, while others regard these attacks as due to a continuance of the cause. Extensive attachments should be treated by iridectomy, though when the pupil is occluded this will avail little, because the capsule is then generally opaque. In these cases it will commonly be found necessary to remove the lens, and even then the papillary space is apt to fill again with inflammatory material. Injuries of the Iris.—The iris is frequently torn b}T blows that do not make an external wound, and lacerations may occur at the ciliary border, causing partial (irido-dialysis) or complete (irideremia) separa- tion, and in the radiating fibres. The iris may also he retroverted so that it lies on the ciliary body. These injuries are usually followed by hemorrhage into the anterior chamber. Treatment is simple. The eye should be protected from the light and atropine should be instilled to allay irritation. When an external wound has been made and the iris has prolapsed, it may, if soon after the injury, be replaced if it is not injured, but usually it will be found necessary to remove the incarcerated portion, after which the wound should be treated antiseptically. Tumors of the Iris and Ciliary Body.—These may be cysts, tu- berculous deposits, or sarcomata. Cysts usually follow penetrating wounds, and should be removed through an incision in the nearest corneal border, the iris and cyst being drawn out and excised. Tuber- culous deposits must be treated expectantly, unless they show a tend- ency to extend, when the eye should be enucleated. Sarcomata of the iris are pigmented, while those of the ciliary body may escape notice for a time. Excision of the globe is the only proper treatment, and this should be performed early. Pupillary Reaction.—When the pupils differ in size the cause is 688 INJURIES AND DISEASES OF THE EYE. usually pathological. Mydriasis may be caused by a spasmodic con- traction of the radiating muscular fibres, or by paralysis of the sphincter (oculo-motor paralysis). The spasmodic contraction is caused by cere- bral irritation. Paralysis of the oculo-motor nerve may affect the pupil alone, or may also involve accommodation, and may affect the extrinsic muscles which the nerve supplies. Its causes are syphilis, cerebral diseases, and such poisons as the mydriatic alkaloids and ptomaines. Paralysis of the sphincter and of accommodation may also be due to traumatism—concussion, acting locally—and to increased intra-ocular tension causing pressure upon the nerves. In complete blindness the pupil dilates from lack of reflex action due to loss of light perception. Myosis may be due to spasm of the sphincter fibres or to paralysis of the cervical sympathetic. The spasmodic variety is caused by begin- ning meningitis, by the myotic alkaloids, and by opium, chloral, and nicotine. Paralysis of the radiating muscular fibres is caused by par- alysis of the cervical sympathetic, spinal injuries, and tabes dorsalis. This form of myosis may be distinguished by the fact that the pupil while failing to react to light will usually act synchronously with ac- commodation and convergence (Argyll-Robertson phenomenon). Hippus is rapid dilatation and contraction of the pupil, probably due to nervous disorders. Albinism.—Gould thinks that albinos are healthy in body and mind, and that there is no discoverable hereditary cause. He believes that the entire pathological influence is exerted upon the eye, and that the condition is caused by transparency of the iris which fails to keep out the light. Cataract. The use of cocaine and the possibility of securing asepsis have sim- plified the removal of cataract and afforded brilliant results. The discovery that a cataract is forming in an eye does not now cause the mental depression and feeling of hopelessness, induced by anticipated blindness, that at one time characterized such cases, because the aver- age man is now sufficiently well informed to know that the operation is at present so well understood, and so successfully performed, that re- stored vision is almost a certainty if the case is a proper one for treat- ment. Some surgeons believe that the progress of incipient cataract may be stayed, and that eyes thus affected may last a long time for useful vision. They advise thorough examination of these eyes, and recom- mend that all sources of irritation should be removed, that errors of refraction should be accurately corrected, that attention should be directed to the general health of the patient, and that, as far as possi- ble, any irregularity or abnormality should be treated by appropri- ate remedies. The time for operating causes much discussion among ophthalmic surgeons, but it seems that an eye should be what Landolt calls “operable.” By this it is meant that the lens should be of nearly uniform consistence, with a minimum amount of cortical substance— in other words “ripe”—“when there has resulted a pathological dehiscence between the crystalline fibres and their implantation upon the anterior, subcapsular epithelium.” But vision may fail and yet CATARACT. 689 this condition of maturity not arrive, wherefore artificial ripening is practised by not a few operators. This is done by stroking the lens with any smooth instrument of proper size, either through the cornea, or directly from the anterior chamber after paracentesis has been per- formed, care being taken not to injure the iris. Others introduce the point of a needle just within the capsule and by this means hasten opacification. Again there are those who perform a preliminary iridec- tomy in addition to massage of the lens. The amount of vision in the other eye should have some influence in determining the time for ex- traction. When vision is still sufficient for the performance of the patient’s ordinary duties, there is nothing to be gained by removing the cataract from the worse eye, but as soon as the second eye fails to such an extent that duties are interfered with, or there is difficulty in going about, the first lens should be removed if the eye is “operable.” The general condition of the patient requires attention, and, before operating, the heart, blood-vessels, liver, and kidneys should be examined. Some operators prefer to keep the patient, if away from home, under observa- tion for several days, and always administer a purgative or laxative a day or two before operating; while others prefer to operate at once, and unless there is constipation do not consider preliminary treatment necessary. Strict antiseptic precautions must be followed in preparing the instruments. When possible the patient should take a bath and put on clean clothes; the face must be thoroughly cleansed with a solution of bichloride of mercury (1 in 3000), the eyelids being carefully washed with soap and water. The eye is thoroughly bathed with the solution of salt and boric asid. Particular attention should be paid to the eyebrows and cilise, and to the beards of men. A clean towel should be folded around the head so that the hair may be entirely covered. The operator and assistant should carefully cleanse their hands, first with soap and water and then in a strong solution of bichloride of mercury or other an- tiseptic. Two or three drops of a four-per-cent, solution of cocaine are instilled at about fifteen, ten, and five minutes before commencing the operation. Some operators prefer to have the patient in a reclining chair, while others use an operating table, and many the bed upon which the patient is to lie afterward. It would seem safer to use the bed when possible, though some surgeons do not hesitate to operate even in their offices, and to send the patient home afterward by con- veyance, or on foot if the distance is short. The speculum is used by most surgeons for separating the lids, but a few employ the elevator, and a lesser number hold the lids with the fingers. The incision is made wholly within the cornea, the puncture and counter-puncture being in the corneo-scleral junction. The incision is usually upward, but a few make it downward. The surgeon must exercise his judg- ment about the size of the incision, which should be governed by the probable size of the lens; this should have an easy exit, thereby pre- venting the retention of cortical matter. The quicker the incision is made the cleaner will be the edges of the wound, and the less liability will there be of the iris falling upon the edge of the knife. The capsule is lacerated by some operators as the knife passes through the chamber. Probably the majority of surgeons now dispense with an iridectomy, and the advantages to be gained are, (1) saving of time, (2) less muti- lation and less exposure to inflammation of cut surfaces, (3) mainte- 690 INJURIES AND DISEASES OF THE EYE. nance of a round pupil, and therefore better vision. The disadvantages are, (1) the smaller exit for the lens, (2) the liability of cortical matter being retained in a place where it may cause inflammation, and (3) the danger of subsequent prolapsus of the iris into the corneal wound. Both methods are to be recommended, but the surgeon must suit the operation to the case. For the typical, senile, ripe cataract, the simple operation is better; but when there is much cortical' matter, when the iris will not return to its normal position, or when there is fluid vitreous, iridectomy should be practised. Unquestionably a preliminary iri- dectomy, performed several weeks before the extraction, simplifies the operation wonderfully, but there is, of course, danger by opening the eye twice, though the simple performance of iridectomy is rarely fol- lowed by any serious results, while the easy and rapid recovery of the patient upon whom the preliminary operation has been performed has much to recommend it. The claim that better vision follows the avoidance of iridectomy cannot always be substantiated. For lacer- ating'the capsule several methods are advised, and each has staunch advocates. Some make a cross in the centre of the membrane, others a T-shaped opening, others a peripheral cut along the upper margin, and quite a number believe in tearing out a piece by means of special forceps. Any of these plans will answer the purpose of liberating the lens, but it seems that the peripheral laceration advocated by Knapp is most rational, because the cortical matter if retained in the capsule will then be where it can do no harm. Expulsion of the lens in the capsule is the ideal operation, but the danger of losing vitreous will prevent its adoption. Before expelling the lens it is advisable to re- move the blepharostat. The lens may then be easily and safely expelled by pressing with the finger or spoon handle through the lower lid at the lower border of the cornea, and with the thumb or finger through the upper lid just above the cornea, the patient at the same time turning the eye downward. By this means vitreous is less apt to be lost. Any cortical matter is now carefully forced out by the same movements, or, which some operators prefer, the anterior chamber may be irrigated by special syringes. This practice has not been generally adopted, but is highly praised by those who advocate it. The eye and cul-de-sac are are now carefully washed with the solution of boric acid. Atropine is instilled by some surgeons, while others, who have equally good results, do not use it except in special cases. Eserine is sometimes used after the simple operation, but as it is likely to cause iritis it is better not to employ it, especially as the pupil naturally contracts after the extraction. In the matter of dressings there is considerable diversity of opinion. Custom and satisfaction with results induce many to retain the ban- dage and pad, though the bandages are much lighter than formerly. Others prefer closing the lids with a piece of soft and flexible plaster, such as gold-beater’s skin, or isinglass or glycerol plaster, while a few ad- vocate no dressing at all. It is true that the best splints are the lids, and that heavy dressings tightly applied may cause the edges of the incision to gape, and thus protract recovery and increase for a time astigmatism, but a light pad of cotton applied over a square of aseptic gauze, and held in place by strips of silk isinglass plaster stuck to the forehead and cheek, or by a light gauze bandage, seems desirable as a GLAUCOMA. 691 means of affording protection from blows, or from pressure accidentally applied. Many operators close both eyes after the operation, while a considerable number close only the one. The operated eye is usually kept closed for a week, and those who close both eyes generally keep the well eye closed for two or three days. When there are no signs of trouble the dressings are often left for three or four days without disturbance, but the comfort of the patient is increased by putting fresh dressings on every day, which can be done without detriment to the eye. It is safer to keep the patient quiet on his back, in bed, for a time after the operation, and if possible to keep him in bed for a day or two; but many surgeons do not confine their patients, nor do they in- sist upon their remaining quiet, and some even allow them to go to their homes after the operation has been finished, and require only that bright light should be excluded from the room. Atropine should be in- stilled on the third or fourth day if it has not been used before, in order to prevent adhesions of the iris to the capsule. Any pain or swelling of the lids should cause an examination of the eye to be made, and if suppuration has commenced in the incision nothing but the actual cautery will avail, and this should be thoroughly applied to every por- tion involved. Afterward atropine and aseptic solutions should be regularly used. Iritis should be treated as heretofore directed. When a secondary operation is necessary for opaque capsule, it should not be performed until all inflammation following the extraction has subsided. The same care should be exercised in cleanliness, and in tearing the capsule the vitreous should be disturbed as little as possible. Glaucoma. Ophthalmologists are still discussing the causes of glaucoma, and many new opinions are constantly being expressed, proving that our knowledge on the subject is still unsettled. It is pretty well decided that changes in the circulation of the eye produce the external appear- ance and the increase of intra-ocular tension. Richey maintains that gout is the true etiological factor of the chronic glaucoma, and “that acute glaucoma is merely a paroxysmal expression of the same affec- tion; that local irritation, or trauma, excites an attack of glaucoma only in the presence of dyscrasia; that operation saves the eye during the paroxysm; that operation serves little purpose in chronic glau- coma, even when it does not, by irritation, hasten the disease process or precipitate a paroxysm; that chronic glaucoma is a neurosis, a progressive atrophy, with the feature of inflammation with deficient power, varied by periods of apparent rest; that correcting and control- ling individual habits, especially in the character and amount of food taken, will do more to preserve vision than operation; and that there may be a possibility of aborting chronic glaucoma, »if the tendency to it be recognized at an early date.” Taking into consideration, there- fore, that some constitutional defect or weakness has been the cause of the circulatory changes in the eye which have in turn brought on the glaucomatous attack, it is very necessary that the existence of any dys- crasia should be known, and that it should be treated by the most appropriate methods. When glaucoma supervenes, the operative treat- 692 INJURIES AND DISEASES OF THE EYE. ment is the only one from which any assistance may be expected, but in this, too, are many disappointments. C. S. Bull, after a large ex- perience, concludes that operation upon a chronic glaucoma is a grave responsibility, and that the patient should be made fully aware of the doubt of benefit, and of the possible chance of utter failure and loss of vision. The stationary condition is better treated with eserine, and fre- quent examinations should be made; when the disease exists in both eyes and when vision is good, the more advanced should be operated upon first; iridectomy is not always followed by good results, but lessened vision or total loss may follow. All things being equal, the earlier the opera- tion is performed the more likely is it to be successful; disease is gener- ally present in both eyes sooner or later; the age and health of the patient determine the advisability of operation, fair vision in such cases pre- cluding interference; the condition of the field of vision, the acuity of vision, and the depth of the anterior chamber, do not indicate the chances for success, the appearance and mobility of the iris being more important. When this reacts promptly to eserine, the operation is more apt to be successful (Nettleship), and in these cases the visual acuity and condition of the field are better; the depth of the excavation and color of the optic disk bear no fixed relation to the condition of the field or of vision, nor to prognosis; the condition of tension does not in- dicate the time for operating unless it steadily increases, nor does it necessarily affect the visual acuity or the field. Gruening summarizes as follows in regard to iridectomy for glau- coma: 1. In acute inflammatory glaucoma iridectomy yields brilliant results. 2. In chronic inflammatory glaucoma without degenerative changes in the iris, iridectomy gives satisfactory results. 3. In chronic inflammatory glaucoma with degenerative changes in the iris, neither iridectomy nor anterior sclerotomy gives to the patient the desired relief. Posterior sclerotomy may do it at times. 4. In simple glau- coma iridectomy generally maintains the previous condition, and is therefore indicated. 5. In intermittent glaucoma the operation of iridectomy is often followed by reduction of sight. Hemorrhagic Glaucoma.—This disease is comparatively rare, and fortunately so, because all cases have been invariably lost, the treatment ending in enucleation of the eye on account of the terrible pain. In most cases there is general arterial sclerosis, with profound hyaline or fibrous degeneration of the retinal vessels, the vessels of the choroid and iris being affected less regularly. Retinal vacuoles are found filled with fibrinous exudates, or empty, and they naturally accompany the hyaline degeneration of the vascular system of the retina. Hemor- rhages maybe present, or the blood may have disappeared by absorption (old cases). The choroid may show inflammatory infiltration, or may be healthy (Pagenstecher). The iris is affected as the choroid, except that the vessels are more apt to degenerate. Adhesive obliteration of the iris angle and of Fontana’s spaces is not constantly found as in acute or subacute irritative glaucoma. When it exists, it is caused by increasing irritation of all parts of the globe and is not a cause of them. Hemorrhagic glaucoma seems to be a disease rather of retinal origin than of the uveal tract, as is irritative glaucoma (Poncet). The hard- ness of the eye is the only point in common. In the irritative form the OPHTHALMOSCOPIC DISEASES. 693 outlets of nutritive fluids are affected, but in the hemorrhagic form the retinal vessels. It is a general disease in which the eye participates; not a true glaucoma, but a local affection, the expression of a par- ticular general condition. Excavations of the nerve and narrowing of tne field on the nasal side are not common.1 Treatment.—The only hope of successfully combating the disease is to treat it vigorously during the “hemorrhagic period,” and as Eisley says, “our care must first be devoted to the general condition of the patient, and second, ‘to remove the congestion of the eyeball.’” As the condition is that of general arterio-sclerosis, the patient must be carefully watched as to diet, occupation, and rest. Potassium iodide and bromide are frequently used, as are also iodide of iron and bichlo- ride of mercury. When there is albumin in the urine Eisley advises Basham’s mixture with corrosive sublimate added, and avoids the iodine salts, and when there is turgidity of the choroidal circulation and head- ache he has employed ergot with good results. Malarial poisoning should be treated by quinine and arsenic.2 Weak solutions of eserine may be of use and plain smoked glasses give comfort. Stilling and de Schweinitz have recommended chloral for its action in reducing tension. When “the period of confirmed glaucoma” has set in, enucle- ation is the only known means of relief. Ophthalmoscopic Diseases. Affections of the Vitreous.—Intra-ocular diseases and distur- bances can only be diagnosed with certainty by aid of the ophthalmo- scope, and, passing the lens, the vitreous comes next for inspection. When clear and transparent, acute diseases of the choroid may gener- ally be excluded, and at times retinal diseases, but retinitis may exist without vitreous opacity. The vitreous is rarely primarily affected, but becomes so from lesions of the surrounding parts. Vitreous opacities are of various kinds. The large, irregularly shaped bodies that float about with the movements of the eye, or at times remain compara- tively quiet, are the results of retinal hemorrhage. The dust-like opacities seen when the eye is suddenly moved, indicate choroiditis (syphilitic), while general opacity with string-like bands indicates an inflammation that has involved the ciliary body, choroid, and retina. In cases of myopia of high grade, vitreous opacities from choroidal involvement are frequent. Bodies that project into the vitreous may be detached portions 'of the retina, tumors, or collections of pus. Foreign bodies may, at times be detected by the ophthalmoscope, but in old cases are usually encapsulated. Synchisis scintillans is a condi- tion of the vitreous in which it appears to be full of falling stars, and this is due to the presence of cholesterin crystals. Treatment.—The blood from retinal hemorrhages usually disappears without any special treatment, though small doses of mercury will no doubt hasten the absorption. Opacities caused by syphilis are usually absorbed under the influence of mercury and iodide of potassium. 1 Valude and Dubief (translated by A. A. Hubbell for Ophthal. Record, from Annales d’Oculistlque, Aout, 1892). 2 University Medical Magazine, November, 1898. 694 INJURIES AND DISEASES OF THE EYE. Spalding and others treat vitreous opacities by hypodermic injections- of pilocarpine, using gr. T’y once a day for two weeks, unless the heart is weakened. The dose may be increased to gr. but usually gr. y is sufficient. It is not necessary to produce the physiological effects. De Schweinitz advises the fluid extract of jaborandi in doses of ten drops three times a day. He also uses potassium iodide, and thinks eserine particularly valuable, especially in cases of hemorrhagic origin that are prone to become glaucomatous. For membranous opacities in the vitreous that can be seen and located by the ophthalmoscope, C. S. Bull advises division of the obstructions. The eye is cocainized, and a double- edged needle or Graefe knife is plunged into the vitreous, a little in front of the equator and about the lower edge of the internal or exter- nal rectus muscle, and the bands are divided. But little reaction follows, and the eye is kept closed for only two or three days. Bull reports marked improvement of vision in some cases. Choroiditis.—There are four distinct layers in the choroid proper. Choroiditis may exist some time before it is recognized, because not until the pigment layer of the retina has become involved can the changes he seen, and therefore the retina is inflamed when there is choroiditis and the condition is really choroido-retinitis. Inflammation of the choroid generally exists in spots (disseminated), or it may extend over the entire coat (serous and purulent). Berry distinguishes the types of choroidi- tis as follows: (1) disseminated choroiditis, atrophic and exudative; (2) senile central choroiditis; (3) syphilitic choroiditis; (4) sclero- choroiditis, anterior and posterior, and (5) purulent choroiditis, trau- matic, embolic, and metastatic. The disseminated form is the most common, and first appears as yel- low or reddish spots, more or less round in shape. These subsequently become whiter and are surrounded by a border of pigment. The white patch is the sclera, which is exposed by the degeneration of the super- imposed retina and choroid. The patches are seen first in the equator, and may spread and ultimately involve the macula, causing at first metamorphopsia and micropsia, and finally scotoma. r Disseminated choroiditis is usually caused by syphilis, and is uncommon in children. Senile central choroiditis is seen in old persons as an irregularly shaped patch of lighter color than the surrounding part, and occupying the macular region. It causes metamorphopsia and scotoma, thereby diminishing vision, but rarely causes blindness. No treatment does good. Syphilitic choroiditis is a common occurrence among the late sec- ondary and early tertiary lesions of syphilis, and is most frequent among elderly persons. There are vitreous opacities and hypersemia of the disk, and vision may or may not be reduced. Perfect recovery may take place, or there may he permanent impairment of vision due to opacities and scotomata. Mercury, preferably by inunction, is the best remedy, and Darier's subconjunctival injections of the solution of bichloride of mercury (1 in 1000) may be tried, or the hypodermic in- jection of cyanide of mercury as advocated by Chibret. Sclero-choroiditis occurs anteriorly and posteriorly when there is weakening of the sclera. The treatment is unsatisfactory. Purulent choroiditis may be confined to the choroid, or involve OPHTHALMOSCOPIC DISEASES. 695 all the tissues of the eye {panophthalmitis). It is usually caused by infection following traumatism, or by metastasis, especially occurring in children who have had meningitis. (This form leads to shrinking of the globe and never to panophthalmitis.) Sympathetic inflamma- tion is not apt to follow the injuries which lead to this form of cho- roiditis, which may also be caused by infection from pyaemia, puerperal fever, erysipelas, suppurative endocarditis, and injuries about the face. Panophthalmitis is treated like any form of abscess, but it is safer not to enucleate or eviscerate the globe until all inflammation has subsided. Tuberculous choroiditis exists rarely, and only in connection with general tuberculosis. It may occur in two forms in the same eye—as miliary tubercle and as larger masses. Hemorrhage in the choroid is less frequent than hemorrhage in the retina, from which it may be distinguished by the different shape of the effused patch, which is more or less round in area, and lies under the retinal vessels. Ossification occasionally occurs in old and shrunken eyes, and by pressure may excite inflammation and render enucleation necessary. Detachment of the choroid is very rare, and is caused by traumatism, serous effusion, and tumors. Retinitis.—The circulation in the retina does not give any positive knowledge of the condition of the circulation in the brain or heart, and it is not always easy to diagnose anaemia or hyperaemia. The relative size of the arteries and veins may give some idea of their true condi- tion, for in hyperaemia and inflammation the calibre, tortuosity, and length of the veins are generally increased while the arteries may not be changed. Anosmia of the retina is caused by hemorrhage, spasm of the vessels, the stage of collapse in cholera, and toxic doses of quinine, and most commonly follows atrophic changes in the optic nerve. Hem- orrhages from the retinal vessels are common, and upon their situation depends their shape, those of the nerve layer being flame-shaped or linear, while those which are deeper are round and more solid. The subjective symptoms are interference with vision (usually sudden), scotomata, and metamorphopsia. Recent hemorrhages in the retina give objects a red appearance. The effused blood may be entirely absorbed and leave no bad results, or scotomata due to degenerative spots may remain. In old persons these hemorrhages, when numerous, may cause the so-called hemorrhagic glaucoma, and such cases should receive careful supervision for many months. Retinal hemorrhages may follow traumatism, or altered conditions of the blood and blood- vessels, and these changes are produced by pyaemia, septicaemia, ulcer- ative endocarditis, diseases of the liver, spleen, or kidneys, atheroma of blood-vessels, anaemia, haemophilia, purpura, scurvy, diabetes, gout, malaria, disturbances of the circulation due to heart diseases, suffoca- tion, compression of the carotid artery, menstrual disorders, and sudden reduction of tension following operations for cataract and glaucoma. Retinitis is usually associated with choroiditis and cyclitis, but at times exists as a primary inflammation in diseases in which there is an altered condition of the blood and vessels, such as septi- caemia, syphilis, albuminuria, diabetes, anaemia, and oxaluria. With 696 injuries and diseases of the eye. retinitis, besides hemorrhages and the changes in the blood-vessels, there are often loss of transparency, changes in the papilla, atrophy, in- creased or diminished vision, change of field, pain, and photophobia. The prognosis is generally unfavorable on account of the connection with grave constitutional disease, and in most instances both eyes are affected. Embolism of the Central Retinal Artery.—This occurs in elderly persons who have heart disease and atheromatous vessels. The onset is sudden, painless, and frequently occurs at night, or while making some exertion, such as stooping. Vision is quickly lost, and only in rare cases is regained by the plug being carried further on into one of the arterial branches. The ophthalmoscope shows the retinal vessels empty, or nearly so, with frequently interrupted or beaded currents. A foggy halo surrounds the disk and macular region, while in the centre of the latter is seen the characteristic “ cherry red spot” due to the choroid showing through the layer of rods and cones. Massage and para- centesis of the anterior chamber may be tried with the hope of moving the plug, but treatment is of little use and atrophy soon follows. Detachment of the Retina.—This is. a serious and tolerably fre- quent occurrence in affections of the eye. It is usually situated in the lower portion of the fundus, is more common in men than women, and is seen oftenest in myopic eyes. The separation takes place between the nerve and pigment layers, the latter adhering to the choroid, and between them is a yellow serous fluid. The researches of Leber and Nordensen have pretty well proved that when not traumatic it is caused by a fibrillar shrinking of the anterior portion of the vitreous, causing first a rent in the retina, through which fluid enters and pro- duces detachment. The edges of the rent are always turned toward the vitreous, and can at times be seen by aid of the ophthalmoscope. The subjective symptoms are impairment or entire loss of vision, meta- morphopsia, and night-blindness; and these may be preceded by rays, flashes, and muscse volitantes. The field of vision is also imperfect. The objective symptoms are at times difficult to make out, on account of the hazy vitreous, but are altered color and depth of the fundus, this being gray or bluish, and the vessels which cross over it being darker than normal. It is not focussed by the same glass as the other portions of the fundus, and the parallactic movements of the vessels over the fundus prove a difference in depth. The detached por- tion is at times pushed so far forward that it can be seen through the pupil without a glass. Treatment is unsatisfactory. Probably as much benefit has been de- rived from placing the patient flat upon his back in bed and injecting pilocarpine hypodermically, as from any other method. Iodide of potas- sium may also be employed. Schoeler’s method of injecting tincture of iodine (3 drops) near the point of rupture, thereby producing irrita- tion that might cause re-adhesion, has not been satisfactory. Diseases of the Optic Nerve.—The normal optic papilla is nearly round or oval in form, with distinct edges, showing at times the white and glistening border of the sclera, and usually some choroidal pig- OPHTHALMOSCOPIC DISEASES. 697 ment that is more abundant at the temporal edge. It is lighter than the surrounding fundus, and with different shades of color on its own surface. Optic neuritis is divided into papillitis, in which the papilla alone is affected, and papillo-retinitis, or neuro-retinitis in which the retina also is involved. Papillitis is generally caused by cerebral disease, though this may also cause neuro-retinitis. The papilla is swollen and hypersemic, it has a striated and rough appearance, and its edges are frequently ob- scured. The veins are distended and tortuous, while the arteries are not changed in size, or are smaller, and often disappear under the swol- len tissues. The transparency is much less than normal, and the promi- nence, Avhich is at times considerable, may be approximately measured by allowing 1 mm. for every 3 D. The amount of swelling is not always in relation to the loss of vision, for at times, when swelling is greatest, vision may for the time be unaffected, but sooner or later it commences to fail and may be entirely lost. Optic Neuritis.—Sudden loss of vision has other causes than the swell- ing, whereas gradual diminution may be caused by compression. The field of vision is often concentrically narrowed or irregular, and at times more affected on the temporal than on the nasal side, while the color sense is lost to a considerable extent. Cerebral papillitis is usually bilateral, but has occurred on one side in cases reported by Hughlings Jackson in brain tumors involving the opposite hemisphere. Extreme swelling of the nerve has been known as “choked disk,” and was sup- posed to be different from descending neuritis, but the distinction is untenable. Optic neuritis is caused most frequently by brain tumors, next by meningitis, hemorrhage (rare), hydrocephalus (uncommon), and at times by purulent inflammation of the middle ear, softening of the brain, and rarely by abscess. Valude reports a case of burn in the third degree upon which iodoform was used. This was followed by blindness, optic neuritis, atrophy, diarrhoea, headache, and vomiting. Afterward some vision was recovered, but no color perception. As to the true relation between papillitis and brain disease there has been some con- troversy, but Leber says, that intra-cranial tumors, as also tuberculosis, give rise to congestion of the vessels, secretory inflammation, hydrops ventriculorum, and increased pressure. The products of tissue-change of these neoplasms become mingled with inflammatory stimulus, and, passing with the cerebro-spinal fluid into the intravaginal space of the optic nerve as far as the eye, give rise there to neuritis and papil- litis. The entire nerve may be inflamed, but owing to the collection of irritative fluid at the end, the most intense reaction occurs there. Retro-bulbar neuritis has perhaps similar pathological conditions, but the papilla is little if at all affected. There is central scotoma, but it is not so regular as that of toxic amblyopia, nor is it confined to the same area, but may extend to the inner side of the point of fixation. Again it occurs generally in but one eye, though both may be affected, and it is equally common in men and women. It may be confounded with toxic amblyopia, but the scotoma and its monocular character are differential points. The prognosis is less favorable, and but less than half of the acute casds recover. The treatment must depend upon the cause. Tumors of the brain, if located, may be removed, as this branch of 698 INJURIES AND DISEASES OF THE EYE. surgery has been wonderfully developed. Removal of the fluid from the optic sheath (de YVecker) may do good, and all cases should be treated with iodide of potassium. Atrophy of the optic nerve is primary, secondary, or consecutive. It is primary when it originates in the nerve itself; secondary when it follows changes in the retina, choroid, or central nervous system, and consecutive when it follows neuritis. In appearance the nerve is white and excavated (when primary), and the vessels are much smaller than normal. Examinations of light and color sense, and as to restricted condition of field, are important in deciding whether or not the process is progressive. Berry says that restriction of the field of vision, when more or less concentric, and especially when the sense of color is rela- tively more defective than the sense of form, is always suggestive of progression. Central vision is usually lost as restriction increases, and Berry again says, “in all cases where there is merely a central scotoma, without any narrowing of the field, the prognosis is good.” It is often difficult to diagnose the cause of atrophy, and besides the ophthal- moscopic changes other symptoms of a general character must be taken into consideration, such as the reflexes, movements of the pupils, etc. Unilateral atrophies are usually caused by retinal or orbital changes, though the cause may be found within the cranium. Changes at the base of the brain cause pallor of the disk, but not constriction of the vessels unless there has been a papillitis. Nettleship shows that about seventy-five per cent, of cases of bilateral atrophy are due to the causes which produce degenerative changes in the sensory tracts of the spinal cord and brain. In tabes dorsalis atrophy occurs in about fifteen per cent. Primary optic atrophy is more common in men than women, and accounts for one-fourth of all cases of blindness. Amblyopia, or dimness of vision, may be congenital, and therefore due to defects in the eye or at the visual centres, reflex, or traumatic. Certain drugs and toxic agents cause amblyopias in some of which there are special features. Under this head may be mentioned uraemic, glycosuric, and malarial amblyopia, that from loss of blood, that from drugs, and hysterical and pretended amblyopia. The prognosis in all may be favorable if the changes have not gone too far and if the causes have not existed too long. In chronic retro-bulbar neuritis, or tobacco amblyopia, there is but little to be learned by ophthalmoscopic exam- ination, but more important is the central scotoma, especially for red and green. It is oval in shape, and extends between the fixation point and the blind spot. It is usually caused by the combined abuse of tobacco and alcohol, although it has been seen when tobacco alone was used. The lesion is in the papillo-macular fibres. The prognosis is good when the cause is abated, and the treatment consists in giving strychnine until its physiological effects appear. Quinine Amblyopia.—According to de Schweinitz, prolongation of quinine blindness causes true atrophy, and thrombosis of the central vessels may be expected in severe cases of the toxic action of the drug. He concludes, “it seems, then, very likely that the original effect of quinine is upon the vaso-motor centres, producing constriction of the vessels; that finally changes in the vessels themselves are set up, owing, perhaps, to an endo-vasculitis; that thrombosis may dccur. and that the result of all these is an extensive atrophy of the visual tract. ” TUMORS of tiie orbit.—strabismus. 699 Later investigations (not yet published) by de Schweinitz prove that similar effects are produced by the other alkaloids of cinchona bark. Other cranial nerves are not injured. The treatment consists in discon- tinuing the drug, and in the exhibition of nitrite of amyl, strychnine, and digitalis. The other forms of amblyopia should be treated on gen- eral principles, it being of course first necessary to learn their cause. Tumors of the Optic Nerve are exceedingly rare, and are divided by Leber into the essential and the non-essential. The former spring from the nerve-tissue itself, the latter from the sheath, and involve the nerve by extension. The growth of the essential tumors is very slow, lasting at times for years, and generally causing blindness and perhaps proptosis. The growths are usually myxomata or fibromata, and a case of neu- roma has been reported. Operation has not as a rule been followed by good results. Tumors of the Orbit. These may be benign or malignant, and they may begin in the orbit or may extend from the neighboring cavities. Orbital tumors are rare, and especially those of the optic nerve. Usually orbital tumors do not spread to the eyeball, and therefore when both ball and orbit are in- volved, the former has generally been the starting-point. Upon the position of the tumor depends its effect upon the ball. Tumors occupy- ing the space between the orbital muscles do not at first interfere with the movements or position of the eye, but may finally cause outward displacement, while those in other parts of the cavity press the eye up- ward, downward, inward, or outward, according to their position. Orbital tumors are bony (exostoses), vascular, cystic, lymphadenom- atous, sarcomatous, and rarely carcinomatous. These tumors should always be removed as soon as discovered, when sometimes the eye may be saved, but usually vision is lost, and in cases of malignant growths death generally occurs. The entire orbital contents should be removed when the tumors are malignant, but when the surrounding cavities and bones of the face are invaded, the operation, while it may give temporarly relief, undoubtedly hastens the end. Strabismus. Division of the ocular muscles is not done with the freedom of former years, and tenotomy and advancement are now regarded by most ophthalmic surgeons as the last steps in conjunction with other methods for gaining binocular vision, or for bringing a deviating eye to its natural position. Every condition of a squinting eye, viz., its acuity of vision, refraction, strength of muscles, and amount of devia- tion, should be accurately measured and known before any operative procedure is considered. Most ophthalmologists require their patients to wear correcting glasses, and to exercise, if necessary, weak muscles by the aid of prisms and otherwise, before advising operative treat- ment. The management of squinting amblyopic eyes requires much care and good judgment, because there is no incentive for such eyes to 700 INJURIES AND DISEASES OF THE EYE. remain straight. The muscles often act normally when the fellow-eye is closed, proving that there is no actual loss of power. These eyes will in some cases gradually recover their normal positions as the patients grow older, while in other cases the deviation may increase to the extreme limit. Tenotomy of the contracted muscle may not only fail to correct the defect, but may cause the eye to deviate equally in the opposite direction, wherefore it is probable that advancement will accomplish more in such cases than tenotomy; or it may be advisable to perform the operations on the opposing muscles, either at the same time or separately. When operative interference has been decided upon according to the characteristics of the case, we must decide whether it shall be tenotomy, advancement, or both. In cases of insufficiency, some surgeons (von Graefe, Abadie, and G. T. Stevens) have advocated partial or graduated tenotomies. When hyperphoria is present it is claimed that graduated tenotomies accomplish a great deal, for there is often much discomfort from even one or two degrees of deviation. Dr. G. T. Stevens, of New York, has devised special forceps and scissors for this mode of procedure. Cocaine is of inestimable value in this class of operations, as enabling the results to be seen as the operation progresses. Tenotomy is still performed after the method described by Arlt, and by the so-called subconjunctival method. The advocates of the latter claim that it is attended by less exposure of the subconjunctival tissues and less likelihood of the caruncle sinking. Advancement is performed by making a vertical incision over the tendon, which is then raised upon a hook. A suture with two needles is now passed through the muscle just hack of its junction with the tendon, when the latter is divided, and the conjunctiva is dissected from the first incision to the corneo-scleral junction. The muscle is next drawn forward and fixed in its new position by passing the needles through the conjunctival and episcleral tissues, and bringing them out, one above and one below the cornea. The ends are tied, both eyes are dressed antiseptically and closed by a bandage, and the patient is kept quiet in bed for several days. The sutures should be left in as long as they will hold without creating too much irritation. Prince’s pulley operation is an ingenious method of advancing a muscle. A suture is introduced vertically, near the corneo-scleral junction, through the conjunctival and episcleral tissues, and the ends are tied, making a stationary loop. The muscle is next pierced hack of the tendon by a needle carrying a suture, which after emerging is carried forward through the loop. The ends are then tied, and the advancement is regulated by tightening or loosening the thread. The objections to muscle advancement are the liability of the sutures tearing out and rendering the operation useless, the amount of irritation that is set up by the operation, the danger of wounding the ciliary body if the needles pass too deeply into the sclera, and the deformity that is caused by “ hunching” the tissues. Landolt maintains that only by advancement can the normal movements be retained, and he rarely operates for insufficiency. He performs tenot- omy with advancement upon the worse cases of strabismus, and de- clares that sutures do not tear out when introduced into the episcleral tissue. treatment of eye diseases by subconjunctival injections. 701 Treatment of Eye Diseases by Subconjunctival Injections. This method and that of the intra-ocular injection of certain drugs in solution have received considerable attention in recent years from Darier, Abadie, and others. It seems that the subconjunctival injec- tion of drugs is to be preferred to the latter method, for it has been proved that the drug is as readily absorbed from below the conjunctiva as from Tenon’s space, and that there is less liability of injury to the inner coats (choroid and retina) when these are not wounded by the needle. Darier says, in referring to the action of the bichloride or cyanide of mercury for wounds, “ it acts as an antiseptic. . . . In gen- eral treatment it is often antisyphilitic; but it has also in many cases a bactericidal, microbicidal, antiseptic action which is of great impor- tance.” This mode of treatment is especially useful for syphilitic diseases of the eye, but has also been successfully tried in cases of iridocyclitis and sympathetic ophthalmia. Other drugs besides mercury have been employed for various diseases, hut not with very favorable results, so that the method has finally narrowed itself down to using the soluble salts of mercury, of which the sublimate and the cyanide are the best. Darier rather favors the latter. He admits, however, that for bringing the patient quickly and thoroughly under the influence of the drug, no treatment can equal that by inunc- tion, and especially when the subconjunctival injections are also used. For infecting ulcer of the cornea, no treatment is followed by better results, and in retino-choroiditis the improved condition is readily seen by ophthalmoscopic examination as well as recognized by the increase of vision. In affections of the optic nerve, only recent cases have im- proved. No benefit has followed when there has been gray spinal atrophy, while in white atrophy following inflammatory action there has been slight improvement. Darier says that “subconjunctival in- jections are contra-indicated, momentarily at least, every time that a circulatory stasis renders the absorption of the medicine difficult or im- possible by the obstructed lymphatic passages.” For this reason, in acute inflammatory processes of the iris and ciliary body, it is contra- indicated, and general treatment is to be preferred. Darier injects every day, or as often as circumstances require, five cubic centimetres of a solution which contains 0.005 milligramme of cyanide of mercury, the same amount of cocaine, and 0.035 milligramme of chloride of sodium. The sublimate may be used in the strength of 1 to 1000, and two or three minims are injected at a time. The injections may cause considerable pain and swelling, but the former sulsides after an hour or two. Darier uses a Pravaz syringe with a platinum-tipped needle which can readily be sterilized in a flame, but any form of hypodermic syringe will answer if it is perfectly clean. Note.—In the preceding pages I have drawn frequently from standard works on Ophthal- mology, especially those of de Scliweinitz, Fuchs, and Berry, and from journals both special and general. I have not always given credit for views and opinions expressed, but as the article is meant to supplement that written by Dr. Williams in Yol. IV., and not to contain the opinions of any one author, it has not been considered necessary to mention every name. When subjects have been omitted it has been thought that the original article was sufficient. INJURIES AND DISEASES OF THE EAR. BY ALBERT H. BUCK, M.D., OF NEW YORK. Since 1884, when the article on “Injuries and Diseases of the Ear” was written for the “International Encyclopaedia of Surgery,” the domain of aural pathology and therapeutics has been enriched in vari- ous directions. Thus, for example, we have reached, during these years, a more perfect knowledge of the intimate relationship between nasal and vault troubles and affections of the ear; and as a result of this increased knowledge I am warranted in saying that many a case is now rescued from more or less serious impairment of the hearing, which in those and still earlier days would have been dismissed as incurable. Then there is another large class of ear cases to which a great deal of attention has been paid during the last decade; I refer to those affected with chronic ulcerative disease of the invisible portions of the tympanic cavity—the recessus epitympanicus or the vault of the tympanum, the ossicles which occupy a part of this hidden vault, and the still more remote mastoid antrum. These are the cases which fur- nish the greater part of the mortality from ear disease, a mortality which—I am pleased to be able to say—is growing steadily less as the years go by. The diminution of this death-rate is due to the fact that we are now able to treat a large percentage of these cases successfully, relieving them of the foul discharge which almost always characterizes chronic disease of the vault of the tympanum, and removing from the immediate neighborhood of the brain a dangerous focus of disease. There are two ways by which these results are usually obtained: one, by the systematic cleansing of the vault of the tympanum with perox- ide of hydrogen or with weak bichloride solutions forced through suit- ably bent glass or metal canuke, the ossicles (if present) not being dis- turbed ; the other, by the employment of precisely the same measures after first removing the hammer and anvil. In the majority of in- stances a faithful and intelligent employment of the first of these methods will effect the desired cure, but in a few cases, especially those in which the opening into the middle ear is small, the most skil- ful use of the slender probe and the most faithful employment of anti- septic intra-tympanic washes will not produce this result, and we shall then he justified in urging upon the patient ossiculectomy—as this operative removal of the hammer and anvil is termed. The technical details of both this operation and that for the removal of the stirrup—stapedectomy—need not be given in this place; they 703 704 injuries and diseases of the ear. belong more properly in the special treatises on otology. I may state here, however, that while ossiculectomy lias now won for itself an accepted position as a valuable therapeutic procedure in cases of chronic discharge from the middle ear, the value of both this and stapedec- tomy, in the treatment of non-purulent cases of middle-ear disease, has not yet been demonstrated. Of the numerous remedies discovered during the last ten years a few have proved extremely useful to the aural surgeon. Perhaps the most conspicuous of these is the peroxide of hydrogen, a most useful intra- tympanic cleansing fluid. There are also several new remedies, in the form of powders, which have met with considerable favor at the hands of aural surgeons. It is still doubtful, however, whether any one of these can be assigned a higher place, in the scale of usefulness, than boric acid and iodoform. Finally, the technique of the mastoid operation is now well settled; the superiority of the chiselling over the boring method being almost universally admitted. In view of the limited amount of space which in this volume can properly be devoted to the discussion of otological matters, I propose to restrict myself almost wholly to the consideration of the topic last mentioned. Such a course, furthermore, commends itself to me with special force for the reason that the account which I have given of this operation in my previous article is in many re- spects faulty. Technique of the Mastoid Operation. Instruments Required.—The cowhide mallet sold in the instrument shops is every way more satisfactory than that of steel (with lead fill- ing). It is a much lighter tool to handle, and yet with it the operator can readily force the chisel through the densest hone tissue. One can work more quickly with chisels than with gouges, and they are much easier to keep sharp. Six chisels of three different sizes—that is, of three different breadths at the cutting edge—and one or two small gouges will serve as an adequate supply. The broadest chisel should not exceed inch (about 5 mm.) in breadth, and the smallest of the three* should have a breadth of a little over T\- inch (2 mm.). The lower part of the chisel, down to the base of the cutting edge, should he quite thick (see Fig. 1703), so as to prevent any springing on the part of the instrument, and also so as to facilitate the sharpening of the cut- ting edge. Chisels for mastoid work should be kept veiy sharp. Volkmcimds spoons (Fig. 1700), with broad and strong handles of hollow steel or aluminium, are extremely useful in removing the deeper bone tissue ordinarily encountered in mastoid processes. The howls should have sharp cutting edges and should he of three different sizes, viz., about 8 mm., 7 mm., and 4 mm. in diameter. Silver or hard-rubber canulas about 4 inches in length, slightly bent at one extremity, and broadening out into a bulbous mass at the other (for the purpose of connecting it with the rubber tubing of some form of douche or syringe), are needed for irrigation purposes. Two sizes (2 mm. and a little over 1 mm. in diameter) are sufficient. The mastoid hook guide, pictured in Fig. 1701, serves the purpose of a trustworthy landmark, by means of which the operator can know, at any moment during the TECHNIQUE OF THE MASTOID OPERATION. 705 progress of his work, whether he is on the right track toward the mas- toid antrum—the goal which he is aiming to reach. The mode of using this instrument will be described farther on. Usually one re- tractor suffices, but in exceptional cases, where the mastoid integu- Fig. 1700. Volkmann's Spoons. merits are greatly swollen, two may be found necessary. They should be made of steel, and the prongs should be so disposed as to press flat- wise against the tissues (Fig. 1702). ’ This, I believe, concludes the list of special instruments needed in this operation. Besides these, of course, there will be needed a strong straight knife, a blunt periosteum elevator, an ordinary thumb forceps Fig. 1701. Mastoid Hook Guide. for removing chips of bone, one or two Bowman’s probes, seven or eight long and slender self-clamping artery forceps, and needles curved flatwise. Preparations for the Operation.—In most cases it is necessary to shave off the hair for a certain distance above and behind the mastoid region, owing to the fact that it encroaches upon the very area in which Fig. 1702. Retractor. the operator must make his incision; but in some persons this area is quite free from a growth of hair, and the shaving may then perfectly well be dispensed with, provided the case be one in which it is almost certain that operative interference will not go beyond the mere estab- 706 INJURIES AND DISEASES OF THE EAR. lishment of a free channel through the bone down to the antrum. But if there is the least doubt about the extent of operative interference that may be required, it is better to shave off the hair from the imme- diate neighborhood of the mastoid process and subject the skin surface thus exposed to a thorough scrubbing and disinfection. In the case of women with long hair it is not an easy matter to protect the latter from the blood and other materials that escape from the wound or from the ear. An elastic rubber cap, such as is worn by women bathers at the seaside resorts in France, furnishes the desired protection, but I have thus far failed to find these or similar caps at any of the rubber shops in this city. A folded towel, wrung out of a 1-2000 bichloride solution and wrapped firmly round the patient's head, makes a fairly good substitute. The rigid antiseptic precautions which are considered so very necessary in some other operations, are of less value in this. In nine cases out of ten we are engaged in the work of establishing a new and larger channel for the drainage of a focus of disease which is presumably sufficiently septic to undo all the beneficial effects of any attempt that we may make to render instruments, hands, cloths, etc., really aseptic. What is of much greater importance is to ter- minate the operation by the most careful efforts to cleanse and render aseptic not only the centre of the disease in the mastoid antrum or neighborhood, but also all the cut surfaces and adjacent skin. The External Incision.—This should be made in a curving direc- tion, very nearly parallel with the line of attachment of the auricle. It should begin at a point above and a little in front of the orifice of the external auditor}7 canal, and it should end at the tip of the mastoid process. A margin of skin, at least half an inch in breadth, should everywhere intervene between the edge of this cut and the line of attachment of the auricle. The effort should be made, in this first in- cision, to carry the point of the knife through the periosteum, as well as through the skin, throughout the entire length of the cut. Control of the Bleeding.—Pressure with the finger of an assistant, in the immediate vicinity of the wound, will usually control the bleed- ing sufficiently to enable the operator to proceed with the second step of the operation, viz., the separation of the periosteum from the under- lying bone, over the outer and anterior surface of the mastoid, and just above the orifice of the osseous external auditory canal. After this has been accomplished, his first care should be to control, in some more permanent fashion, the bleeding—not so much on account of the possi- ble weakening effects of the loss of blood, but particularly because he will require, from this point onward, as clear a view as he can obtain of the field of operation. If there are any spurting vessels, their mouths should be closed by means of artery forceps; and if troublesome oozing of blood still continues after the forceps have been applied, small hot sponges, squeezed as dry as possible after being removed from the hot sublimate solution (1-2000 or 1-3000), may be crowded into the wound and left there for three or four minutes. Still another effective method of controlling this general oozing of blood from numer- ous small vessels is to allow very hot water—as hot as the hand can bear for a few instants—to trickle from a sponge into the open wound, or to be injected into it by a suitable syringe. Ligation of the bleed- ing vessels is generally not necessary, and should be avoided in the TECHNIQUE OF THE MASTOID OPERATION. 707 ■case of vessels situated in that part of the wound which is afterward to be closed by sutures. In the case of a weak person, or when the surgeon or a competent assistant cannot visit the patient within six or eight hours after the operation, the safer rule is to apply a ligature to the posterior auricular—the only artery that is large enough to fur- nish any considerable loss of blood. In a few cases the bleeding from the vessels in the substance of the mastoid bone, after the chiselling has laid bare the deeper cellular structure peculiar to this region, is quite copious. Hot water seems to exert very little influence upon this diffuse bleeding from vessels within the bone, and we may be forced to stuff the cavity with iodoform gauze and patiently wait for the bleed- ing to stop. Landmarks that May he Used in Searching for the Mastoid An- trum.—When the bleeding from the soft parts covering the mastoid process has been stopped, the surgeon may proceed, without further delay, to cut away by the aid of chisels and Volkmann’s spoons those portions of the bone which conceal from view the mastoid antrum. The exact location of this small cavity should be kept constantly before his mind’s eye as he removes, hit by bit, the intervening bone substance. Without artificial help of some kind, this is no easy task. The best natural landmark, the curving edge of the entrance to the external auditory canal, is not constantly in view, owing to the presence of blood in sufficient quantity to conceal it. Then, too, the very first steps of the chiselling may so alter the picture as to make the operator feel that he must again and again take note of his bearings before he can safely remove more bone substance. What is needed, therefore, is some artificial landmark which shall always be visible to the operator, even when the average amount of bleeding is going on, which shall remain immovably fixed in the same position, and which shall not hamper the operator in any of his manipulations. The mastoid hook guide, pictured in Fig. 1701, answers these requirements in a fairly satisfactory degree. The retractor shown in Fig. 1702 is first applied to the soft parts constituting the anterior flap of the wound, and the whole is drawn well forward so as to bring the posterior and upper edge of the bony external auditory canal into view. Then the steel hook guide is to be hooked into the canal from above, between the soft parts and the bone, and the roughened tip of the hook is to be kept, by an assis- tant, pressed firmly against the upper wall of the canal. The round knob of steel on the convex side of the hook will then be found to stand up conspicuously in front of the area of bone surface which is to be removed by chiselling. The sides of the pit which the operator is about to make in the bone should, converge toward a point seemingly situ- ated directly behind this knob of steel; or, to speak more correctly, toward a point in a transverse vertical plane which runs parallel to one passing through the steel knob, and which, at the same time, is only a short distance (from k to inch) from it. The use of the word “be- hind” has reference, of course, to the relations which exist when the body is in the vertical position, and the assistant who holds the hook in position can facilitate the operator’s estimate of these relations by keep- ing it constantly in the line of the vertical axis of the patient’s bod}'. The Proper Mode of Using the Chisels and the Volkmann Spoons.— Two or three simple rules will suffice to guide the beginner in his em- 708 INJURIES AND DISEASES OF THE EAR. ployment of these instruments. In the first place, the chisel should not be held at or near a right angle to the surface of the skull, but in such a a manner as to form an oblique angle with it (Fig. 1703). The bevelled edge should be kept uppermost. It is safer to remove the bone in small chips. Light blows of the mallot, frequent- ly repeated, are better than a few heavy ones. When softened bone, or the cellular bone structure peculiar to the central part of the mastoid process, is reached. Yolk- mann’s spoons will be found more efficacious and safer than the chisel. Frequent probing of the sides and bottom of the excavation is a very necessary procedure, if the operator wishes to get early information of the proximity of the lateral sinus, of an abscess cavity, or of the mastoid antrum. On reaching the latter the surgeon should take particular care not to push any stray chip or fragment of bone into the middle ear. It is scarcely possible to lay down any fixed rule in regard to the amount of bone substance that should be removed at the operation: surgeons are unanimous in regard to the necessity of removing all carious and softened portions of bone tissue. A few authorities insist upon the desirability of cutting away, in the majority of cases, a large part of the tip of the mastoid process, as other- wise a separate and isolated collection of pus in this part of the bone may be overlooked. Such a rule seems to me to be too sweeping in its char- acter. It is enough, it seems to me, if we restrict the adoption of this plan to those cases in which the symptoms, before the operation, have pointed to the spread of the mastoid inflammation to the tissues along the side of the neck. In all other cases we shall have done all that is required of us when we have established a broad channel down to the mastoid antrum, and have removed all bone substance that is carious or that seems to be unnaturally softened. Dangers of the Operation.—The possible wounding of the lateral sinus is the only serious danger that may be encountered. But only a reckless operator is likely to seriously injure this fairly tough vein when it is not softened by disease. If, however, its wall has been thinned in consequence of ulcerative action, it may easily be broken through by even a careful operator. On the other hand, the wounding of the facial nerve in the vicinity of the antrum is an accident that may very readily occur. It is therefore important not to indulge in instru- mental manipulations, scraping the bone, etc., in this cavity, unless we are perfectly sure that such interference is necessitated by the carious condition of the part. What I have said in regard to the lateral sinus, applies equally well to other portions of the dura mater; the danger of wounding it is small. Opening into the Groove for the Lateral Sinus, or into the Cranial Cavity at Some Other Point.—When, in the course of the operation, carious or even blackened bone is encountered, it is our clear duty to remove it, even if by so doing the dura mater or the wall of the lateral sinus be exposed to view. But it is not so easy to formulate any definite rule about laying bare the lateral sinus in cases in which carious bone or blackened bone (that is, bone in which venous stasis has taken place) is not encountered in the course of the ordinary mastoid oper- Fig. 1703 Mode of Applying Chisel to Mastoid. 709 TECHNIQUE OF THE MASTOID OPERATION. ation. In the presence of hone tissue that is only moderately congested, and in the absence of any other evidences of inflammatory action along the course of the jugular vein, we should certainly not be warranted in opening into the sigmoid fossa. But if the substance of the mastoid bone is found to be highly congested, and if it bleeds copiously from all the surfaces cut with the chisel or with Volkmann’s spoon, we have a right to assume that a certain amount of periphlebitis must exist in the sigmoid groove surrounding the lateral sinus ; but from this circum- stance alone we are not warranted in believing that this periphlebitis has reached the purulent stage. If, however, the tissues beneath and behind the mastoid process are considerably infiltrated at the same time, we may confidently assume that the periphlebitis has gone on to the point of filling the space between the vein (lateral sinus) and the sur- rounding bone with pus, and we may proceed without hesitation to make an opening into this space and afford an outlet for the imprisoned fluid. At this point another question arises, namely, whether we shall remove the rest of the mastoid process so as to obliterate entirely the .bony channel through which runs the jugular vein from the sigmoid fossa down to the side of the neck; or whether we shall rest satisfied with the establishment of a simple opening for drainage, as described above. In the few cases in which this question has arisen I have referred the matter to a general surgeon, and in each instance the re- moval of all this mass of bone has been advocated, on the ground that in no other way could we be sure of preventing the encagement of pus at some point along this tortuous channel. Final Steps of the Operation.—Thorough irrigation of all the cavi- ties and recesses of the antrum and middle ear proper is a matter of great importance in all chronic cases. As long as any decomposing cheesy material or other source of irritation is allowed to remain stowed away in some nook or corner of the tympanum or communicating cavi- ties, just so long may we expect the old discharge from the ear to con- tinue, in greater or less quantity. A weak, lukewarm bichloride solu- tion (1-4000 or 1-5000) is perhaps as good as any other for irrigating purposes. When the solution injected through the wound into the antrum, by means of one of the canulas already described, ceases to bring away debris, and escapes from the wound or from the external auditory canal in a perfectly clear condition, the surgeon must be care- ful not to draw the inference that he has washed away all offending material from the middle ear. He should make repeated use of a slender silver probe, bent at the knobbed end, in the hope that he may in this way loosen masses which the stream from the canula has failed to dislodge. If, after two or three trials of this nature, he finds that the escaping fluid still remains clear, he may safely infer that he has accomplished the task which he set out to perform. It is not a matter of any importance whether a bulb syringe or a gravity douche be used in connection with the long slender canula. In the acute cases, where the inflammation has developed in a previously healthy tympanum, the irrigation of the cavities of the middle ear is unnecessary. They con- tain nothing but laudable pus, which is harmless if it be provided with a free outlet; and there is always danger, if we irrigate under these circumstances, of washing into the middle ear some small chip or frag- 710 INJURIES AND DISEASES OF THE EAR. ment of bone that will lodge there and materially delay the ultimate healing. On the other hand, the outside wound and the excavation in the mastoid bone should in every case receive the most thorough wash- ing with the bichloride solution. Opinions differ in regard to the question whether the outside wound should be left entirely open or be partly closed by sutures. Very few, I think, would venture to entertain the hope of securing primary union of the lips of the outside wound throughout its entire extent; but there are some who advocate the policy of keeping the parts in such a per- fectly aseptic condition that healing shall take place almost without the formation of pus. I am quite ready to admit that there are some cases in which this plan may perfectly well be adopted, but I think it will be found safer, in the long run, to permit a certain amount of pus-formation to accompany the granulating process. Have we not facts in our possession, especially in the medical literature of former times, which justify us in believing that such a discharge, if kept within reasonable bounds, exerts a curative effect upon any deeper- seated inflammation that may still be smouldering in the vicinity? As regards the question whether the wound should be left entirely open or not, I do not believe that any fixed rule can be laid down. I almost always apply sutures to the upper horizontal portion of the wound, but in quite a number of instances the early occurrence of a chill, with a marked rise in temperature and perhaps a return of the pain, has compelled me to remove them and restore the wound to its gaping con- dition. In all or nearly all of these instances the mastoid integuments, at the time of operation, have been a good deal congested and infiltrated. In this class of cases, therefore, I have at one time or another followed three different plans, and I cannot say which is most to be commended, as I have had reason at times to he dissatisfied with all of them. One method is to introduce one or two silver sutures in the horizontal por- tion of the wound and tie them very loosely, with the expectation of tightening them properly after the swelling and inflammation of the skin have subsided. In some cases this plan works satisfactorily, while in others the presence of the sutures seems to perpetuate the irritation and infiltration of the skin through which they pass. A second method is to leave the entire wound gaping until the skin has nearly returned to its natural condition, and then, after scraping away all intervening loose granulations, and washing the parts thoroughly with a fairly strong (1-2000 or 1-3000) bichloride solution, to bring the edges of the horizontal portion into accurate coaptation by means of the or- dinary silk sutures. There is only one objection to this plan; it in- volves the infliction of considerable pain, or the brief administration of an anaesthetic, both of which are unpleasant things for the patient. The third plan leaves out sutures altogether. The wound is allowed to heal by granulation, and the edges are coaxed together by the use of a pad applied against the auricle and kept pressing backward and upward by means of a bandage. The most serious objection to this method is this: a slight drooping of the auricle—recognizable, it is true, only when the patient’s face is closely scanned from in front—may be left as a permanent result. In patients of the male sex this slight lack of symmetry is a matter of no great importance, but in women it is scarcely permissible to leave any recognizable deformity of this nature. TECHNIQUE OF THE MASTOID OPERATION. 711 The After-management of the Wound.—During the first twenty-four hours following the operation there is apt to be a somewhat active ooz- ing of bloody serum from the wound, and special provision should be made to catch this abundant escape of fluid. A pad composed of several thicknesses of iodoform gauze is first laid over the wound, and then over this is placed a large mass (a double handful) of absorbent cotton. A few turns of a gauze bandage, carried from the back of the neck over the forehead, will keep the whole firmly in position. It is not usually necessary to leave a drainage tube in the wound. The only thing that may render this desirable is the discovery, after the horizontal part of the wound has been sutured, that the anterior flap completely over- laps the posterior edge of the excavation in the bone, and so threatens to interfere with the free escape of discharge from the deeper parts of the ear. In anticipation of this difficulty, it has been my rule, in recent years, to cut out a shallow groove in the surface of the mastoid bone, from the posterior edge of the excavation backward to the posterior edge of the wound in the skin. This supplies all the mechanical requis- ites of a drainage tube, and greatly facilitates the introduction of a can- ula for irrigation purposes. When the skin surrounding the wound looks red and tense, wet applications will he found the most suitable. A soft linen pad, saturated in a wash composed of one part of alcohol to three parts of a 1-3000 or 1-4000 bichloride solution, will be found to answer well the desired purpose. The pad should receive a fresh wetting every half or three-quarters of an hour; and when bedtime comes, a dry dressing (a pad of iodoform gauze and some absorbent cotton outside of it, with a light head bandage to keep the whole in place) may be substituted for the night. In most cases, irrigation of the excavation in the bone may be entirely dispensed with after the third, fourth, or fifth day, and the wound may be then treated in all re- spects as if it were an ordinary wound on the surface of the body. DISEASES AND INJURIES OF THE NOSE AND ITS ACCESSORY SINUSES. BY RALPH W. SEISS, M.D., PROFESSOR OF OTOLOGY IN THE PHILADELPHIA POLYCLINIC. Examination and Instruments for General Treatment. Innumerable new instruments and methods have been devised dur- ing the last ten years, but only a few are valuable enough to demand special mention. The electric light, used either as a small incan- descent lamp introduced directly into the mouth or nose, or attached to the head band in place of a forehead mirror (Trouve’s apparatus), has come into quite general employment. The hand lamp is of great value in the diagnosis of diseases of the antrum, hut the head light has the great disadvantage of giving a narrow light line in the centre of the field, the sur- rounding area being insuffi- ciently illuminated. Its use is mostly confined to cases in which ether anaesthesia is re- quired, and in which an ex- posed flame is of course inadmissible. Numerous portable batteries are on the market, the storage battery having perhaps the preference. The older forms of spring specula have been very largely abandoned, and some modification of Kramer’s dilator is now almost universally employed by rhinologists. (Fig. 1704.) Since the general use of cocaine, palate hooks are much more valu- able than formerly, and some one of the various late models should form a part of the rhinologist’s out- fit. The self-retaining hook of White, of Richmond, is one of the best for general purposes. (Fig. 1705.) In the general treatment of nasal diseases the fine spray atomizer and delicate syringe have almost entirely superseded grosser instru- Fig. 1704. Kramer’s Dilator. Fig. 1705. White’s Palate Hook. 713 714 DISEASES AND INJURIES OF NOSE AND ACCESSORY SINUSES. ments and the use of powders. A pressure of from ten to twenty pounds is used by the majority of rhinologists, and the employment of so great a force as “forty pounds or more to the square inch” has been almost wholly abandoned as irritating and injurious. Medicated pow- ders have been less used than formerly, and I do not myself employ them except to stop hemorrhage or cover an ulcerated surface. The whole treatment of nasal diseases has become much more gentle and conservative, the great injury to the Eustachian tubes, middle ears, and accessory sinuses of the nose, and the remote ills resulting from many lauded measures, having necessitated such a change. Antiseptic surgery has been as valuable in nasal operations as in those on other regions of the body, but the possibility of rendering or keeping the fossa sterile is more than doubtful. Surgical wounds are treated almost exclusively by the “open method,” dependence being placed on antiseptic irrigation and dusting powders used once or many times a day. A very ingenious method of using the “closed dressing” has been devised by Roe, of Rochester, N. Y.,1 consisting of plugs made of “thin metallic plates, evenly, carefully, and firmly wound with anti- septically prepared Angora wool or bichloride cotton, and which be- fore being introduced are dipped into a solution of bichloride of mer- cury (1 to 3000). The metal plugs should be of such size and shape that when wound with cotton and inserted in the nostril they com- pletely cover the wounded surface.” This or any other “closed method” is thought by most rhinologists to produce more irritation than the amount of sepsis uncontrollable by proper and thorough open treatment. Coryza or Rhinitis. Acute Coryza.—But little has been added to our knowledge of the pathology of this disease, the most important points being the demon- stration of its causative relation to acute otitis and inflammation of the frontal and other sinuses. The treatment of an acute rhinitis has, however, been made much more satisfactory by the introduction of such new drugs as cocaine and menthol, and by improved methods of application. A “cold in the head'’ may often be aborted in its early stages by the following method : From three to five drops of a five-per-cent, solution of cocaine muriate are first injected into each nostril by means of an ordinary medicine dropper. Complete contraction usually results in from five to eight minutes, thoroughly opening up the nasal chambers, and permitting the otherwise impossible, thorough use of an antiseptic spray. The latter is to be gently but thoroughly used until the fossre are absolutely free from mucus and debris; I commonly employ a solution of boric acid, borate of sodium, and chloride of sodium, but Dobell’s solution and compounds containing Listerine are perhaps equally valuable. After thorough cleansing, the membrane should be freely coated with a spray of liquid albolene containing from three to five grains of menthol and camphor to the ounce. Very frequently the coryza will wholly disappear, not to return, after the above-described treatment, and in all cases it will be found to run a much shorter and milder course than 1 Medical News, March 28, 1891. CORYZA OR RHINITIS. 715 if left to take care of itself. If the patient is not seen until infiltration has progressed, the same sprays may he used with some benefit, but the cocaine should be omitted, as at this stage it seriously lowers the tone of the membrane and aggravates and prolongs the disease. It is during the stage of acute vascular distention that the alkaloid acts most hap- pily. The use of menthol as an inhalant is of much value all through the course of the disease. The “inhalers” employed are well knowm to the drug trade, and consist of glass tubes filled with menthol crystals, which are confined by two perforated discs of metal or fibre. The end of the tube terminates in a cone, which is introduced into the nostril during inspiration, the menthol fumes being thus drawn into the nose. A sensation of coolness and comfort is produced, very satisfactory to the patient; the inhalation may be used as frequently as may seem de- sirabie. Much of the sedative treatment which will be discussed under hay fever applies equally to an attack of ordinary acute coryza, and may be used with benefit in the latter disease. Internally, a dose of about TV grain of morphine may be given at bedtime along with a hot whiskey lemonade, and will complete the cure in many instances. Quinine, although occasionally useful, is a remedy which I seldom employ, as its use greatly increases the dangers of Eustachian sal- pingitis and middle-ear complications. After a “cold” has become es- tablished sodium bromide may he given in full doses, and seems to shorten the attack while it certainly adds to the comfort of the patient. Tincture of euphrasia in ten-drop doses has been highly recommended by G. M. Garland, but has given less satisfactory results in other hands. Beverly Robinson gives carbonate of ammonium “ in frequently repeated and tolerably large doses.” In long-continued attacks tonics are often needed, strychnine and a reliable wine of coca being especially valuable. Complications from extension of the disease to the Eustachian tubes, frontal sinuses, larnyx, etc., demand close attention and appropriate treatment, and make up the dangers of an attack of acute coryza, the complication often developing after the nasal inflammation appears to have nearly run its course. Idiosyncratic Coryza.—Numerous elaborate papers have been con- tributed to the subject of “hay fever,” adding greatly to our knowledge of both the pathology and the treatment of this disease. The causes of the paroxysms have been proved to be central or peripheral neuroses, which may be excited by a great variety of irritants, internal or ex- ternal, physical or mental. As MacDonald1 puts it, “ the sneezing, lach- rymation, rhinorrlicea, and swelling of the inferior turbinated bodies are but physiological symptoms produced in individuals whose nerve-termi- nations or nerve-centres, from pathological or other reasons, are of a peculiarly sensitive nature.” The predisposing cause being a functional derangement of the nerve-centres (J. W. Mackenzie), the local phe- nomena may be produced by any irritant acting either on the nasal mucous membrane or on the central or peripheral nervous system. The most common local irritants are the pollen of grasses, of the ragweed, and of roses; almost any form of dust will bring on paroxysms in very sensitive subjects. As I have elsewhere shown,2 such purely mental 1 Diseases of the Nose, 2d edition, p. 219. 2 Paper read in the Section of Laryngology, American Medical Association, 1892. 716 DISEASES AND INJURIES OF NOSE AND ACCESSORY SINUSES. factors as anxiety, fright, or anger, as well as mental overwork, also frequently bring on typical attacks. The disease has been aptly named vaso-motor coryza, and occurs almost solely in “nervous” patients with ill-controlled vaso-motor centres, who complain of troublesome cardiac action, profuse perspirations, sensations of numbness in the limbs, cold extremities, etc. Idiosyncratic corzya is therefore regarded as essen- tially a nervous disease, demanding both peripheral and general treat- ment. The results of examination of the nose are not conclusive. The ordi- nary symptoms of acute coryza are present during the acute attack, and any of the lesions of chronic rhinitis may also be found. In long- standing cases the inferior turbinated bodies frequently present a re- markable pallor of surface. Treatment.—The therapeutic management of typical cases of hay fever is divisible into that proper for the attack, and the methods which may be used during the intervals to prevent return of the disease. A sufficiently strong solution of cocaine will nearly always relieve a parox- ysm for a limited time; but the alkaloid ultimately rather aggravates than relieves the local disease, and is invariably followed by more or le§s constitutional poisoning and serious results. Used only occasion- ally as an adjuvant to more radical measures, simply to tide the patient over the height of the attack, cocaine has a legitimate field of useful- ness in this disease. The solution used must never exceed ten per cent, in strength, and four per cent, is sufficient for many cases; the appli- cations should not be made oftener than two or three times in the twenty-four hours. The solution is best applied by the ordinary medi- cine dropper, the patient bending the head backward and injecting a few drops of the fluid into the nasal chamber; frequently only one side will require anaesthetizing to secure relief. Menthol stands next in value to cocaine as an agent for the relief of acute paroxysms. It may be used as an inhalant as described under acute coryza, or as a spray dissolved in fluid albolene—the strength in the latter case should range from four to ten grains to the ounce, as may be best suited to the individual case. Cubeb cigarettes give great comfort to a few patients, the smoke being allowed to escape from the mouth through the nostrils; from three to five may be allowed each day. Aqueous nasal sprays usually act as irritants during the height of the attack, but sedative inhalations through the mouth, on the other hand, often act well in allaying irritation of the lower respiratory tract. Such minor points as the wearing of blue glasses in the sunlight, and a respirator when dust is to be encountered, together with the use of gos- samer veils whenever possible, often make up the difference between absolute wretchedness and comparative comfort to the patient. MacDonald recommends the opium pipe, a few whiffs being suffi- cient, and speaks in the highest terms of chromic acid, finding it the most valuable local remedy.1 He uses it in the form of “a spray of very weak chromic acid, to of a grain to the ounce of water. This should be sprayed warm into the nose for five minutes three or four times a day, according to the severity of the case and the relief experienced.” Among the many internal remedies which have been lauded as 1 Diseases of the Nose, p. 239. CORYZA OR RHINITIS. 717 valuable in the acute stage of idiosyncratic coryza, morphine is the most reliable. From yg- to Ty grain of morphine sulphate may he given twice or oftener per diem, and will insure comfort in many cases; for evident reasons it should be given as little as possible. Atropine, anti- pyrine, asafcetida, and valerian have their advocates, but in the hands of specialists seem seldom to give relief at all commensurate with their drawbacks. Tonics, stimulants, and nutrients are very often indicated, and the mode of life should be as hygienic as possible. Climatic change to a high elevation or barren sea-coast, or such as is given by a long sea voyage, often offers the only hope of relief in severe examples of the “pollen cases.” During the interval between the attacks, a liay-fever patient should receive careful and appropriate treatment for any form of nasal disease which may exist. If any form of chronic rhinitis be present it must be cured; any serious obstructions to respiration, whether ecchondroses, bony spurs, or polypi, must be removed; and all hypergesthetic areas should be carefully searched for and cautiously cauterized. The discovery and destruction of these sensitive areas in purely “pol- len cases” may be said to comprise the successful treatment of the dis- ease. They should be sought for by careful probing under full illumi- nation and inspection, and are not usually very difficult to localize by the starting, sneezing, or other evidences of unusual irritation given by the patient, even without his verbal statements. The anterior por- tions of the septum and the anterior region of the middle turbinated body are the most common situations of the sensitive spots. When localized, the area should be lightly seared with the cautery point, great care being taken not to burn too extensive an area or to interfere seriously with the blood supply. If every area of abnormal sensibility can be found, and the nerve-endings destroyed, there will be no return of the paroxysms in at least fifty per cent, of the purely pollen cases. In regard to the “ central” vaso-motor cases, space forbids a proper consideration of their treatment, which frequently comes within the province of the neurologist rather than of the surgeon. The patient requires treatment more than the local disease, and such measures as well chosen climatic changes, rest, systematic outdoor exercise, regu- lated bathings, general faradization and massage, are commonly much more valuable than surgical procedures. Local treatment has at least a palliative action, and may act also by transmitting favorable influ- ences to the medulla; the various medical measures above mentioned are indicated, and any special source of irritation must be removed. Other neuroses, especially of the eyes, larynx, and bronchi, may exist in hay-fever cases and be more or less dependent on the nasal disease. Their cure depends on the early removal of the cause by proper means, medical or surgical. Chronic Rhinitis.—Although extensive contributions have been made to our knowledge of both the pathology and the treatment of this group of diseases, the general aspect of the subject remains the same. Perhaps the most important advances have been in the establishment of the direct etiological relationship between chronic coryza and many, or perhaps most, diseases of the ears, larynx, and bronchi, and of the eyes in many instances. Practically all cases of otitis media are now known 718 DISEASES AND INJURIES OF NOSE AND ACCESSORY SINUSES. to depend on nasal disease.1 Chronic larvngo-bronchitis, with its many complications, has a similar starting-point in most instances; and many ocular neuroses, as well as most diseases of the lachrymal duct, are now recognized as being directly dependent on chronic rhinitis of one or other of its many types. Treatment.—Recognizing the high physiological importance of the nasal membrane, and its intimate association with various remote con- ditions, nasal therapeutics has become much more conservative than formerly. Destructive procedures are now seldom used for minor con- ditions, and are never employed in any condition where more moderate treatment will at all suffice. Simple chronic coryza is almost universally treated by sprays com- bined with proper hygienic management. In addition to the standard solutions mentioned in Dr. Lefferts’ article,2 resorcin (5 grains to the fluidounce), the distillate of liamamelis, and boric acid (10 grains to the fluidounce), are extensively used by rhinologists, either alone or in various combinations. Powders have been very generally abandoned, as causing far more irritation than benefit, and medicated bougies are rarely if ever em- ployed in this disease by American specialists. Depletion by plunging a small tenotomy knife into the congested turbinated tissue has been recommended by Daly,3 and lately by MacDonald of London, but has not been generally adopted. General measures directed to the vaso- motor system are of great value in many instances, and cases in which the disease depends on a gouty or other diathesis demand special treat- ment directed to the constitutional condition. Chronic hypertrophic rhinitis has been shown to be a disease of very various types, but generally divisible for therapeutic purposes into two stages, (a) vascular dilatation with hypertrophy; (h) complete hyper- trophy or sclerosis.4 The former type is treated as simple rhinitis, with the addition of various surgical measures to relieve stenosis. The measures fully described in Dr. Lefferts’ article are still universally em- ployed, but destructive agents are less used than formerly. The intro- duction of cocaine has made practicable many delicate procedures scarcely possible before it came into use, and its almost universal em- ployment may be regarded as one of the greatest modern advances in nasal surgery. In early and vascular hypertrophies great benefit frequently results from the use of Hubbard's nasal-dilator bag. The instrument con- sists of a violin-shaped rubber bag, inches long and f inch wide at the extremities. The bag ends in a short rubber tube, through which a straight catheter is passed to the head of the dilator, and the end of the tube is tied firmly around it; the catheter is fitted to a half-ounce syringe in any convenient manner. To use the instrument, it is wet with Dobell's solution and slipped, while in a collapsed state, into the nasal fossa; when over the point of distention, the syringe, filled with tepid, hot or cold water, as may best suit the indications, is fitted, and the bag is dilated with any desirable amount of pressure for from one to five minutes. The engorged sinuses are thus emptied without either 1 Swinbourne, Medical Record, August 6, 1892. 2 Vol. IV, supra. 3 Medical and Surgical Reporter, Nov. 17, 1886. 4 See paper by the author, Amer. Jour. Med. Sciences, February, 1889. CORYZA OR RHINITIS. 719 irritation or reaction ensuing, and the results are most satisfactory in many instances. The treatment may be repeated several times a week, or even daily in some cases. Among the newer agents for the reduction of hypertrophies which will not yield to milder measures, trichloracetic acid has been very highly lauded.1 The eschar produced by its application is particularly dry and clean, and the resulting irritation is less than with almost any other agent. In the second stage of hypertrophic rhinitis, stimulating and altera- tive sprays and pigments are still of much value, and should always be given a fair trial; the hyperplastic tissue, how- ever, often fails to yield to any mea- sures other than surgical. The galvano-cautery is as popular as it was ten years ago, but is used with much more caution, quite a number of cases of fatal cerebral disease from its use on the middle turbinated body having been reported.2 The older form of Jarvis’s snare has been replaced by that of Wright (Fig. 1706), or by some similar form requiring but one hand for its man- ipulation. The number of new forceps, septum knives, etc., is legion, and various forms of electric drill are much used for the removal of bony or cartilaginous masses. Regarding the necessity of operation upon posterior hypertrophies, Harrison Allen3 has shown it to be rarely called for, and regards it as a good rule to suspend operative treatment until all other morbid conditions have been carefully corrected. Hypertrophy of the pharyngeal tonsil has received a large share of the attention of rhinologists during the last few years. By some the condition is regarded as a most formidable malady, responsible for very many of the diseased states of childhood and adolescence. Others, among them myself, believe the enlargements to be a serious men- ace only when of large size, and when associated with widespread in- flammation of the upper air-passages. The greatest danger of post- nasal adenoids is to the organs of hearing, many cases of catarrhal deafness being dependent on the pressure upon and obstruction of the Eustachian tubes caused by the growths. The lungs, throat, and gen- eral development also suffer in many instances, and the characteristic stupid face and nasal deformity are soon established. As to treatment, many believe, as I do, that early cases can often be satisfactorily cured by post-nasal applications of glycerite of iodine, combined with thorough and ivell-chosen treatment of the whole naso- pharyngeal tract. More advanced stages of hypertrophy, obstructing respiration, call for partial or complete removal, either by the methods already suggested or by the use of Gottstein’s curette, which is now the favorite instrument for the purpose. Operative measures may be Fig. 1706. Wright’s Nasal Snare. 1 Killian, Miinchener med. Woch., No. 39, 1891. - Munch, med. Woch., No. 51. 3 University Med. Magazine, August, 1890. 720 DISEASES AND INJURIES OF NOSE AND ACCESSORY SINUSES. very easily overdone here as elsewhere in the naso-pharynx. The neo- plastic glands may take on sarcomatous changes, speedily terminating the life of the individual, apparently as a result of too energetic treat- ment.1 Hemorrhage may be alarming and difficult to arrest, or serious Eustachian salpingitis and purulent otitis, with any of its complica- tions, may result from too heroic surgery. Chronic atrophy of the pharyngeal tonsil with its annoying and almost incurable symptoms may also be brought about by the radical ablation advocated in certain text-books. The subsequent treatment of all operative cases is of the greatest importance. The pharyngeal vault should be carefully washed out at least once a day with some mild antiseptic solution, such as Dobell's, with double the usual amount of carbolic acid, and the same precautions as to exposure, etc., should be observed as after any minor operation. In my practice a fine silver Eustachian catheter fitted to a half-ounce syringe is used to wash out the vault, a delicate jet being thrown upward behind the palate after introducing the cathe- ter through the mouth. Much of the danger of subsequent otitis is thus obviated, and healing is much more rapid and satisfactory than when no such measures are employed. Atrophic Rhinitis.—The final stage of “hypertrophic catarrh” is now considered a form of atrophy as well as the more typical “ozaena.” The former condition, better named sclerotic rhinitis, is characterized by marked thinning of the turbinated tissue with wasting of all the structures of the nose, the glands and venous sinuses being gradually replaced by fibrous tissue. The surface of the mucous membrane is light colored and rugose, and papillomatous changes are common; but erosions, epithelial desquamation with consequent crust formation, and involvement of bone, rarely occur. But little can be done for this form of nasal disease. Alterative sprays, local faradization, massage, and similar measures, frequently give relief to the symptoms, but a cure cannot be expected. True ozsena probably depends on the presence of a rhino-bacillus, de- scribed by Marano2 and Loewenberg; it is a capsulated form and diminishes in abundance proportionately with the institution and efficacy of antiseptic treatment. Ozaena is characterized by rapid atrophy of all the intra-nasal tissues, including the turbinated bones; the cavities become greatly enlarged, and the epithelial layer becomes non-ciliated. Crust formation and extensive erosions consequently occur, and the patient being unable to clear the nose, decomposition and the consequent ozaena stench are developed. The most important additions to the therapeutics of this disease are the employment of europhen and allied compounds, massage, and the local use of the faradic current. Europhen 1 may be used either in the form of powder, or as an ointment of five-per-cent or ten-per-cent, strength. In the latter case its use is advantageously combined with massage. A straight, firm cotton holder is tightly wrapped with cotton at its extremity so as to form a pointed cylinder about one inch in length; the tuft is then well charged with the europhen ointment and intro- 1 Delie, Revue de Laryngologie, Iso. 18, 1891. 2 Arcli. deLaryng., d'eRhin., etc., Avril, 1890. 3 Therapeutisciie Monat., September, 1891. TUMORS OF THE NOSE. 721 duced into one nasal chamber. The “massage” consists of a quick, uniform, rubbing motion, the cotton cylinder being pressed somewhat firmly against the mucous membrane, and the entire surface subjected in turn to the friction. The sittings may occupy from two to six min- utes, the patient being given brief intervals of rest between; great care is requisite, and the occurrence of hemorrhage is a very unfortunate ac- cident, the dense clots greatly aggravating the nasal crusting. Fara- dism is of much value in all cases of rhinitis cirrhotica. The positive pole is applied directly to the membrane by means of the long nasal electrode, and the negative is placed over the antrum or is held in the hand of the patient. A moderate current should be employed, and the sittings should occupy from six to ten minutes, two or three times a week. Tumors of the Nose. This subject has been lately largely cleared of the haze of unscien- tific uncertainty which for years has clouded it. I have adopted the following classification after somewhat extensive microscopical study of the subject.1 Leaving aside the true malignant growths, and cer- tain mixed tumors, both of which occur in the nose as in other mucous membranes, four types of local new growth are found in the nasal chambers: (1) Angeiomcita (telangiectatic degeneration). (2) Adeno- mata (glandular hyperplasia). (3) Myxomata (mucous degeneration). (4) Papillomata (dendritic epithelial tumors). Adenomas and myxo- mas, the latter being often but a degenerative stage of the former, are the ordinary “mucous” or “gelatinoid polypi” so common in the nasal cavities. The minute structure of nasal pseudo-adenomata resembles in all details that of the true neoplasm, viz., a fibrous-tissue matrix con- taining numerous tubular glands lined by epithelium. The connective tissue is exceedingly vascular, and extensive inflammatory small-cell infiltration is always present. Myxomata contain very little connec- tive tissue, being composed of a few stellate cells holding in their meshes structureless mucoid tissue. Papillomata of small size are very common in the posterior nasal region, resulting, like this form of neoplasm generally, from prolonged irritation of the epithelial layer.2 Vascular degeneration of turbinated tissue—pseudo-angeioma—is occasionally found; the boggy, very vas- cular masses are usually situated at the anterior end of the middle and lower turbinated bodies. In the surgical removal of these growths, comparatively little has been added to our previous knowledge. Electrolysis is frequently used, and is said to be effective even in the case of cartilaginous outgrowths;3 the bipolar method has been advocated by the latest investigators. The perfection of the galvano-cautery has made the radical treatment of nasal polpyi much more certain. The point of attachment should be thoroughly seared in most cases; polypi which come from beneath the middle turbinated body are followed up to the hiatus semilunaris by Casselberry, by insinuating a fine electrode slightly curved on the flat;4 1 University Med. Magazine, Jan., 1892. 2 Amer. Jour. Med. Sciences, Feb., 1889. 3 Bergoine et Moure, Arcli. de Chirurgie de Bordeaux, Nos. 3 et 4, 1892. 4 New York Med. Jour., No. 20, 1891. 722 DISEASES AND INJURIES OF NOSE AND ACCESSORY SINUSES. and those which spring from the superior meatus posteriorly are reached by a curved electrode introduced through the mouth. In very exceptional cases a cure can only be secured after removal of the ante- rior-inferior extremity of the middle turbinated body, by means of curved serrated scissors or a powerful snare. A large number of cases of malignant growth of the nasal region have been reported during the last few years in medical literature. The general aspect of the subject remains, however, practically unchanged, and the surgical principles and technique involved belong to the pro- vince of the general surgeon. Nasal Neuroses. These bear an important part in clinical medicine, it having been established by scores of independent observers that the highly sensitive nasal lining may affect reflexly many other organs. Eye symptoms, such as asthenopia, contraction of the visual field, ocular pain, subjec- tive color sensations, and infra-orbital neuralgia, are very frequently due to intra-nasal conditions, and are only curable by treatment of the nose. Inflammatory eye affections, such as catarrhal and follicular conjunctivitis, blepharitis, and obstruction of the lachrymal duct, are also lesions commonly cured by removal of the causative nasal disease.1 Urinary incontinence, cardiac neuroses, bronchial asthma, and vari- ous phases of neurasthenia, are almost daily relieved by the rhinologist by intra-nasal measures. Treatment must always be of the most gen- tle and conservative type to secure good results, for, as Beverly Robin- son has very aptly pointed out,2 indiscriminate surgical measures may increase or even originate the very conditions which they are designed to relieve, by the formation of cicatricial tissue and by reflecting irritation. Diseases of the Accessory Sinuses of the Nose. These are at present treated upon quite different lines from those fol- lowed a few years ago. The frontal sinus is probably inflamed in all cases of severe acute coryza, and pus accumulations in it are much more common than was formerly taught. Mild cases generally yield promptly to proper treat- ment of the causative coryza. When deformity is evident and the pain great, a blister of cantharidal collodion should be placed over the frontal sinus, or just above it. Internally, atropine sulphate, of a grain every hour for sixteen hours, or until the throat is very dry, has a bene- ficial effect in many cases; the bromides in large doses also have a valu- able controlling influence on the severity of the symptoms. Trephining the anterior wall is very rarely called for, and forcibly opening the sinus through the nose seems to me to be a wholly theoretical measure. Subacute or chronic cases usually soon get well if the nasal disease is cured. The mouth of the infundibulum, and probably a portion of its length, may be washed out and medicated by means of a delicate 1 Hamilton, Journal of Laryngology, London, June, 1890. 2 Medical Record, April 19, 1890. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 723 ■curved syringe passed with great gentleness into the middle meatus. The introduction of a fine probe into the sinus, as recommended by Juratz, is feasible in a small proportion of cases only, and is of very doubt fulutility. Applications of pyoktanin are advocated by Cholewa, of Berlin, and have been largely used in Philadelphia. I regard it as one of the feeblest and most unpleasant of antiseptics, and much prefer solutions of carbolic acid, and oily solutions of the antiseptic volatile oils, camphor, menthol, etc. Diseases of the Ethmoidal Sinus.—These have been recently classified by Bosworth 1 as follows: (1) extra-cellular myxomatous de- generation, with or without purulent discharge; (2) purulent ethmoi- ditis with nasal polypi; (3) intra-cellular myxomatous degeneration, with or without pus. The treatment advised by this author consists in uncovering the eth- moid cells by removing the convex cap of the middle turbinated body by means of the snare, and subsequently breaking up and destroying, as far as posssible, the trabeculae by means of the electric burr or the curette. I should myself prefer to confine such radical, and not alto- gether safe, measures, to very severe and otherwise incurable cases. Most earl)7 cases will yield to the thorough use of antiseptic sprays, and of similar solutions thrown around the turbinated body by means of a delicate nasal syringe, with applications of iodine or europhen, and with general treatment of the naso-pharyngeal tract. Polypi and masses of granulation tissue must of course be removed by the snare or forceps to make room for future procedures, and the conservative use of a deli- cate curette is of value in a few cases. The region involved is par- ticularly vulnerable, great subsequent irritation resulting from ap- parently mild procedures; and energetic treatment not infrequently originates the condition it is designed to cure. Purulent ethmoiditis consists pathologically of an osteitis granulosa or a caries suppurativa,2 and is essentially a deep-seated bone lesion. The ordinary symptoms are pain referred to the bridge of the nose or brow, interference with olfaction, and the usual symptoms of an aggra- vated chronic rhinitis. On inspection the middle meatus is found to be encroached upon by the enlarged middle turbinated body. The mucous membrane may be dry and rugose, or may be studded with polypi and oozing muco-pus. Probing is often better omitted; by its use the mass is usually found soft and yielding, and one or more areas of dead bone may be found; frequently, however, the areas are bared by the manipulation. The treatment of all forms of chronic ethmoiditis consists in follow- ing generally accepted surgical principles: employing free drainage and antiseptic treatment, with stimulants to promote a more healthy action in the part. The various methods used by rhinologists to se- cure these results have been already indicated. Their special applica- tion depends on the conditions present in any given case. Purulent and Myxomatous Disease of the Sphenoidal Sinus.— This affection has had a number of cases added to its literature during 1 New York Med. Journal, No. 675, 1891. 2 MacDonald, Diseases of the Nose, 2d ed., p. 86. 724 DISEASES AND INJURIES OF NOSE AND ACCESSORY SINUSES. the last few years. In a few cases only has the disease been recognized during life, and in still fewer has it been treated and cured. Ruault1 has reported a case in which the sinus was trephined, drained, and cured, the procedures being carried out through the nasal passage. The great anatomical variability of this sinus, and the obscurity of the symptoms caused by its diseased conditions, render its therapeutics at present most uncertain. Two cases of myxomatous polypus in the sphenoidal sinus have been reported, one by Zuckerkandl and the other by J. J. Clark;' in both the growths were found by post-mortem examination. Purulent Inflammation of the Maxillary Sinus.—The diagnosis of antral disease has been greatly simplified by the introduction of the electric lamp into rhinological work. Trans-illumination is secured by introducing a five-volt lamp into the mouth and directing the patient to close the lips upon the handle; the room being darkened, the current is thrown on, and immediately a rosy-red light suffuses the face and gradually fades out as the eye is approached. If there he pus or a solid tumor in the antrum, that side of the face, especially opposite the molar prominence, is less bright than the opposite side. Cystic disease on the contrary gives more brilliant illumination of the affected side. ' If from any cause the walls of the sinus are thickened, the illumination may he defective, and the diagnosis is therefore not positive but only confirmatory. Purulent catarrh of the maxillary sinus, occurring as a sequel of acute or chronic rhinitis, very rarely calls for the radical measures lately in vogue. Many cases will get well without special treatment, if the nasal lesions can be cured, and even severe examples frequently recover without operative interference. All swellings which interfere with drainage from the antrum through its natural opening must first be removed—temporarily by cocaine, or permanently by applications of the galvano-cautery. The patient being instructed to lean the head toward the shoulder corresponding to the affected side, an atomizer throwing a strong coarse spray, or a nasal syringe, is introduced through the nasal speculum and pointed as nearly as may be at the opening of the sinus into the middle meatus. The spray or jet is then thrown in- to the nasal chamber with some force, and this is repeated one or more times at each sitting. Several weeks of daily or tri-weekly treatment may be required, but convalescence is usually less prolonged than after operative interference, and the patient is saved much pain and annoy- ance. Any non-irritating antiseptic solution may be used for the pur- pose, but peroxide of hydrogen has been less reliable in my hands than solutions of boric and carbolic acids, borate of sodium, and the volatile oils. Intractable cases are only curable by drainage and irrigation, and the operation now almost universally favored is that of Mikulicz,4 con- sisting in opening the sinus through the inferior meatus of the nose, either with a special knife or by means of a trocar. Dundas Grant advocates the use of a straight trocar and canula, three inches long by 1 Arch, de Lar., de Rhin., etc., Juiu, 1890. 2 Journal of Laryngology and Rhinology, London, No. 2, 1892. 3 Heryng, Berlin, klin. Woch., Nos. 85 und 36, 1889. 4 Archivf. klin. Cliir., 1887. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 725 a millimetre and a half in diameter; the proximal end is made to fit the nozzle of a small syringe, after withdrawal of the trocar. The sinus is washed out with a warm antiseptic solution, and the punc- ture is kept open—with a short tube if necessary—and irrigated daily. Convalescence is frequently much retarded, and more stimu- lating solutions, possibly even silver nitrate, may be required. The whole nasal cavity should always receive appropriate treatment, and in direct relation to the thoroughness with which all minor details are carried out will be the success obtained in this as in all other diseases of this part. INJURIES AND DISEASES OF THE FACE, CHEEKS, AND LIPS. BY JOHN B. ROBERTS, A.M., M.D., PROFESSOR OF SURGERY IN THE PHILADELPHIA POLYCLINIC AND IN THE WOMAN’S MEDICAL COLLEGE OF PENNSYLVANIA, SURGEON TO THE METHODIST HOSPITAL OF PHILADELPHIA. lx this article will be considered the injuries and surgical diseases of the soft parts of the face, excluding those of the nose, mouth, eyes, and ears, which are considered elsewhere. Anatomical and Surgical Peculiarities. The skin of the face is thin, very vascular and elastic, and closely adherent to the subcutaneous cellular tissue and muscles. The direct insertion of many of the facial muscles into the lower surface of the skin not only prevents the latter from slipping freely over the under- lying tissue, but gives to the face its lines or wrinkles of expression. Certain of these furrows, such as the naso-labial, are permanent even in repose; others are only made evident by ever-changing mental emo- tions. The muscular fibres are enveloped in deposits of adipose tissue, whose unusual absence in conditions of inanition gives the face under such circumstances a characteristic cadaveric appearance. The operat- ing surgeon should remember not to make his incisions across these facial furrows of forehead or cheek, but parallel to or even along the bottom of them. Thus will he make the least conspicuous scars. AVhenever possible a scar should be placed in a region usually in shadow. Thus it is that wounds made under the brow or lower mar- gin of the jaw, and parallel to these bony edges, cause little deformity. Care should be taken that the hair of the eyebrow and beard should not be made to grow in an abnormal direction by unwisely placed incisions. It must be recollected that scars made in childhood increase in length as the patient grows; hence wounds made in badly chosen situations or directions may become undesirably conspicuous. An incision consist- ing of a series of long curves makes perhaps a less noticeable scar than a perfectly straight cut. The free bleeding which is apt to obscure the seat of operation soon ceases under pressure with sponges or haemostatic forceps, though tor- sion and an occasional catgut ligature may be demanded. Diminished 727 728 blood supply to the face may be temporarily obtained by digital com- pression of the common carotid arteries, or by acupressure of the trunks of the two facial arteries by means of acupressure pins or temporary ligatures, applied just before those vessels cross the lower margin of the jaw. It is stated that septic inflammations of the face spread with rapidity because the facial veins are unusually patent and free from valves, and communicate freely with the cavernous sinuses and internal jugular veins. The bones of the face are very vascular, and hence readily unite after incision or fracture, and only become necrotic under severe septic processes. They yield somewhat to pressure, and seem to regain their original contour if not subjected to too great displacement. Congen- ital absence of the nasal and other bones of the face is occasionally seen and must be remembered as a possible cause of facial deformity. Portions of tissue, osseous and soft, seemingly devitalized by injury, will often live and aid in the reconstruction of damaged areas; espe- cially is this true if heat and an aseptic condition are maintained by frequent irrigation with warm water (105° F.). Pieces of the lip, ear, chin, or nose, completely severed by accident, will occasionally become adherent and live if promptly adjusted with fine and kept warm and free from septic germs. Doubtful tissue should not be sacrificed until its destruction by gangrene has been fully determined. These characteristics of the facial structures afford opportunity for much successful plastic and osteo-plastic surgery. Incisions made obliquely to the plane of the surface can be approxi- mated by fine sutures with greater accuracy than vertical cuts; and accidental wounds will at times leave less scarring if the contiguous edges are appropriately bevelled before the sutures are inserted. Fino catgut or silk makes the best suturing material; and a strip or two of gauze, held in position with collodion, the best dressing if the wound is aseptic. Catgut sometimes allows premature gaping of the edges because of its early absorption, and I am apt, therefore, to use fine sterile silk when I am especially anxious that the line of union shall be perfect. Drainage can be dispensed with in aseptic wounds. Atten- tion to these details is essential in doing artistic work upon the face. Non-absorbable sutures should be removed in from two to five days. When wounds of the cheek enter the mouth, it may be wise to approximate the mucous membrane by a special set of sutures intro- duced from the buccal surface. The cutaneous union can thus be kept more free from contamination by oral micro-organisms. In operation wounds of the cheeks and lips the mucous membrane should be left intact when possible. Drainage, when needed, should usually be made into the mouth, in order to prevent external scarring consequent upon delayed union. It has been proposed to unite wounds of the face by fine catgut sutures so inserted that the needle punctures are made on the cut edges of the true skin and not on the external surface, but this subcuticular method of suturing is unnecessary if oblique incisions and careful stitching are employed and if rapid union is thereby obtained. Operative procedures on the face must be undertaken with a due respect for the duct of the parotid gland, which, lying under the deep fascia, runs as far forward as the anterior edge of the masseter muscle, in a line from the middle of the lobe of the ear to a point midway be- INJURIES AND DISEASES OF THE FACE, CHEEKS, AND LIPS. WOUNDS OF THE FACE. 729 tween the ala of the nose and the angle of the mouth. At the anterior edge of the masseter, which can readily be felt, it takes a deeper course and, perforating the buccinator and mucous membrane obliquely, enters the mouth opposite the second molar tooth of the upper jaw. If the nature of the operation requires division of this duct, it is good sur- gery to isolate the portion coming from the parotid gland, to make an opening through the buccal tissues into the mouth, and to carry the stump of the duct through this opening. Thus a new salivary ori- fice will be made in the mucous membrane and a cutaneous fistula will be avoided. The branches of the seventh nerve, which give motion to the mus- cles of expression and radiate from a point just below the auricle, must not be ruthlessly divided by a longitudinal incision in front of the ear. The motor paralysis so induced would cause indescribable deform- ity. Division of the sensory nerves coming out of the supra-orbital, infra-orbital, and mental foramina is less objectionable, since the numbness thereby caused makes no change in the facial wrinkles or expression. Skin grafting in its various forms, and plastic operations by all methods, have a most brilliant field in the prevention and correction of facial deformities. Occasionally it is well to allow a flap, raised for a reparative purpose, to thicken by inflammatory exudate before suturing it in place. Its tissue, drained of blood and with lowered temperature immediately after dissection, may gain additional vitality if not at once attached by stitches, and sloughing of its edges may thus be avoided. The insertion of a piece of aseptic oiled silk or rubber tissue under the flap will prevent its union to the underlying structures during the three or four days required for inflammatory plethora and thickening. Wounds of the Face. The face especially escapes injury by reason of the mobility of the cervical vertebrae, the warning afforded by vision, and the automatic protection given by the upper extremities, the obliquity of the lower end of the humerus causing flexion of the elbow to bring the protecting hand directly in front of the mouth and lower part of the face. The discoloration due to contusions is often a source of anxiety to the patient. Cold compresses with moderate pressure, continued for five or ten hours after the receipt of an injury, tend to lessen the subcu- taneous bleeding and are advantageous, but subsequently cold applica- tions should be omitted, as they probably delay the absorption upon which the removal of the discoloration depends. Multiple antiseptic punctures, followed by squeezing to extrude the extravasated blood, may be utilized in severe cases. Perfect asepsis must be maintained lest suppuration be induced. Chloride of ammonium, arnica, and other drugs applied locally, probably exert very little influence in hastening removal of the “ black and blue” discoloration except when accompanied by friction, which is probably the valuable part of the treatment by these various lotions or liniments. The use of flesh-colored paint will partially disguise the alteration in color due to bruises. Gunshot wounds of the face are best managed by applying at once 730 INJURIES AND DISEASES OF THE FACE, CHEEKS, AND LIPS. a dry antiseptic dressing without previously resorting to exploration with a probe, which will seldom give any valuable information and may cause sepsis. This primary antiseptic occlusion may lead to heal- ing by means of a moist blood clot within the wound, since gunshot wounds in this region are often, and perhaps usually, aseptic. Punctured wounds may be similarly managed unless there is reason to believe that the injury has been caused by a specially septic instru- ment. Then, of course, free incision and sterilization of the wound to its very bottom is demanded, but even under such circumstances it is often judicious to wait a few hours until preparations can be made for a thoroughly antiseptic operation. Wounds involving the nasal, tarsal, and auricular cartilages may often be accurately approximated without passing the sutures through the cartilaginous tissue, though there is no objection to carrying the needle through the cartilage if preferred. In wounds made by firearms at close range, particles of unburnt powder may become embedded in the skin, and if not removed will leave permanent blue stains similar to those produced by tattooing with car- bonaceous substances. A similar discoloration is often found in miners and others who have been injured by blows from pieces of coal. The powder or coal-dust thus carried into the tissues should be removed immediately after the receipt of the injury. This may be accomplished by thoroughly scrubbing the burnt or lacerated parts with soap and water by means of a nail-brush. Anaesthesia may be required for the proper execution of this important part of the treatment. Picking out the particles of carbon with forceps is scarcely thorough enough. If healing has occurred over the embedded carbon, the blue disfigure- ment is only remediable by the tedious removal of every minute parti- cle. Each blue point may be excised by a small circular punch, or croton oil may be pricked into the skin with a needle, and the pigment removed by the suppuration so induced. The minute white scars left by these methods are less noticeable than the tattoo marks. It has been proposed to attempt combustive destruction of the carbon by in- troducing a red-hot galvano-caustic needle into the skin at the dis- colored spots. The chemical applications employed by dermatologists to remove tattoo stains intentionally produced, may in certain cases be valuable; but discolorations due to accidental wounds are probably too deep to be satisfactorily removed by such means. Cicatricial Deformities and Deformed Scars. Cicatrices which would be of no importance on hidden parts of the body must be avoided on the face. Abscesses may sometimes be opened from the mouth, and an external scar avoided. The disfiguring and often self-convicting cicatrices of syphilitic ulcers and-of gummy tumors allowed to ulcerate, are readily prevented by early and large doses of mercury and potassium iodide. No such lesion should be per- mitted to indelibly mar the features because of the carelessness or ignorance of a surgeon who looks for syphilis only in the lowly. Tuberculous abscesses should be incised and curetted before the skin becomes thinned and a puckered scar probable. Spontaneous evacua- CICATRICIAL DEFORMITIES AXD DEFORMED SCARS. 731 tion is therefore to be deprecated. Occasionally a softened tubercular gland, or a tubercular abscess, may be drained by transfixing it with a needle carrying wire, silkworm gut, or silk, and leaving the suture material in the abscess as a sort of seton. This method is valuable as a means of preventing increase in the abscess and thinning of the skin when incision and curetting have to be delayed, hut the latter operation is always preferable. The depressed scar of an old tubercular abscess may he improved by abrading the surface of the scar, making an elliptical incision around it, and drawing the skin over the abraded sur- face. This elevates the surface and substitutes a linear cicatrix for the depressed and often puckered one. By another method, suggested by Mr. W. Adams, the depressed tissues are separated from the under- lying fascia by a tenotome introduced subcutaneously. Then the scar tissue is elevated to the level of the surrounding skin, and is held in that position by small pins passed underneath. After a few days the pins are withdrawn, leaving the skin fixed in its new situation. When moles, warts, and other tumors, 0£ malignant ulcers, are to be removed, the incisions should be so planned as to minimize the de- formity from cicatricial contraction. In many instances a plastic procedure should be done as a part of the preliminary operation, in order to lessen the cicatrizing tension or transfer it to an area where it will do little harm. These plastic operations justify by their ultimate results the additional incisions and conse- quently augmented hemorrhage. Excisions of growths near the eyelids and mouth very frequently require the gap left to be thus closed by cutaneous flaps from the neighboring skin. It is usually desirable to do both parts of the operation at one sitting, but quite frequently, as in all plastic surgery, secondary or tertiary operations are needed to get the most perfect result. When the entire thickness of the cheeks at the corners of the mouth is extensively re- moved, as for malignant disease, cicatricial lockjaw is pretty certain to occur if the tis- sues are drawn together by sutures. Unless a plastic reconstruction of the cheek (melo- jilasty) is at once done by means of a flap from the neck or elsewhere, it is better to allow the wound to heal by granulation, since under these circumstances, the patient’s use of his jaws may lessen, though it will not entirely obviate, the cicatricial trismus. Bardenheuer 1 fills the gap by a flap cut from the forehead. This he turns downward, so that the skin of the brow substitutes the mucous membrane of the mouth. The raw surface of the flap occupying the gap in the cheek is then covered by a flap taken from the neck, so that the two flaps are placed with their raw surfaces in apposition. (Fig. lToT.) This method of preventing cicatricial anchylosis is said to be better Fig. 1707. Bardenheuer's Method for Prevention of Cicatricial Closure of Jaw. 1 Deutsche medicinische Wochenschrift. Sajous’s Annual of the Universal Medical Sciences, vol. iii., 1892. 732 INJURIES AND DISEASEE OF THE FACE, CHEEKS, AND LIPS. than treating it after occurrence by osteotomy of the lower jaw so as to make a false joint. Another method of reconstructing the cheek is to dissect a flap from the neck, make a button-hole incision under the lower jaw into the mouth, carry the flap through this opening, and suture it in the gap left by the excised tumor, with the skin surface toward the oral cavity. If the surgeon prefer, the flap may have Thiersch skin shavings applied to its raw surface, either before or after its utilization to close the opening. Sometimes a mucous surface can be given to the region where scar contraction will be most marked, by dissecting a large flap of mucous membrane from each of the lips in front of the excised area, displacing these flaps backward over the gap, and suturing together their upper and lower edges respectively. Plastic operations on the face by V-shaped incision, by sliding, twist- ing, or overturning of flaps, by osteoplastic methods, or by grafting bone, muscle, or skin, are conducted on the general principles of plastic surgery. The pedicles of such flaps as those used in the method of meloplasty just described, are divided after their circulation has been secured from the new region. The surfaces left bare by the dissection of the flaps should be immediately covered with a pavement of skin shavings. When very large portions of the face have been lost by injury, operation, or disease, prosthetic appliances of celluloid, wax, and other materials may be successfully constructed to imitate the missing struc- tures. The artistic success of these attempts is sometimes unexpectedly good. The keloid growth that occurs in old scars not unfrequently returns after excision. It is said that in negroes, in whom keloid disease is common, the excrescence softens and even disappears as the patient ad- vances in adult life.1 Fistulse upon the Surface of the Face. Fistulous openings upon the face occur in connection with injuries and diseases of the salivary and lachrymal apparatus, the frontal and maxillary sinuses, and the mouth. Sloughing of the tissues of the cheeks, from excessive ptyalism or from gangrene as a sequel of one of the fevers of low type, may readily cause a communication between the surface of the cheek and the cavity of the mouth. These same pathological changes, or wounds of the cheek, may cause a salivary fistula, whereby the secretion of the parotid gland is emptied upon the cutaneous surface because of an abnormal opening into the parotid duct. Similar lesions may result in salivary fistulse of the ducts of the sublingual and submaxillary glands, the location of the abnor- mal orifice varying with the anatomical situation of the primary lesion. Abscesses or gangrene may give rise to a communication between a lobule of one of the salivary glands and the surface, thus causing a fistula in which the duct, of the gland is not involved. The saliva escaping from the abnormal orifices in such glandular fistulse will prob- ably be less in amount than from openings of the same size connecting 1 See Dr. J. Collins Warren’s paper, and subsequent discussion, on Cicatrices, etc., in Transactions of the American Surgical Association, vol. xi., 1893. FISTULA UPON THE SUKFACE OF THE FACE. 733 with the ducts. It is possible for the saliva to escape from an ulcerat- ing or otherwise diseased lobule, and, burrowing under the tissues, to make its exit, or cause a cystic tumor, at a distant point. Garretson records a case in which he believed that the sublingual gland had thus communicated with and caused distention of a bursa above the hyoid bone. Agnew saw a congenital salivary fistula which opened on the auricle at the anterior part of the helix. A blow may cause subcu- taneous rupture of the parotid duct and cause swelling from salivary infiltration. Impaction of fishbones, air, or calculi in the salivary ducts may cause obstruction and inflammatory symptoms leading to fistulse. I once treated a case of inflammatory obstruction of the parotid duct in which there occurred a transudation upon the cheek when the patient’s salivary glands were stimulated by masticating food. This was prob- ably saliva leaking through the skin. The patient unfortunately passed out of my care before a chemical examination of the exuded fluid had been made. Necrosis of the malar bone may cause sinuses whose orifices resemble salivary fistulee. Garretson records a case of sinus in the face, due to a misplaced molar tooth lying on the ramus of the lower jaw under the parotid gland. It, of course, did not discharge saliva. The probe and chemical tests will aid in the diagnosis of such cases. Tincture of chloride of iron, mixed on a white surface with the suspected fluid, will give a pink reaction with the sulphocyamde of potassium present if saliva is mixed with the discharge. In operating on the deep structures of the cheek, the exact position of the duct of the parotid gland may be kept in view by passing a fine lachrymal probe or acupuncture needle along its track from the buccal opening. Ordinarily, however, the line already ghTen will be a suffi- cient guide to its position. Various operations have been employed for closing the external orifice in salivary fistula. The essential part of the treatment is the establish- ment of a free opening for leading the saliva into the mouth. After this has been accomplished, the cutaneous orifice will often close spon- taneously. The exact location of the oral orifice made by the surgeon is not important, if it remains sufficiently large. The late Dr. Post, in his article on this subject in Vol. IV. of the En- cyclopaedia, has detailed several methods. One or two others may with propriety be mentioned here. An opening for salivary drainage, at or above the fistula, may be made into the mouth, as advised by Agnew, by passing a probe along the duct from the mucous surface of the cheek, and then carrying a thread, by means of a needle, around the probe through the tissues without perforating the skin. The probe is then withdrawn, and the ligature, which has been introduced from the mouth, is tied and allowed to ulcerate through the encircled duct and mucous membrane. Thus the duct is cut off from the external open- ing, which is closed by the application of stimulants or caustics, or by a plastic procedure, if spontaneous healing does not occur. In some cases a cure may be effected by slitting up the duct with scissors and suturing the mucous membrane so as to divert the stream of saliva from the external orifice. Garretson has succeeded in making the internal opening large and the cutaneous orifice small by using a coni- cal plug, of cotton or wire, carried through the entire thickness of 734 INJUlilES AND DISEASES OF THE FACE, CHEEKS, AND LIPS. the cheek. A mere thread comes through the cutaneous opening while the base of the cone occupies the opening in the mucous membrane. Thus the saliva is carried in the direction of the larger opening, and finally the minute external opening is closed. Irregularly placed glandular fistulae may he remediable only by dis- secting out the offending portion of the secreting gland. Fistulae resulting from suppurative disease of the frontal sinus and lachrymal sac usually need the establishment of drainage downward into the nose. Antral accumulations may be drained into the nose by a per- foration made below the inferior turbinated bone, or into the mouth by an opening made above the bicuspid teeth. A drill or strong carti- lage knife should he employed, and the opening should be kept patulous by a tent or plug. The cavity often requires irrigation with mild anti- septic solutions if the cure is to be expedited. Extraction of a tooth is seldom required. Facial Spasm. The intractable spasm of the muscles supplied by the facial nerve, called histrionic spasm or tic convulsif, at times becomes so annoying that the surgeon is consulted. The spasms which are usually clonic, though occasionally tonic, are not associated with pain, and this disease is quite different from the neuralgia of the fifth cranial nerve called tic douloureux. Gray has proposed the term palmus for the former con- dition.' The patient should not be subjected to stretching of the facial nerve, which has some value at least as a temporary measure, until medical treatment has proved to be unavailing. Galvanism has been employed, as have arsenic, atropine, and kindred remedies, administered by hypo- dermic injection or by the mouth. Hammond claims to have given some relief by an apparatus consisting of a spring and pads, to make pressure on the facial nerves at their points of exit. This was worn by his patient with benefit, but the pressure could not be borne for more than a couple of hours. Nerve stretching has not been very satisfactory; but it is an opera- tion of no special danger, and has afforded relief for as much as five years in at least one case. The incision, made immediately behind the auricle, should be about two and a half inches long, and angular, with the apex of the angle, in the middle of the cut, pointing backward at the point of the mastoid process. The facial nerve is found in the nar- row space between the parotid gland in front and the sterno-cleido- mastoid muscle behind. The nerve is situated at a depth of from one to one and a half inches, and lies in front of the fascia over the pre- vertebral muscles. It is uncovered at about a half-inch in front of the stylo-mastoid foramen, through which the nerve makes its exit from the cranium, and is in front of the centre of the anterior margin of the mastoid process, and from a quarter to a half inch anterior to that spot. If the posterior belly of the digastric is seen, the operator must keep above its border. The transverse processes of the vertebrae and the styloid process are aids to the identification of the relations. Eeflected light from a head-mirror may be requisite to illuminate the 1 Amer. Journ. Med. Sci., May, 1895, p. 535. TRIGEMINAL NEURALGIA. 735 deep cavity. A needle-like electrode passed successively over the vari- ous structures in the bottom of the wound, while a wet sponge elec- trode is applied to the cheek, will identify the nerve by causing twitch- ing of the facial muscles. The current should be weak, since a strong current will, according to Keen,1 produce muscular reaction even when the electrode is not in contact with the nerve, because the moisture in the wound will conduct the current to all the exposed tissues. Baum’s method of reaching the nerve, which is here described, is preferable to that by an incision in front of the auricle, as advocated by Hueter. Neurectomy will stop the spasm, but causes a disfiguring palsy. Facial neurotomy with immediate nerve-suture occurs to me as a pos- sible method of treatment. The section would relieve the spasm, and muscular power would probably return as regeneration of the sutured nerve took place. Fig. 1708. Trigeminal Neuralgia. The neuralgia which af- fects the fifth cranial nerve often demands surgical treat- ment. The disease is some- times called “ facial” neural- gia, but this is a confusing designation, since it may lead to the supposition that it affects the seventh cranial, or facial, nerve, which is a motor nerve and the seat of the spasmodic motor affec- tion just described as tic con- vulsif. Tic douloureux, tri- facial neuralgia, and epilep- tiform neuralgia of the fifth nerve are better descriptive names for the malady now under consideration. The name epileptiform neuralgia is applicable because of the irregularly occurring explosions or convulsions of agonizing pain in the areas of distribution of one or more of the three divisions of the nerve. The motor nerves of the face, however, may he secondarily affected, causing muscular contortion or local paralysis; but these symptoms are incidental and not necessarily present. The superior and inferior maxillary divisions are more apt to be the seat of this violent neuralgia than the supra-orbital division, which is the frequent location of the simple neuralgias associated with malaria and migraine. Nerve Changes in Trigeminal Neuralgia. (Rose.) 1 Trans. American Surgical Association, 1886, p. 285. 736 IXJUllIES AXD DISEASES OF THE FACE, CHEEKS, AND LIPS. The pathology and causation of this torturing disease is not under- stood. It has been asserted that obliterating endarteritis of the nutrient vessels of the nerve is often present,1 and evidences of sclerosis of the nerves and ascending neuritis have been found. (Fig. 1708.) The suggestion that syphilis may be an agency in the etiology seems plausible if endarteritis is the factor of importance. The conditions giving rise to the pain, whatever they are, may be situated in the deep origin of the nerve fibres in the pons and medulla, in the sensory root before it reaches the Gasserian ganglion, in the ganglion, or in the nerve trunks or. branches. It is possible that the nerves may be sub- jected to pressure at their foramina of exit from the skull, because of a relatively small orifice, or of swelling due to periostitis or perineuritis. Peripheral causes may be cicatrices, tumors, diseased teeth, foreign bodies, retained secretion in the frontal sinus, and similar irritating lesions. The operative treatment will be modified by the character of the supposed etiology. Every organ should be examined, and every ascertainable cause of toxic, reflex, or functional irritation should be removed. The disease is one of middle or advanced age, and is characterized by attacks of more or less periodic shooting pain, exceedingly severe, and radiating from the supra-orbital, infra-orbital, or mental foramen. During the intervals between these paroxysms there may be no pain at all, or irregular painful sensations which are quite insignificant as com- pared with the epileptiform neuralgic paroxysms. The disease usually attacks one side of the face only, and may be located in one, two, or all three divisions of the trifacial nerve. Gradually, in the course of months or years, the paroxysms become more frequent and the inter- vals shorter. The patient finally becomes dominated with the dread of causing an outbreak of pain, which is started by talking, eating, coughing, or having anything touch the skin over the distribution of the peripheral branches of the nerve. Unexpected noises or draughts of air may incite a seizure. Facial contortions, at the time the lancinat- ing pain occurs, as well as ptosis, strabismus, and clonic spasm of the muscles moving the lower jaw or head, may occur from secondary im- plication of motor nerves. Hyperaemia or tumefaction of the face, lachrymation, sweating, and other vascular and secretory symptoms may occur on the affected side of the face and mouth. Medicinal treatment is of service in the milder cases, and in the early stages of those which finally require operative measures. Many rem- edies such as quinine, chloral, cocaine, arsenic, aconite, antipyrine, gelsemium, and nitroglycerin have been used with varying success, as have local applications of menthol, croton-chloral, and belladonna. Nitroglycerin, sodium nitrite, and similar drugs seem specially in- dicated in view of the investigations of Dana and Putnam pointing to obliterative endarteritis as a possible cause of the disease. Great relief to the patient is afforded by excision of the nerves affected, .but the pain usually returns in a few months or years. The comfort experienced after neurectomy is, however, so immediate and so great that the operation should be performed as soon as the inefficiency of medicinal treatment is established. Thus the pain-habit and the grave disturbances of health, due to years of agonizing neuralgia, may be de- 1 C. L. Dana, Journal of Nervous and Mental Disease, No. 1, 1891. TRIGEMINAL NEURALGIA. 737 layed. Sometimes, though very rarely, the patient is permanently cured. The recurrence of pain is due to regeneration of the excised nerve tissue, or to a sort of nervous anastomosis taking jilace through communicating nerves. Hence, neurotomy is not to be recom- mended, but neurectomy, combined with stretching of the central and peripheral portions of the affected nerve, should be chosen. As large a piece of nerve as can be readily reached should be excised. The opera- tion should be repeated as often as the pain returns, for experience shows that removal of the unidentified structures at the seat of a former operation, and the stretching of the supposed nerve-stump, will afford further relief, often lasting many months. The operative attack should be made upon the nerve as near its central origin as possible, due regard, however, being had for the risks of those operations which aim at excision of the Gasserian ganglion itself, or of the deep portions of any of the three divisions. Neurectomy of the branches making exit at the supra-orbital, infra-orbital, or mental fora- mina respectively, is practically free from danger, and often gives great comfort. These points should therefore be chosen for the earlier opera- tions. It will be readily understood that these operations will be in- effective if the lesion is behind the foramina, but it is rare that the surgeon can localize the cause of the neuralgia. The painful nerve, after exposure, should be thoroughly stretched by traction in both a central and a peripheral direction, and an inch or more, if possible, of the nerve trunk should be extracted. In operating upon the second division of the nerve, the spheno-pala- tine ganglion (Meckel’s) just in front of the foramen rotundum should be removed, if neurectomy at the infra-orbital foramen, with extrac- tion of a long piece of nerve, has proved unavailing. If the third di- vision is the painful trunk, excision should be done above the dental foramen in the lower jaw, or just below the oval foramen in the sphenoid bone, if neurectomy at the mental foramen or in the inferior dental canal has failed to give relief. As the exact seat and nature of the cause of the disease is usually undeterminable, success is more apt to be obtained, and a longer period of freedom from pain gained, by cutting away the nerve as near the brain as possible. The torturing character of the disease makes death preferable to life, wherefore the most severe operative procedures are ultimately justifiable. The less severe opera- tions, however, should be undertaken before those which are more dangerous are recommended to the patient. If two or all three of the divisions of the trigeminus are affected, the deeper operations are more clearly indicated. Ligation of the common carotid artery 1 of the affected side has given relief in some cases. I have twice performed this operation in patients previously subjected to neurectomy of the anterior parts of the nerves. Both cases were immediately relieved, but in time the pain recurred, and in one of them I subsequently did an intracranial neurectomy of the second and third divisions immediately in front of the Gasserian ganglion. Neurectomy of the supra-orbital nerve or terminal branch of the first division is performed by a horizontal incision just below the eyebrow, over the junction of the inner and middle thirds of the supra-orbital _ 1 An elaborate article on the various operations and their results, by Dr. G. R. Fowler, will be found in the Annals of Surgery, vol. iii., for 1886. 738 INJURIES AND DISEASES OF THE FACE, CHEEKS, AND LIPS. ridge. The attachment of the eyelid to the bone is divided and the orbi- tal fat pressed downward, and the nerve is then isolated, lifted up on a strabismus or other blunt hook, and divided as far back in the orbit as possible. Before its division it should he grasped by forceps far back and drawn forward, so as to stretch the portion near the brain. After it has been divided, traction should be made on the part to be excised, in order that the peripheral branches supplying the forehead may be stretched and dragged out of the tissues. This method enables the surgeon to extract the greatest amount of the nerve and its branches. The second division is dealt with by the orbital, antral, or ptergygo- maxillary route. The various methods are well described in detail by Rose.1 One method of operating by each route will here suffice. The infra-orbital foramen is exposed by a transverse cut under the orbit. A second incision may be made from the nasal end of the first incision along the naso-labial furrow. This additional wound gives more room by enabling the surgeon to turn down a flap, but is not essen- tial. A longitudinal cut from the middle of the first incision is, I think, less desirable, because of the greater prominence of the cicatrix. The portion of the lower margin of the orbit above the foramen is readily cut out by a chisel, and access is thus obtained to the nerve. The orbital contents are next carefully held up with a retractor, while the thin roof of the canal in the floor of the orbit is broken through and the nerve uncovered. It is stretched with forceps and cut off as far back in the orbit as possible. The peripheral branches are then torn out of the muscles and skin, by steady traction made on the detached piece of nerve. If the operator prefer, the periosteum may be detached from the floor of the orbit and held up along with the eye and orbital fat, while the canal is being laid open. When the antral route is chosen, illumination with an electric light and mirror is almost a necessity. A Y-shaped or T-shaped incision, with the centre over the foramen and the lower end extending nearly to the corner of the mouth, lays bare the front of the upper jawbone. The anterior wall of the antrum is then opened by a chisel or trephine, the posterior wall of the cavity similarly perforated, and the spheno- maxillary fossa reached. Incision of the mucous membrane of the roof of the antrum, and breaking away the layer of bone under the nerve, give the surgeon an opportunity to remove the latter with or without the spheno-palatine ganglion, which, however, should be re- moved if possible. Bleeding is often very free during the deep manipu- lations, but pressure with gauze is readily applied and is usually suf- ficient. There is no objection to cutting off and ligating the arteries which accompany the painful nerves in their canals, when operating upon any of the divisions. The pterygo-maxillary operation may be done by an inverted V- shaped incision, with the apex just behind and below the external angular process of the frontal bone. One limb of the A is carried downward and backward to the tragus, and the other downward and forward upon the cheek, the zygoma is sawn through near each extrem- ity, the temporal fascia is detached from the upper edge of the zygoma, and the detached zygoma with the masseter is turned downward. The 1 The Surgical Treatment of Neuralgia of the Fifth Nerve, by Wm. Hose, F.R.C.S. London, 1892. TRIGEM1XAL NEURALGIA. 739 fissure between the pterygoid process and the upper jawbone is thus uncovered, and the spheno-palatine ganglion of Meckel is made acces- sible. To remove the infra-or- bital nerve as well as the gan- glion, an additional operation under the orbital margin is re- quired. Eose considers this method a good one, if it is de- cided not to attempt extirpation of the Gasserian ganglion itself. (Fig. 1T09.) The lingual and inferior den- tal nerves are the sensory branches of the third division which usually demand surgical treatment for neuralgia. The latter is the only one claiming attention in an article on the surgery of the face, as the lin- gual nerve comes within the limits of the surgery of the oral cavity. The inferior dental nerve may be excised at the mental foramen by an incision made through the mucous mem- brane within the mouth, or through the skin. In the cuta- neous method the incision should be made under the lower border of the jaw, the skin being then drawn upward. It is better, however, to reach the nerve within the canal by cutting away the anterior layer of the jaw with trephine or chisel, near the junction of the body and the ascending ramus. Several inches of the nerve can be re- moved by subsequently chisel- ling out the roof of the canal as far forward as the mental foramen. It can be satisfac- torily excised also just above its entrance into the inferior dental canal, by trephining the jaw below the sigmoid notch and deepening that notch by cutting away the bridge over the opening thus made. (Fig. 1710.) This is a good method of reaching the lingual nerve as well as the inferior dental, and is practically the same opera- tion as that used by Eose to reach and divide the third division just under the oval foramen. A large horseshoe incision is made around Fig. 1709. Diagram Showing: Dissection Necessary to Expose Sec- ond Division of Fifth Nerve, According to Braun-Lossen Method, a, Zygomatic arch divided and turned down; b, temporal tendon arising from coronoid process and held back by retractor; c, superior maxillary nerve and Meckel’s ganglion; d, infra-orbital nerve at emergence from canal. (Rose.) Fig. 1710. Side View of Lower Jaw Showing Position of Trephine Opening in Operation for Deepening Sigmoid Notch. The Two Upper Dotted Lines Indicate the Extent of the Bridge of Bone. (Rose.) 740 INJUlilES AXD DISEASES OF THE FACE, CHEEKS, AXD LIPS. the posterior border of the ascending ramus of the lower jaw. It begins about the middle of the zygoma, is carried downward and backward, and then forward below the lower border of the horizontal ramus. After the flap is raised, the deep fascia and masseter muscle are cut by a transverse incision below and parallel to the parotid duct. The peri- osteum is then raised, the bone trephined, and the sigmoid notch deep- ened by cutting away the bridge of bone above the trephine perforation. The nerve can then be excised just as it emerges from the foramen ovale or a little distance below it, according to the wishes of the operator. When the operations already described for trigeminal neuralgia have failed to give permanent relief, it is proper to enter the cranium and excise the nerve trunks in front of the Gasserian ganglion, and to remove as much as possible of the ganglion itself. This may be done by trephining the base of the skull, or by opening it through the squamous portion of the temporal bone. The former operation has been especially advocated and employed by Rose1 and Andrews,2 while the latter has been perfected by Hartley and Krause, though previously suggested by Horsley. The basal method requires section of the zygoma and coronoid process, detachment of the masseter and temporal muscles, and the application of a specially constructed trephine or chisel to the region near the oval foramen. After the ganglion has been extirpated the divided bones are sutured, or the zygoma may be sutured and the coronoid process removed. This operation seems to be more formidable than that by opening the skull through the temporal fossa according to Hartley’s method.3 Experience on the cadaver and in the living subject has convinced me of the value and feasibility of the latter operation. An omega-shaped incision is made over the temporal fossa, so that the ends of the cut will be near the tragus and external angular process of the frontal bone, and its convexity at the temporal ridge. The tissues are incised down to the bone, and a chisel or surgical engine is then used to divide the bone along the same line. With an elevator the divided bone and soft tissues are pried up, and are turned down over the zygoma as a sort of trap-door. The bone breaks across the base of the incision, and the skin, muscle, and periosteum serve as a hinge. The middle meningeal artery is seen in the dura and ligated if necessary, and the dura is then carefully detached from the base of the skull until the three divisions of the trigeminus and the Gasserian ganglion are exposed. Care is required to avoid injuring the cavernous sinus, and illumination by an electric-light head-mirror is almost a requisite. After the ganglion has been curetted away with a small sharp spoon, or torn out with forceps, the brain and dura are allowed to fall into their normal posi- tion, the osteoplastic flap is turned up so as to close the opening in the cranium, and sutures are applied. (See Figs. 1694, 1695, pp. 636, 637, supra.) Many surgeons have operated by this route and method with rapid union of the wound and satisfactory results. The cases are too recent, however, to prove anything as to permanency of cure. The ganglion has not been removed in all the cases, but in certain of them an intra- 1 Op. cit. ! Journal of American Medical Association, 1891. 3 Annals of Surgery, May, 1893, p. 512. HARELIP, 741 cranial neurectomy only has been done. Mr. Rose lias operated by the basal method on at least six cases, with one death, and Andrews and others have taken this route. Horsley’s1 method of reaching the gan- glion and the emerging nerve-trunks by opening the dura mater and exposing the temporo-sphenoidal lobe is a more serious operation than Hartley’s modification. One of Rose’s patients had been free from pain for nearly two years after re- moval of the ganglion, and was still well when the report was made. A recent survey of the litera- ture of the subject shows 21 cases operated upon by the basal route, with 3 deaths, and 20 cases oper- ated upon by the temporal route, with 2 deaths." Fig. 1711. Harelip. This deformity is due to imper- fect closure of the embryonic fis- sures of the foetus. The congen- ital defect may be so extensive as to include the cheek and head as well as the lip. Very rarely a similar cleft is found in the lower lip; and occasionally the cleft in ‘the upper lip is in the median line. The recent monograph of Rose gives much valuable information about the causation and varieties of this malformation. The correction of the deformity in harelip involves much more than the mere closure of the cleft. The lip, even in simple cases, is usually imperfectly developed on the side of the cleft away from the middle line. This is fully appreciable when the lips are closed, and should be noticed in every case before the incisions are made. The operator must lengthen this side of the lip and elevate the nasal ala, flattening of which ordinarily ac- companies the labial defect. There must be a perfect adaptation of the skin and mu- cous membrane at the junction of these structures on the edge of the lip, and no vermilion mucous membrane should be per- mitted to remain along the cutaneous scar left by the operation. Error is sometimes committed by not freeing the lip thoroughly from the upper jaw. The first step should consist in dividing the mucous membrane between the lip and gum, and paring the tissues loose on both sides of the median line. This detachment may at times go as high as the infra-orbital foramen before the tension has been sufficiently relieved. Aggravated Harelip ; Fissure Extending Into Eye and Cranium. (Wyeth.) 1 British Medical Journal, Dec. 5, 1891. 2 See the author’s article in Dennis’s “System of Surgery, ” vol. ii., p. 914. 742 INJURIES AND DISEASES OF THE FACE, CHEEKS, AND LIPS. Ail estimate of the character of the incisions to be made is obtained by observing the manner in which the upper lip is deficient in length on one side. I have often satisfactorily lengthened the lip and nar- rowed the flattened nostril by an incision along the groove between the wing of the nose and the cheek, with a transverse incision outward from the cut made in denuding the edge of the congeni- tal gap. This makes a curved flap to be displaced downward, lengthening the lip, and frees the ala of the nose so that it can be brought nearer the septum either with or without sutures. The incisions which pare off the edges of the cleft should change their direction before they reach the border of the lip, and turn inward so as to leave a tongue of tissue covered by mucous mem- brane; these tongues assist in lengthening the lip, and also prevent the notch in its margin which is often seen when the wound has healed. (Fig. 1714.) It is important that the denudation of the edges should include enough tissue to reach a place where the edges attain the full thick- ness of the lip. Inexperienced operators sometimes cut away too little, and have only thin edges to bring together with the sutures. Instead of sacrificing tissue by paring away the edges of the cleft in order to get freshened surfaces of contact, the operator may split the margins of the gap where mucous membrane and skin come together,, parallel to the plane of the lip. This is similar to the flap-splitting operation employed in repairing old lacerations of the perineum. The mucous are more voluminous than the cutaneous flaps, and may, as suggested by Fenger,1 be first brought together across the gap by sutures tied within the mouth. The muscles and skin are subsequently unit- ed by other sutures tied on the outside, and the* outer wound is thus shut off from the micro-organisms of the mouth. In this operation the harelip-pin suture is abandoned, and silk, silkworm gut, or wire is used. I myself have abandoned the pin suture in harelip operations, whatever form of incision is adopted. An aseptic wound, with silk su- tures and a collodion dressing, gives great satisfaction. If pins are used they should be removed in two or three days, as their longer retention is liable to cause undesirable scarring. Fig. 1713. Central Fissure of Lip With Deficiency of Intermaxillary Bones. Howse’s Case. (Bryant.) Fig. 1714. Method of Lengthening Short Side of Cleft in Harelip and Decreasing Flattening of Nose by Incisions, One Extending Outwards Along Mu- co-cutaneous Junction and One Around Ala of Nose. 1 Journal American Medical Association, August 1, 1891, p. 176. INJURIES AND DISEASES OF THE MOUTH, TONGUE, FAUCES, PALATE, AND JAWS. BY J. EWING MEARS, M.D., PROFESSOR OF ANATOMY AND CLINICAL SURGERY IN THE PENNSYLVANIA COLLEGE OF DENTAL SURGERY, GYNAECOLOGIST TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL, SURGEON TO ST. AGNES’S HOSPITAL, EX-PRESIDENT OF THE AMERICAN SURGICAL ASSOCIATION, ETC. Affections of the Tongue. Wounds of the Tongue.—In operations for the relief of wounds of the tongue, it is desirable that the surgeon should have the organ under complete control. This is best accomplished by passing a strong aseptic silk ligature through its apex and tying it in a loop. Anaes- thesia should be ind uced in all cases of a serious nature, especially in children. Hemorrhage from wounds of the tongue is sometimes very difficult to control, and in patients who are the subjects of haemo- philia death may follow from slight wounds, as by biting the tongue. In cases of severe hemorrhage, or when the ranine artery is wounded, it may be necessary to apply a ligature to the lingual artery as it passes forward above the border of the greater cornu of the hyoid bone. Owing to the moisture of the tongue and its constant movement, sutures when applied should be very carefully tied. In gunshot wounds of the tongue the ball may lodge in its substance, and instances are recorded in which a bullet, passing through the jaw, has driven a tooth into the tongue, the tooth becoming embedded and producing severe inflammation. The foreign body may be detected by passing a probe along the track of the wound, and when its position is ascertained it should be excised. Conditions Affecting the Figenum.—The frsenum of the tongue may be so short as to interfere with the proper movements in suction on the part of the child. The test as to the absence of this condition is the ability of the child to project the tip sufficiently forward to touch the red border of the lower lip. \rery severe hemorrhage has occurred from division of the fraenum owing to wounding of the ranine artery. Absence of the frsenum has been noted in a number of instances. In these cases, the tongue falls back into the fauces and presents the appearance of a tumor. Danger from suffocation is constantly present, and one case is reported in which death occurred from this cause. 743 744 INJURIES AND DISEASES OF THE MOUTH, ETC. Suturing the tongue to the floor of the mouth was suggested by the late Professor S. D. Gross as a means of relief, although doubtful as to its efficacy. Ranula.—In addition to the methods of treatment usually practised, 1 have found incision of the cyst-wall, evacuation of the contents, and packing with iodoform gauze successful. Cysts.—Later investigations into the character of sublingual cysts show that they are usually dermoid and may contain hair, teeth, alid bone, as well as the usual cheesy matter found in dermoid cysts. They are formed by involution of the epiblast during development, and are situated between the muscles connected with the tongue and the floor of the mouth. This fact makes their removal through the mouth some- times difficult, especially if they have attained any considerable size. Carcinoma op the Tongue.—Carcinomatous affections of the tongue and their treatment by surgical procedures have been so thoroughly discussed by Mr. Heath in the fourth volume of this work that but little can be added. In a paper read before the American Surgical Associa- tion, Dr. N. P. Dandridge1 concludes that the removal of the tongue in carcinomatous affections is justifiable, prolongs life, adds com- fort to the patient, and affords a reasonable hope of permanent cure. All operations should be preceded by an effort to secure thorough disinfection of the mouth and teeth. When the disease is confined to the tongue, Whitehead’s method, removal by the scissors, is preferred. Preliminary ligature of the lingual artery is not considered necessary. Unilateral extirpation is advocated when disease is limited to one-half of the organ, and Baker’s method of tearing through the raphe should always be employed. When the disease has extended to and involved the floor of the mouth, submaxillary gland and cervical glands, Koch- er’s operation is advised. By this operation the cavity of the mouth is opened through the digastric triangle, and the tongue, being drawn through the wound, is removed by the scissors or galvano-cautery. Preliminary tracheotomy is performed with subsequent tamponade of the fauces. The glands involved can be removed by the incisions made to enter the month. Preliminary tracheotomy is thought to add an unnecessary element of danger to removal of the tongue, in ordinary cases. Volkmann has achieved remarkable successes in cases of exten- sive disease by opening the mouth by lateral division of the lower jaw at the position of the canine or first molar tooth. It is desirable in all cases to get the patient out of bed at the earliest possible moment after the operation, and to feed him generously. Allusion has been made by by Mr. Heath to ligation of the lingual artery for the purpose of checking hemorrhage and arresting the growth of cancerous disease of the tongue. In the case of a man aged sixty-five years who suffered from carcinoma involving the left side of the tongue, palate, floor of the mouth, and inner surface of the cheek, I tied the left common carotid artery, with the result of securing cicatrization of the ulcerated surfaces; right hemiplegia, however, followed the operation, and within a year the patient died from exhaustion. ’Transactions, vol. x., 1892 malformations and diseases of the palate. 745 Malformations and Diseases of the Palate. Cleft Palate.—Within the past few years the discussion of the question as to the operative or mechanical treatment of cleft of the palate has been revived, and great activity has been manifested in de- vising new methods of operative procedure through which better re- sults as to articulation have been secured. The great difficulty of obtaining the adaptation of a perfectly satisfactory mechanical ap- pliance, and the necessity which exists of its occasional renewal and its constant cleansing, make it desirable to avoid these conditions by ope- ration, even if perfect articulation is not attained by such proced- ure. Diligent investigation, stud}7 of results obtained, and repeated efforts by new methods, will, it would seem probable, lead to the removal of difficulties which now prevent perfect results. With the view of giving such movement to the soft palate as will enable it after opera- tion to be placed against the posterior wall of the pharynx, and thus efficiently shut off the nasal from the pharyngeal cavity, Billroth has devised an operation by means of which the mucous membrane at the side of the velum is alone divided and then used to cover the cleft, after the internal plates of the pterygoid processes are severed by the chisel and approximated. This procedure completely relaxes the tensor palati muscles, and permits the palate to be acted upon by the levator palati and palato-pharyngei in such manner as to bring it in contact with the posterior pharyngeal wall. Billroth ascribes the failure to secure the application of the soft palate to the posterior wall of the pharynx, to the division of a circular muscle, the anterior portion of which is contained in the velum. If, in the operation of closure, the remaining part of this muscle be cut through, occlusion of the nasal cavities becomes impossible; hence the incision of only the mucous membrane and section of the internal pterygoid plates. Wolff1 claims great advantages for a plastic operation over the use of mechan- ical appliances. He also discusses the post-operative treatment for the correction of speech troubles. The opinion of surgeons has been modified of late with regard to the time for removal of the sutures. Formerly it was thought desirable to permit them to remain from a period of from six days to a fortnight, and Mr. Heath states that fine wire sutures may be left for weeks or even months, as long as they do not scratch the tongue. My experi- ence has been unfavorable to this practice, fistulous tracks occurring in some instances in the line of the suture as a result of this long reten- tion. I now endeavor to secure removal of all sutures within a period of five or six days, removing one or two on the third or fourth and the remaining on the fifth or sixth day. Rotter, of Munich, describes2 an operation for cleft palate in a case in which there was also a labial fissure. To close the cleft he borrowed a frontal periosteal skin flap with a long pedicle, grafting the raw surface of the flap with epidermal grafts, and holding it with its grafted surface up upon the forehead, with a bandage, for a period of eight days. At the expiration of this time the grafts had taken, giving a skin flap cov- 1 Berliner klinische Wochenschrift, 4 Marz, 1890. 2 Mtinchener medicinische Wochenschrift. 746 INJURIES AND DISEASES OF THE MOUTH, ETC. ered with epidermis on both sides. The object of this was to prevent the drjflng up of the flap when in position and exposed to the double air current, nasal and oral. This method, which was successful in the case reported, can only be employed where a labial cleft coexists with a cleft of the palate. Affections of the Pharynx. Wounds of the Pharynx.—These are usually self-inflicted. They may, however, be the result of accident, or may be produced in surgical operations. When suicidal, homicidal, or accidental, their gravity may be greatly increased by the involvement of adjacent structures. In sim- ple wounds of the part hemorrhage is usually slight and readily con- trolled. Emphysema of the neck may follow a wound of the pharynx, as may also aphonia from the contiguity of the larynx. A question of interest relates to the use of sutures in closing the pharyngeal wound: formerly it was the practice to close the wound of the pharynx and that through the overlying tissues but experience has shown that the introduction of sutures in the pharyngeal wound is apt to lead to inflammation and sloughing, and that the reparative process follows more quickly in such wounds when not closed by stitches. The wound in the superficial tissues may be sutured, space being left for drainage by tube or gauze. For a few days liquids and foods may pass through the wound, but this may be partially overcome by attention to the position of the patient’s head, which should be inclined to the side opposite the wound. If it be found necessary, alimentation may he conducted by the rectum and afterward the stomach-tube may he employed. Fistulse sometimes follow pharyngeal wounds and become sources of great annoyance and discomfort. The use of the galvano- cautery, or of nitrate of silver applied by means of the porte-caustique, may be of service in causing their obliteration. Tonsillitis.—Two forms of acute inflammation of the tonsils are- recognized—the follicular and the parenchymatous. The former in- volves the lining membrane of the follicles, which branch out into the substance of the gland and the adenoid capsules which surround them. In the parenchymatous variety the entire gland is involved. The rheumatic and gouty diathesis has been assigned as a cause of tonsil- litis, as has sexual excitement. The high temperature, with the great prostration which attends the severe forms of inflammation of the ton- sils, has led to the opinion that the disease is of septic origin. The late Professor Agnew attributed great importance to the use of guaiacum as a remedy in the parenchymatous form. Three or four grains may be given every two or three hours in the form of a lozenge, which is allowed to dissolve in the mouth, its action being supplemented by the local application of the ammoniated tincture of guaiac to the sur- face of the tonsils. Pharyngitis.—A form of pharyngitis characterized by a dry, red, and glazed condition of the mucous membrane sometimes exists in per- sons of advanced life who have suffered from repeated attacks of AFFECTIONS OF THE JAWS. 747 catarrh. As in these cases the submucous connective tissue gradually disappears, the disease has been designated atrophic pharyngitis. Internal administration as well as topical application of cubebs or of ammonium muriate may palliate the affection. In order to keep the mouth closed during sleep and thus prevent dryness of the fauces, it is advised to hold the jaws together at night with a bandage. Tumors of the Pharynx.—While tumors of the pharynx are rare in their occurrence, instances are recorded in which the various forms of lipoma, papilloma, fibroma, and chondroma have been observed. The most usual varieties are the adenoma, sarcoma, and carcinoma. Adenoma appears most frequently in the shape of vegetations covering the roof and sides of the pharynx, which give rise to constant hawking, and sometimes to difficulty of hearing and of articulation. Inspection of the pharynx will reveal the growths when they extend below the palatal arch, and by the aid of the pharyngeal mirror they may be seen when seated above this point. In mild cases they may be removed by the application of a dilute solution of nitrate of silver. When firm they may require the use of scissors, Volkmann’sspoon, or the galvanic cautery. Carcinoma of the pharynx is usually associated with disease of adjacent structures. When a large surface is involved but little can be accom- plished for relief by operative procedures. When the disease is limited to the lateral or posterior portion of the pharynx, sub-hyoidean pharyn- gotomy may be successfully performed. In one case Billroth removed the pharynx, part of the oesophagus, and the entire larynx except the epiglottis, part of the trachea, and the thyroid gland. The patient died at the end of six weeks from the accidental passage of a sound into the mediastinum. Sarcoma of the round-celled variety invades the phar- ynx, and may be removed by operation through the mouth, or in graver cases by sub-hyoidean pharyngotomy. Retropharyngeal Tumors.—I have reported the successful removal of a sarcomatous tumor of the size of a lemon from the basilar portion of the occipital bone by the method of operation described by Cheever, through the neck, with division of the lower jaw and incision of the pharynx; slight necrosis of the jaw followed. Affections of the Jaws. Alveolar abscess is defined to be an abscess at the apex of the root of a tooth, due to inflammation originating in the tissues of an exposed pulp and conveyed to the apex by continuity of structure. The tissues lining the walls of the alveolus and reflected on the root of the tooth, may become involved. The treatment in the early stage should be conducted by the dentist, and consists in the treatment of the diseased tooth by cleaning out the affected tissues of the pulp cavity and of the root canal, and by the use of antiseptic douches and packing with proper materials saturated with antiseptic agents. Treatment of this character often results in stopping the inflamma- tory action and saving the tooth, which, although dead, may be made useful by proper filling. When the tooth is very much diseased and its 748 INJURIES AND DISEASES OF THE MOUTH, ETC. body to a great extent destroyed, it may become necessary to remove it and treat the inflammatory condition in the alveolus by antiseptic methods. In some cases, when the condition of the roots permits, an artificial tooth may be attached by pins and bands. Necrosis of the Jaws.—Of the various forms of necrosis of the jaws, that produced by the specific effect of phosphorus is of special interest. The disease exists to a great degree among the operatives in match factories in certain portions of the United States, notwithstand- ing the successful results achieved abroad in its prevention. In a paper read before the American Surgical Association in 1885’I announced as my belief, founded on observations made in a number of cases under my care, that the necrotic action was not caused, as had been stated, by the fumes of phosphorus attacking the periosteum through diseased teeth, or through the cavities after extraction of teeth, but that the periosteum of those who had long been exposed to the fumes of the poison was so altered as to make it very susceptible to irritation, and that the irritation accompanying a diseased tooth, or that asso- ciated with the efforts at extraction of diseased teeth, was the factor in the production of inflammation in the already diseased membrane. Closure of the Jaws.—Permanent closure of the jaws may be due to unilateral or bilateral cicatricial formations in the buccal spaces, or to anchylosis of the temporo-maxillary articulation on one or both sides. For the former condition, I have devised a method of operation which in a number of cases of bilateral involvement has afforded com- plete relief, and has permitted permanent opening of the mouth to the extent of an inch and three-quarters between the teeth. Having failed by the methods in use, I was led to adopt one which consists in the passage of a double aseptic silk ligature, by means of a handled, slightly curved needle, between the integument of the cheek and the surface of the cicatricial mass, entering the point of the needle at the corner of the mouth and bringing it out at a point opposite the last molar tooth. The ligature being deposited, is loosely tied and allowed to remain in situ from two to three weeks, or until the surgeon is satis- fied that a mucous lining membrane has formed in the canal in which it lies. In order to form this canal the ligature should be drawn back- ward and forward in its track from time to time. When the lin- ing membrane is formed the cicatricial mass may be divided with the knife, or may be gradually cut through by the ligature, which should then be tied firmly. Subsequent to the division of the mass, the mouth is opened to its fullest extent daily by the use of a mouth gag. In a few weeks this ma}r be dispensed with, and the unaided efforts of the patient in opening the mouth may be depended upon to secure perma- nent relief. It is very desirable in passing the needle that it should be carried closely in contact with the inner surface of the skin, so as not to pass through any portion of the cicatricial mass. In the case of a patient who had suffered from closure of the jaws for a period of twenty-seven years, and who had been the subject of an unsuccessful operation by other methods, I succeeded in affording complete relief by this plan, the mouth being opened to the extent of one and a half 1 Transactions, vol. iii. AFFECTIONS OF THE JAWS. 749 inches; and as the improvement has now continued for six years, it may he regarded as permanent. In anchylosis of the temporo-maxillary articulation I have also obtained good results, in a number of cases, by section of the ramus of the jaw and removal of both coronoid and condyloid processes, thus affording ample room for the formation of a false joint. The operation is performed through the mouth by passing a tenotome beneath the masseter muscle, making an opening through which an Adams saw is carried and the bone is divided. An effort is then made by seizing the upper fragment with the liomjawed forceps, to twist it out of place. If this movement does not succeed, a chisel is placed in the wound over the neck of the condyle, and this portion is cut through, sufficient hone being gouged out of the glenoid fossa to give space. The anterior portion of the upper fragment, with the coronoid process, may be re- moved with cutting pliers, the attachment of the temporal muscle being severed by a blunt-pointed knife. In every instance in which this method has been employed a permanent and fully movable false joint has been established, permitting opening of the mouth to the normal extent, and without any lateral deviation of the lower jaw. INJURIES AND DISEASES OF THE NECK. BY JOSEPH RANSOHOFF, M.D., F.R.C.S. Eng., PROFESSOR OF ANATOMY AND CLINICAL SURGERY IN THE MEDICAL COLLEGE OF OHIO, SUR- GEON TO THE CINCINNATI HOSPITAL AND TO THE GOOD SAMARITAN HOSPITAL, CINCINNATI. Abscess of the Neck. The loose connective-tissue planes of the neck and the lymphatic glands embedded within them are often the seat of purulent infection. This may develop primarily in the neck as a consequence of penetrating wounds, from without or from within, as from the pharynx or oesoph- agus, or may result from direct extension of a like affection from the floor of the mouth, tonsils, jaw, parotid gland, or vertebral column. In the great majority of instances, however, a cervical abscess begins as an adenitis, the result of septic inoculation of a lymphatic gland from a primary lesion situated somewhere in the vast territory drained by the cervical lymph-nodes and plexuses. Although they most often follow infectious lesions of the naso-pharynx and its appendages, abscesses may ensue from apparently trivial lesions of the face, the nasal pas- sages, the external ear, or the scalp. The source of the infection may not be easy to determine, the primary lesion, often slight, having dis- appeared before manifestations of glandular infiltration are discover- able. Among the gravest abscesses of the neck are those which follow in the wake of typhoid fever, small-pox, diphtheria, and particularly scar- latina. To account for these is not difficult when we consider the fre- quency with which Assuring about the tongue, and erosions and ulcera- tions of the pharynx, occur in these diseases. Therefore in addition to the usual pyogenic organisms, the pus from cervical abscesses has been found to contain the bacillus of typhoid, the diplococcus of pneumonia, the ordinary spirillum, and the micrococcus tetrogenes.1 Abscess of the neck for the most part begins as an adenitis of one or a number of glands of a group nearest the point of primary infection. The inflammatory process may, as in glands elsewhere, stop short of suppurative softening, for it is quite certain that besides its function as a filter for septogenic organisms the lymphatic gland can through its wealth of cells render many of them inert. When overwhelmed, pus is produced. From within the glandular capsule, converted into a pus- sac, the peri-glandular connective tissue is invaded with greater or less 1 Roswell Park, Med. News, Oct. 16, 1888. 751 752 INJURIES AND DISEASES OF THE NECK. rapidity, adhesion to the overlying structures follows, and nature forms the path for the sjjontaneous or operative cure of the condition. While abscesses of the neck may be diffuse, there is a distinct ten- dency toward limitation by fasciae and connective-tissue planes within certain well-defined spaces. This applies to purulent foci above and below the deep fasciae. The sub-maxillary gland, with intra-glandular and extra-glandular lymphatics, is contained in such a pocket, from which abscesses are not prone to extend. Indeed, its walls are so im- perforate that any marked infiltration of this region will make itself manifest through pressure effects on the tongue, pharynx, larynx, and vessels situated underneath it. General septic infiltration and slough- ing follow this enchained inflammation, which is fatal in over forty per cent, of the cases in which it occurs. Having been accurately de- scribed by Ludwig,1 this deep-seated phlegmon of the neck is known as “ Angina Ludovici” by continental writers. As early as 1822 Gregory gave a graphic description of the disease.2 In England the subject has been ably treated by K. W. Parker 8 and Morrant Baker.4 It is the termination in sloughing with its attendant grave septic manifestations that distinguishes this “sub-maxillary phlegmon” or “deep phlegmon of the neck'’from milder processes in the same region. Abscesses in this region are oftenest encountered in children, are rela- tively of slow development, and, owing to this and to the greater resist- ance of tissues generally in the young, are not often phlegmonous in character. The more acute the process the greater is the danger of sloughing. A second pocket within which purulent foci are found is underneath the layer of deep fascia which joins the proximal margins of the sternal muscles and lies in front of the trachea. Contained within it are the loosest connective tissue of the neck, ocasionally a median lymph-node, and the thyroid. The abscesses here encountered are ordinarily the result of wounds or operations on the air passages. Tracheotomy is sometimes followed by a peri-tracheal cellulitis which by extension to the mediastinum becomes fatal. Unopened abscesses in this area sometimes cause tracheal stenosis. Koenig 5 reports the case of a child on whom he was about to perform tracheotomy. In front of the trachea and extending into the mediastinum an abscess as large as a walnut was encountered. When this was evacuated, res- piration became so free that the opening of the trachea was not found necessary. A third space is that which corresponds to the superior carotid trian- gle. The large number of lymphatic glands which surround the vas- cular sheath and are beneath both borders of the sterno-mastoid mus- cle, makes this, next to the sub-maxillary triangle, the favorite site of cervical abscesses. Often of slow growth when they follow suppurative, tubercular, or syphilitic adenitis, or when secondary to malignant dis- ease of the subjacent gullet, they are not infrequently mistaken for neoplasms, or for arterial lesions on account of the pulsation of the un- derlying carotid. When pointing occurs, it may be in front of or be- 1 Schmidt’s Jahrbiicher, 1837. Bd. xv., S. 25. 2 London Med. and Pliys. Journal, 1822. 3 Lancet, 1879, vol. ii.' 4 St. Barth. Hosp. Reports, 1890. 6 Lehrbuch f. spec. Chirurgie, Bd. i. ACTINOMYCOSIS. 753 hind the sterno-mastoid, blit in either event the downward progress of the abscess will usually be limited by the fascial covering of the omo- hyoid. In other cases, unless operative measures are instituted, the abscess will dissect its way along the great blood-vessels to the root of the neck and through the upper chest aperture. Not a few lymphatic glands are found in the supra-clavicular triangle, in which abscesses may develop without connection with other pockets of the neck. A cervical abscess, in a patient recently in the wards of the Good Samaritan Hospital, developed in the wake of a suppurating cavity in the apex of the left lung. Abscesses from the axilla often ex- tend into this region, and vice versa. Secondary abscesses dependent on cervical caries sometimes progress in this direction, following the sheaths of the brachial nerves. The dorsal portion of the neck is not often the seat of true abscess, on account of the scarcity of its lymphatics and the greater resistance of its integument. Abscess here may, how- ever, follow furunculosis, or a slight infected wound. In addition to the usual dangers incident to suppuration, deep ab- scesses of the neck are sometimes followed by serious and even fatal hemorrhage. This remark applies particularly to the post-scarlatinal suppuration in which lesions of the veins predominate, although venous hemorrhage is comparatively infrequent. The lesser resistance of the walls of the vein permits the obliteration of its calibre. The thicker arterial wall on the other hand will ulcerate before occlusion' can take place.1 The first extensive tabulation of cases in which the primitive carotid, internal carotid and subclavian, or their larger branches, were opened, was prepared by S. W. Gross.2 The hemorrhage may follow the opening of the abscess immediately, or it may not occur for a number of days. When smaller arteries are opened the hemorrhage will probably be recurrent, although the ulceration of even primitive trunks may not prove fatal except after repeated bleedings. Actinomycosis. Closely resembling in their clinical features chronic cervical abscesses are the suppurating granulomata of actinomycosis, first described in man by Israel.3 The ray fungus may gain access through carious teeth, ulcerated gums, or tonsils, and may find a nidus in the cervical glands. The point of invasion in the mouth or pharynx may not show any trace of the disease. Cases of this kind have recently been reported by Ban- neft and Blok.4 Although the fungus may itself produce pus, the sup- puration in actinomycosis is generally caused by the ordinary pus-form- ing organisms. The discharge from actinomycotic abscesses may be whey-like in appearance, or may resemble the pus of chronic abscesses from other causes. Its characteristic is the presence in the pus of many yellow or pearly granules, at most the size of a pin’s head, which when examined by transmitted light are distinctly brownish. Microscopic examination reveals more or less complete rosettes of club- shaped fungi. In cases of what might be termed primary cervical 1 Lindner, Deutsch. med. Wochenschr., 1887, S. 522. 2 Amer. Journ. Med. Sciences, 1871. 3 Virchow’s Archiv, Bd. lxxiv., S. 15. 4 Annals of Surgery, vol. xii., p. 392. 754 INJURIES AND DISEASES OF THE NECK. actinomycosis, the diagnosis sometimes cannot be made from abscesses due to other causes except by an incision. When the actinomycotic tumor is single, without nodules, and fluctuating, absolute differentia- tion from abscess may be impossible. Since, however, incision, curet- ting and drainage are indicated in the one as in the other, and in both will be followed by a permanent cure, the question of diagnosis may be considered of minor importance. Tuberculosis of the Neck. Chronic inflammations of the lymph nodes of the neck, in Sir George Macleod’s article 1 denominated “scrofulous,” are now known to be tuber- culous in character. Marked by indolence, multiplicity, and a tendency to develop during childhood and adolescence, they are the result of an infection from the mouth, pharynx, or tonsil, and continue long after the primary lesion has disappeared. Ordinarily the gland nearest the seat of invasion is first infected, and within its capsule the diseased process is limited. Sooner or later the glands in the vicinity are involved, until in well-marked cases a single or double chain of lymphatic tumors extends from the angle of the jaw to the clavicle. While only a few of the glands are involved, the danger from general tuberculosis is not marked, the glandular capsule efficiently protecting the system. Wei- gert2 demonstrates that the virus in some cases is successively deposited in contiguous lymphatic glands until it reaches the venous circulation through a lymph-duct, but that in the greater number generalization takes place more directly through a vein. The bacillus tuberculosis is not motile, and therefore infection is carried in the course of the lymph current, or by amoeboid cells through the blood. It is a matter of ordinary clinical observation that only a small per- centage of strumous glands terminate in miliary tuberculosis. Nor is pulmonary tuberculosis a frequent congener or sequel of a like affection of the cervical glands. In 148 cases analyzed by Frankel3 the lungs were affected in only 15. While the anaemia and malnutrition of tuberculosis were marked in 18 patients, the general health was not impaired in 72. Tubercular adenitis is principally a localized infection process. In patients under five years it is often associated with or fol- lowed by tuberculosis of other parts, when the local condition in the neck forms but an unimportant factor of the generalized condition. According to Tibert, Schell, and Lucke, the largest number of tubercu- lous cases are encountered between the ages of ten and twenty. In its beginning, a tubercular gland appears to the naked eye in the guise of a simple hyperplasia. The tumor is firm, consistent, elastic, and on section presents a uniform, grayish, translucent surface. Ke- cent investigations of Friedlander, Foster, Koenig, and others, have shown that in the early stage of the disease miliary nodules are already present, and that within them, far removed from the blood-supply, are the giant-cells of Langhans. It remained for Koch to demonstrate that within the latter were contained the bacilli. In very young subjects 1 See Yol. V., supra. 2 Verbreitungswege der Tuberculose. Jahrbuch f. Kinderlieilk., Bd. xxi., S. 146. 3 Prag. Zeitschrift f. Heilk., 1885, S. 283. TUBERCULOSIS OF-THE NECK. 755 caseation in and about the nodules speedily ensues. Foci, central and peripheral, become fused until the entire gland capsule is tilled with a thick cheesy material resembling inspissated pus, but which primarily contains none of the pus formers. Not infrequently secondary infection by the latter occurs. Often the formation of an abscess leads the way to an abiding cure of a tubercular adenitis. When suppuration attacks a number of glands, extensive peri-adenitis generally results, and in consequence numerous fistulse leading to the glands are formed. Often the latter are found embedded in the abscess cavity, the glandular inflammation being overshadowed by the more extensive process in the surrounding tissues. In older subjects the process of caseation is of slow development, and may not occur at all. It is not uncommon to find tubercular glands as large as a hulled walnut or an egg, which though present for years show no trace of softening. Between these extremes of the rapidly caseatingand the hyperplastic tubercular adenitis, all grades are found, not only in different individuals but in one and the same. Some trivial, local, histological cause may induce caseation in more than half of an entire chain of lymphatics, while the remaining glands in the im- mediate vicinity are not similarly affected. As in tuberculosis of all forms, the hygienic and medicinal treatment of that of the cervical lymphatic glands merits much consideration. The preparations of iodine, iron, and cod-liver oil, have long been found useful, not through any specific effect, but because they are good tonics. In two cases, quite recently under my care, I observed an al- most total disappearance of the double row of glands, some of which had been softened, under the protracted use of creasote. While the tuberculin of Koch promised much for glandular as well as other forms of tuberculosis, it has been very largely discarded, though there are those who still use it in its modified forms, and in minimal doses, with claims of good results and of freedom from the dangers incident to its original mode of employment. When caseation has taken place within a gland capsule, an occasional success may follow iodoform injection. The old-fashioned collar or stock, to keep the parts at rest, may some- times be used with advantage. There is a large number of cases in which, despite local and systemic therapy, the condition remains unchanged, or progresses in regard to the number of glands involved and the tendency to early caseation. Certain is it that in these the operation of complete excision rests on sound surgical principle. While but few of the glands are involved and the peri-glandular structures are free, the operation is simple in the extreme, and with proper precautions is devoid of danger, Lindenbaum 1 reporting 91 operations without a death. The two sides of the neck may be operated on at separate sittings, and practically all the deep-seated lymphatics may be removed. The remaining cicatrices, though they may extend from ear to sternum, are linear, and far less disfiguring than those resulting from spontaneous cure after prolonged suppuration. Nor can the operation be said to be especially difficult when the entire chain of the deep-seated lymphatics is involved, unless extensive sinuses or widespread infiltration of peri-glandular tissues exists. To shell out one gland after another until it is believed that all are removed, use- 1 Centralbl. f. Chir., 1891, S. 857. 756 INJURIES AND DISEASES OF THE NECK. lessly prolongs the operation and enhances its difficulties. By an inci- sion extending from above the uppermost to a point below the lower- most gland, the entire anterior surface of the chain should be freely ex- posed before any attempt to remove a gland is made. With a small four-pronged hook the uppermost gland is then drawn into the wound, the air penetrates the loose connective tissue behind it, and with a little traction on the hook, and here and there the division of a few fibres with the scissors, it is lifted from its bed. If possible, the con- nection of the gland with that below it should not be divided. Trac- tion on this interglandular tissue exposes the next gland, which in turn is seized with the sharp hook and drawn forward, and thus the way is prepared for seizure of the next gland underneath. In this manner, by an incision made from mastoid process to clavicle, I have within three years, in eleven operations, removed the entire chain of deep- seated lymphatics from one or both sides in a surprisingly short time without either death or serious complication. The hemorrhage while the glands are movable is not profuse, and is easily controlled by pres- sure forceps or by ligature. In one of my cases the internal jugular vein was wounded. In 128 cases reported from Billroth’s clinic by Frankel the jugular had to be tied in 16. A danger not to be overlooked in the operation on the parotid lym- phatics, is the division of the facial nerve. This followed an operation by one of my assistants at the Cincinnati Hospital. The patient was a mulatto child of six, from whom I had removed the entire chain from the right side of the neck at a previous operation. The paralysis while complete was of comparatively short duration. Frankel observed facial paresis after 18 operations, but in only 6 was it permanent. In 104 cases operated on in Lucke’s clinic paralysis ensued in four. In two of these it soon disappeared, but in two it continued three years subsequently.1 The difficulties and the perils of the operation are increased, not so much with the number of glands involved, as with the extent of the periglandular infiltration. When suppuration has taken place in and about many of the glands, the operation may become, from adhesion to important veins and nerve trunks, quite formidable. Indeed, at times it may be wiser to leave part of a suppurating gland than to incur the risks of complete extirpation. After thorough curetting it may be safely left to granulate under an iodoform gauze tampon, while the remainder of the wound is closed by sutures in the usual way. In my judgment no part of a caseating tubercular gland ought ever to be buried in a closed wound. To do so would expose the patient to all the dangers of auto-infection of contiguous tissues which were incident to the older methods of removing the caseous foci with a curette, leav- ing apparently healthy gland tissue and capsule as infallible sources of re-infection. When cervical adeno-tuberculosis is associated with tuberculosis else- where, an operation is contra-indicated, as it is also in the acute forms of the disease in which high temperature and rapid extension downward indicate a malignant type. Nor should an operation be counselled in the very young. Fortunately, according to the observations of Schnell,2 Haehl,3 Kish, Lebert, and others, the majority of cases are 1 Haehl, Zeitsclir. f. Chir., Bd. xxxv., S. 392. 2 Erfolge von Extirpation tuberculoser Lymphoma. Bonn, 1885. 3 Loc. cit. LEUK2EMIA AND PSEUDO-LEUKAEMIA. 757 encountered between the ages of six and twenty, and at a time of life when even extensive operations are safely borne. * The measure of success following the operation is determined by the time at which it is done. Even without selection of specially favorable cases, ex- tirpation is followed by most gratifying immediate and final results. When suppuration has been absent before the operation, the wound is permanently healed in from two to three weeks. Local return after a period of three or more years occurs in less than ten per cent, of these cases, and reappearance of the disease elsewhere in only four per cent. In from fifty-seven to seventy per cent, of all cases the operation is followed by complete and permanent recovery. Leukaemia and Pseudo-Leukasmia Closely allied in their early manifestations to tuberculosis are the true lymphomata of glandular leukaemia and of malignant multiple lymphoma, commonly known as Hodg- kin’s disease, or malignant lympho- sarcoma. Both affections develop with predilection in the cervical glands, both superficial and deep, and with greater or less rapidity involve the lymph glands of the axilla and groin, and the deep-seated glands of the trunk. Both diseases occur chiefly in the young, but may occur in adults or even in the old. (Fig. 1715.) There is profound disturbance of nutrition in both forms of lymphoma. Common to both are the pale waxy skin, blanched mucous membranes, systolic heart murmur, great weak- ness, dropsy, and tendency to hemor- rhage. The differentiating feature is the great increase in the number of white blood corpuscles in the simple, and the absence of such increase in the malignant type of the disease. A mi- croscopic count of the blood corpuscles infallibly determines the nature of the lymphoma. The malignancy of Hodg- kin’s disease is further made manifest by secondary deposits, chiefly in the lungs, spleen, liver, and kidneys. The leuksemic variety is rarely associated with like changes in the spleen. According to Winiwarter and Hutchinson, Hodgkin’s disease may develop rather suddenly in an individ- ual who has had indolent glandular tumors localized in the neck or axilla for a long time, possibly for years. Quite often the accession of Fig. 1715. Malignant, Lymphoma of Two Years’ Duration in a Man of Seventy. 758 INJURIES AND DISEASES OF THE NECK. disease in new chains of glands is attended by febrile exacerbations. Clinically, therefore, there is reason for the belief that the disease is of microbic origin, and that the infection of the glands proceeds through the blood-vessels. Glands far removed from each other are often simultaneously enlarged, while those belonging to a chain of which one is already infected may remain normal. Usually the enlargement at- tacks groups of glands in relation with the larger arterial trunks. The glandular tumor always presents a uniform surface. It may be soft, almost to the point of fluctuation, or firm and elastic, like cartilage. The attempt to divide malignant lymphadenoma into a firm and soft variety has been made, but without reason, since it is not unusual for both forms of tumor to be present in one chain of glands. Though a false fluctuation may be present, the tumor never disintegrates, nor does it through peri-adenitis form adhesions to the integument. Whether hard or soft it is always freely movable underneath its cov- erings, and it forms no attachment to glands in its vicinity. The glands can be moved on and about each other with perfect freedom. Attention to these characteristics marks this disease from tuberculosis, with which it most readily may be confounded. The course of this disease is toward a fatal issue in periods varying from one to five years. In the case of a young girl, recently observed, death resulted in a little less than eight months from the appearance of the first glandular swelling in the neck. According to Hutchinson and others, the disease may remain latent in one or two glands for a number of years, and then without any known cause become quickly generalized. W7lien the diagnosis can be made early, extirpation may prevent extension of the disease. In advanced cases surgical interfer- ence can only be harmful, unless it be made to relieve urgent pressure- symptoms on the part of the trachea or oesophagus. Lympho-Sarcoma of the Neck. Distinct from the disease just considered is the sarcoma which de- velops and remains localized in one of the glands of the neck, usually a deep-seated one in connection with the surface or within the sheath of the large vessels. It presents the pathological changes and clinical tendencies of sarcomas elsewhere. Round or spindle-celled in charac- ter, the tumor is first distinctly encapsulated within the gland. In its growth it involves muscles, nerves, skin, and blood-vessels, and not infrequently perforates the larger veins. Early metastases are there- fore sometimes observed in lungs, liver, or spleen. As the tumor approaches the surface, the superficial veins are dilated. The skin assumes a bluish tint and glistening appearance. With the formation of adhesions its nutrition is impaired. It becomes thinner and thinner and finally ulcerates. With the repressing influ- ence of the skin lost, the tumor grows rapidly beyond the general level of the integument, and often assumes a cauliflower form. Whether protruding or not, the exposed surface yields a sanguinolent discharge, always offensive and often largely formed of blood. With or without traumatism, hemorrhages both profuse and recurrent greatly reduce the patient. Purulent infection often is added to the condition and aids not a little in expediting the fatal termination. CARCINOMA OF THE NECK. 759 From their attachment to the vascular sheaths these tumors often receive an imparted pulsation. Almost invariably the attachment is to the jugular rather than to the carotid, probably on account of the greater resistance offered by the firmer coats of the latter to the ad- vancing neoplasm. In its growth the tumor disturbs the anatomical relations of vein and artery, so that it sometimes happens, as in a case operated on by myself, that an inch or more of the vein is excised with the tumor while the artery is not seen in the wound. A further reason for this more frequent involvement of the vein must be sought in the fact that many of these tumors, as Langenbeck first pointed out, develop from or in the vascular sheath, either from the minute lymph nodes or from the firm connective tissue found within. Since all lymphatic tissues are in relation rather to the venous than to the ar- terial trunks, these growths primarily attach themselves to the former. Rarer than the lympho-sarcoma are the fascial sarcomata springing from the deep-seated fascia of the neck. They appear principally about the root of the neck in the supraclavicular fossge or in front of the tra- chea. They are of firmer consistence, contain less of the round-celled elements than the lympho-sarcoma, and develop no tendency toward metastasis. In point of recurrence in loco they are very malignant. But most malignant of the sarcomata of the neck is the melanotic variety, which at times develops primarily in the skin or lymphatic glands of the part. \rirchow reports a case of this kind, and Diettrich 1 several years ago collected ten cases in only one of which did the patient die of an intercurrent disease. The operations were followed by recur- currence in from two weeks to four months. When death followed the operation, secondary deposits were as a rule encountered in the viscera of the trunk. It is therefore doubtful whether, when the diagnosis can be made, operative interference is justified. When, however, melano- sarcoma has developed in a gland it may be impossible to recognize it prior to operation.2 Carcinoma of the Neck. Primary malignant neoplasms of epithelial origin are rare in the neck. They are often encountered in the cervical glands, secondary to primary disease in the tongue, lip, fauces, oesophagus, or mamma. It may be claimed that primary carcinoma never develops in lym- phatic glands. As elsewhere, epithelioma may develop primarily in the integument from a wart, a syphilitic or tubercular ulcer, or the scar of a burn. At times primary malignant disease of the pharynx or thyroid gland will involve the neck in its growth toward the integument. In 1882 Volkmann 3 first described three cases of deep-seated primary cervical carcinoma which he believed sprang from retained epithelial vestiges of the branchial clefts, quiescent through many years, until stimulated by some unknown cause to the hetero-plastic cell prolifera- tion of carcinoma. Konig4 has seen a number of such cases. Others have been described by Samter,5 Richard,6 and Gussenbauer.7 They 1 Archiv f. klin. Chirurg., Bd. xxxv., S. 292. 2 Settegast, Ibid., Bd. xxiv., S. 692. 4Lehrbuch d. spec. Chir., Bd. i. 6 Beit. z. klin. Chir., 1887, S. 165. 3 Central!)], f. Chir., 1882, S. 49. 5 Virchow’s Archiv, Bd cxii., S. 70. 7 Centralbl. f. Chir., 1898, S. 807. 760 INJURIES AND DISEASES OF THE NECK develop by preference in males between fifty and sixty. These cervical carcinomata first ap- pear between the hyoid bone and larynx on the one hand and the vascular trunks on the other, often as tumors of stony hardness. Even when the growth has attained large di- mensions, the integument and pharyngeal wall can be freely moved over its surface. A section from the tumor is at this time like that from a can- cerous mamma. When retro- grade changes and the soften- ing incident thereto have oc- curred, the tumor may be converted into an irregular fluctuating mass of large di- mensions, widely separating the air-passages from the blood-vessels and extending, as in the first of Volkmann’s cases, quite to the base of the skull. Figs. 1716 and 1717 are from drawings made by Dr. De Beck of a case operated on in 1884 at the Good Samaritan Hospital, in which more than an inch of the inter- nal jugular vein was removed. The patient succumbed to recurrence eight months after the operation. Microscopic examination revealed the epithelial character of the growth. The stroma consisted of firm fibrous bands. In the three cases reported by Volkmann, death from secondary hemorrhage followed soon after the operation. The secondary carcinomata of the neck are the result of direct in- fection from primary dis- ease of the lips, tongue, fauces, air - passages, or mamma. The predilection of this disease for the region of the oral cavity explainer the greater frequency of carcinoma of the neck in the submaxillary triangle. The lymphatic glands are first involved. For a time they appear as distinct tu- mors, freely movable on each other and without at- tachments. Afterward a peri-adenitis ensues, prob- ably from added purulent infection. Glands, mus- Fig. 171G. Carcinoma of Neck. Fig. 1717. Carcinoma of Neck. CYSTS OF THE XECIv. 761 cles, fasciae, and integument are welded together in a mass of leathery firmness. Softening occurs at one or more places, and from the result- ing ulcers or sinuses issues a characteristic fetid discharge. In carci- noma of the breast the implication of the cervical lymphatics may pre- cede that of the axillary. Cysts of the Neck. Within solid growths of the neck of epithelial, connective-tissue, or glandular origin, cysts often develop. Aside from those which are secondary, there are many tumors in which from the very beginning the characteristics of a primary cyst are present, that is, a well- defined investing membrane lined with one or more layers of cells, and more or less fluid contents. Thanks to the labors of Hawkins, Voille- mier, Roser, Schede, Madelung, Wagner, Lannelongue, and others, a division of cervical cysts according to their etiological development is now feasible. They may be divided into: (1) Cystic enlargements of bursae, or hygromata. (2) Branchial cysts. (3) Lymphatic. (4) Sanguineous. (5) Hydatid. t Hygroma.—In the mid-line of the neck, in relation with the hyoid bone and thyroid cartilage, are a number of true bursae to facilitate the movements of the larynx and the play of the muscles above. These are the bursa subhyoidea, the bursa prethyroidea, and the bursa supra- hyoidea. The bursa subhyoidea (Boyer), present in all subjects and larger in men than in women, is situated beneath the hyoid bone and the muscles attached to it from below, and in front of the thyro-byoid membrane. The bursa prethyroidea, often absent, and present as a well-developed bursa only in old male subjects, is found between the deep fascia and the incisure of the thyroid cartilage. Corsen 1 found it present six times in twenty-five subjects. In five children examined it was altogether absent. The bursa suprahyoidea (Verneuil) lies between the upper surface of the hyoid bone and the insertion of the genio-hyoid muscles. This bursa is not often found, and when present is prone to hygromatous change (Gruber). Enlargement of these bursae, appearing in frequency according to their order given, manifests itself by a median swelling rarely exceeding a walnut in size, though Gruber describes one of the suprahyoid bursa as large as an orange. Globular in shape, often densely filled, and always attached to and moving with the underlying structures, they present a uniform surface, and when not inflamed cause no distress. Spontaneous rupture or imperfect removal gives vent to the bursal contents, which are clear, of yellowish tint, and very viscid. A tubercular character has not yet been recognized for the cervical hygromata. While the bursal sac remains, a cure is never effected. There remains a long fistulous track, which can be felt as a firm cord underneath the integument and from which mucoid discharge continues indefinitely. For the relief of cervical hygromata a simple incision rarely does more than establish the obnoxious condition just described. In exceptional 1 Corsen : De la Burse pretliyroide (Thtise), 1877. (Quoted by Koenig.) 762 INJURIES AND DISEASES OF THE NECK. cases tapping, with subsequent injection of tincture of iodine, has been followed by cure. Complete excision is the only radical measure of relief. When a fistulous track is all that remains of the bursa, thorough curetting should be resorted to. In one of three cases which I have seen, this treatment was followed by permanent closure. In the event of its failure, complete excision of the fistulous track must be attempted. It should be borne in mind that the subhyoidean bursa is frequently bilocular, and that the fistulous track at its upper end may be bifid, the branches turning away from the mid-line beneath the hyoid bone. Branchial Cysts.—Closely allied to the congenital cervical fistulse described in Sir George Macleod’s article are the cysts which since Poser’s observations are generally denominated branchial. Schede found a cer- vical fistula in one and a branchial cyst in the other of twins. The lateral walls of the pharynx, in the first month of foetal life, are formed on each side by four arches, decreasing in size from above downward and having between them furrows which, according to recent investi- gations of His and Ivolliker, are generally kept from being fissures by a very delicate obturator membrane destined to separate the epiblastic and hypoblastic epithelia. With the exception of the first, from which the auditory meatus, tympanum, and Eustachian tube are formed, the branchial furrows are obliterated by the end of the eighth week. On the one hand imperfect obliteration may give rise to a branchial fistula. Retention, on the other hand, of epiblastic or hypoblastic epithelium beneath the integument, forms the matrix for the formation, early in life or under the developmental activitj7 of the period of puberty, of cysts which bear certain fixed anatomical relations. Although in very rare instances they may occupy the median line, they generally occupy a lateral position, being deep-seated, between the angle of the jaw and the lower border of the larynx. In rarer instances they occupy a lower position in the neck. Since the styloid processes, stylo-hyoid ligament, and greater and lesser horns of the hyoid bone are formed from the branchial plates, these cysts often have more or less firm attachments to the parts named. Primary or secondary adhesions are likewise formed to the sheath of the large vessels of the neck. Particularly when punctures or irritant injections have been resorted to, these adhesions may be firm. They affect chiefly the jugular vein, which more than the artery is exposed to injury in extirpation of the sac. Langenbeck has seen a branchial cyst project into the pharynx. When developed above the hyoid bone, the tumor often projects into the floor of the mouth. Many cases of ranula occurring in the young are doubtless branchial in origin. Externally, branchial cysts are covered by the deep fascia and the sterno-mastoid muscle. Anatomi- cally they are unilocular, but may present a bilobed appearance when indented by a muscular or fascial band. The sac itself consists of thin connective tissue, and may be quite vascular. Forming the inner- most layer of the sac-wall is a layer of pavement or columnar epithe- lium, or both. The thickness of the wall of the sac and of its epithelial strata is directly proportionate to the density of its contents. These may be mucoid, serous, or sanguineous, of the caseous character of an atheroma, or identical with those of a true dermoid. In the latter case CYSTS OF THE NECK. 763 the sac-wall will posses all the elements of the cutis vera. The con- tents then for the most part consist of an epithelial detritus. Teeth are rarely found. In a number of cases the cyst has been found to be a true teratoma containing hair, teeth, and irregular masses of bone or cartilage, while in other cases isolated masses of cartilage have been found.1 When the cyst has for a long time remained latent, its contents may become oleaginous.2 In the serous cysts they may be perfectly limpid, and, the cyst-wall ordinarily being very thin, the tumor may Fig. 1718. Branchial Cysts. appear translucent (hydrocele of the neck). The cysts illustrated in Fig. 1718 contained a clear watery fluid, a few flat epithelial cells, cholesterin crystals, and a trace of albumin. Anatomically these cysts are benign, but cases have been recorded in which, from proliferation of the glandular element of the cyst-wall, a malignant element has been added. Samter3 recently reported a case of this nature in which local recurrence and metastases in the abdomen caused death. Hemorrhage into a serous branchial cyst not infrequently occurs, 1 Buttersack, Virchow’s Archiv, Bd. cvi., 8. 206. 2 Malherbe, Bull, de la Soc. Chir., 1878, p. 257. 3 Virchow’s Archiv, Bd. cxii., S. 70. 764 INJUKIES AXD DISEASES OF THE HECK. thereby changing it into a sanguineous cyst. Cysts which at their first tapping yield a limpid fluid often at subsequent explorations have be- come sanguineous. Coagulation of the blood does not take place. In a few cases the cysts communicate with one of the larger veins by a vessel of considerable calibre. It must always remain a question whether such cysts are branchial or of the primary sanguineous char- acter described below. Although branchial cysts are clearly abnormal developments of rudi- mentary epithelia, and therefore in a pathological sense are always con- genital, they are not as a rule present at birth. Nearly sixty per cent, appear between the tenth and thirtieth years. The first decade of life furnishes about sixteen per cent, of the cases, but no age is exempt.1 Women are oftener than men the subjects of branchial cysts, and the left side appears to be oftener affected than the right. Development, usually slow in the dermoid forms, may be very rapid in the serous. The case presented in Fig. 0004 was of less than four weeks’ growth. To attain the size of a fist, from one to three years are ordinarily required, during which long periods of quiescence may be observed. Except from their pressure-effects branchial cysts produce no symptoms. When developing toward the floor of the mouth they give rise to great distress by pressure on the tongue. When devel- oped near the hyoid bone their grow7th is downward and toward the surface. In the few cysts observed above the clavicle, the pressure effects have likewise been little marked. Branchial cysts are perfectly outlined, soft, fluctuating, and free from pulsation except that which may be imparted from the underlying carotid. The integument, fascia, and muscles overlying them can be freely moved upon them, and they in turn to a much less extent on the tissues underneath. When there are attachments to vascular sheaths lateral movements are possible, while those in the line of the axis of the body are altogether abrogated. The progress of branchial cysts is altogether benign, though chronic. Rupture may take place spontaneously or may follow suppuration in- duced by injections or tapping. Such an accident generally leaves a very obstinate fistula, the occasional closure of which will probably entail a reproduction of the cystic tumor. Treatment.—The rational treatment of branchial cysts is the radical one of total extirpation. The difficulties encountered are in the rupture of the sac before the operation is completed, and in separating adhesions to the larger veins. The former accident may generally be avoided by keeping the knife well without the sac-wall, and by making the first incision of sufficient length. In almost every case it will be necessary to dissect the cyst from the vascular sheath. The internal jugular vein may be wounded at this stage of the operation, necessitating a lateral ligature, or division of the vein between two ligatures. When total ex- tirpation is not feasible, what constitutes the attached base of the sac may be deprived of its epithelium by curetting, and then left in situ. Other methods of treatment are tapping, injection of iodine, aseptic drainage, and partial resection with packing of the wound. In excep- tional cases, as in young children, one or other of these methods may be tried. It may be said of them all that in their end results they are un- 1 Schede, Arch. f. klin. Chir., Bd. cxiv., 8. 1. CYSTS OF THE NECK. 765 certain, and quite as dangerous as extirpation. When they have been tried and have failed, subsequent extirpation is rendered far more difficult. Lymphatic Cysts.—These have been briefly described in a previous volume of this work 1 under the heading of compound congenital cysts. They may be unilocular or multilocular. When the cyst is single, it may be impossible to distinguish it from one of branchial origin if found in the anatomical position of the latter. The lymphatic cysts are found in any part of the circumference of the neck, immediately underneath and involving the integument, or sub-fascial and in their growth displacing muscles, vessels, and nerves, or invading the former. A favorite site is the nucha, the cyst then resting on the cervical spine, which divides it into symmetrical halves. When occupying the front of the neck, the processes of the cyst may project into the floor of the mouth, involve the base of the tongue, and extend over the maxillary border to the face, but never, according to Lannelongue, beyond the line joining the labial commissure and the auditory meatus. In their downward growth the compound cysts may involve the mediastinum. The contents of these cysts are ordinarily clear and limpid, containing a few leucocytes and a marked proportion of albumin, from four to eleven per cent. The larger blood-vessels which are found within the cyst-wall may through rupture change the character of the contents of some of the cysts. A number of theories has been advanced as to the primary source of these congenital cysts. Since the investigations of Wegner,2 Middle- dorf,3 and Lannelongue, it is quite certain that these tumors spring from aberrations of the lymphatic vessels, and that they may be re- garded as cavernous lymphangeiomata. They are often associated with other lesions of the lymphatics, such as macroglossia or macrocheilia. After spontaneous rupture or operative interference long-continued lymphorrhagia has been observed. In very exceptional cases cystic lymphangeiomata have developed later in life. The symptoms produced are those from compression, and when the cysts are superficial they may be negative. In cases of extensive and deep-seated cysts, respiration and deglutition are interfered with to such an extent that death ensues within a few months of birth, from oedema of the glottis or from inanition generally. In a few cases, involving limited areas, spontaneous cure has followed rupture of the sac. The treatment of this condition must ordinarily be palliative. The radical treatment by extirpation is feasible in children only when the tumor is small. Should rapidity of growth or the effects of compression threaten the life of the child, multiple punctures may be resorted to with a view to the reduction of the tumor in size, and the definite oblitera- tion of a number of the cysts. The injection of irritating fluids, such as the tincture of iodine, may be resorted to in properly selected cases. The use of permanent drainage promises much in these cases, provided that wound infection can be avoided. In older children and in adults total extirpation is indicated, unless the necessary dissection would pass the limits of operative safety. 1 Vol. V., p. 200, supra. 3 Ibid., Bd. xxxi., S. 590. 2 Archiv f. klin. Chir., Bd. xx., S. 641. 766 INJURIES AND DISEASES OF THE NECK. Sanguineous Cysts.—A cyst containing blood may develop from an encapsulated hemorrhage, or from bleeding into a solid tumor or a cyst primarily serous and branchial. Other cysts are sanguineous from their inception, and owe their development to anomalies of the large venous trunks or lymphatics of the neck. Although they may be found in any part of the neck, these are generally in relation with the internal jugular or subclavian vein. In three out of eleven cases which have been carefully investigated by Franke1 and reported by Koch, Hueter, and Baiardi, the subclavian vein was not found in one, and the internal jugular in two of the remainder. In a larger number of instances the cyst is connected with one of the veins by a trunk of considerable diameter. In the patient from whom Fig. 1710 was obtained, the deep sur- face of the cyst was adherent to the internal jugular, and from its lower portion there ran to it a branch nearly an inch long and as large as the temporo-maxillary vein. In other cases the cyst ap- pears to be a varix which has be- come separated from the parent vein and stands in no relation with any large trunk. Its growth is not thereby interrupted since, ac- cording to Yirchow,2 it is fed by a number of small branches which empty into the sac. Anomalies of the venous and lymphatic vessels must account for yet other cases, since there may be in the same patient a number of small lymphatic cysts within the wall or just without the principal, sanguineous cyst. In the case above alluded to this condition was found. Four or five of these cysts, vary- ing in size from a pea to a hazelnut, were incised and discharged a clear serous fluid. Finally, an angeioma which is not in connection with any large vein may by absorption of its septa become converted into a san- guineous cyst. Bell:1 recognized this possibility, and reported such a case. In a youth of seventeen recently operated on at the Good Sama- ritan Hospital, a sub-fascial encapsulated angeioma of the submaxillary region, projecting into the floor of the mouth, consisted largely of a central cyst, the walls of which seemed formed of the remainder of the vascular growth. It had no connection with any large vessel. The cyst-wall, generally rather adherent to its surroundings, may measure from one-twentieth to one-sixth of an inch in thickness, and is rarely of equal thickness throughout. Within it the three coats of the vessel have been found.4 The internal surface varies in appear- Fig. 1719. Sanguineous Cyst of the Neck. 1 Deutscli. Zeit. f. Cliir., Bd. xxviii., S. 411. 2 Gescliwulstlelire, Bd. i., S. 154. 3 Principles of Surgery, vol. iii., p. 399. London, 1796. 4 Meyer, Centralbl. f. Cliir., Bd. Ixxxix., S. 663. CYSTS OF THE NECK. 767 ance. In a specimen obtained from a female aged thirty-four (Fig. 1720), some parts were smooth and glistening like the endocardium, while others presenied irregular elevations and trabeculae which tra- versed the cavity and were as large as, and very much like, the chordae tendinese. In other places the surface presented the appearance of an erectile tissue. A very distinct endothelial layer was found over most of the internal surface of the cyst. The contents of a primary sanguineous cyst are fluid, and as a rule not coagulable. According to Paget1 the blood which finds its way into a serous cyst is either partially or wholly coagulated, and more or less decolorized. Primary sanguineous cysts as a rule appear congenitally, or during the first decade of life, although they may appear at the other extreme. They are of slow growth and may for a long time remain stationary, or, on the other hand, they may in a few weeks assume enorm- ous proportions, rapidly extend- ing from mastoid process to clavicle. Disappearance of the tumor or decrease in size by com- pression can only be effected in a minority of cases. Even when at the operation large connecting veins have been found, the tumors have been irreducible. Only when deep-seated do they give rise to distressing symptoms by pressure on the pliarnyx or larynx, into which they have been known to rupture (Vincent,2 Savory).3 Af- ter puncture, these cysts refill very rapidly with blood. Even after aspiration of a serous cyst a threat- ening hemorrhage into the sac occurred in Mr. Birkett’s hands, and by recurring after each puncture produced extreme anaemia.4 The treatment of sanguineous cysts was until recently limited to tap- ping and the injection of irritating or coagulating fluids. Richardson 6 reports a case successfully treated by the injection of perchlorideof iron. This treatment is contra-indicated for cysts from which a connection with a venous trunk can be established by pressure, and since such a con- nection often exists without being demonstrable by so coarse a test, it is doubtful whether injection ought ever be practised. Acupuncture and electrolysis have likewise been resorted to with unsatisfactory re- sults. Aside from their uncertainty, the danger of sepsis from either of these methods is very considerable. Woerner0 has quite recently reported a death from the injection of iodine. The radical measure of total extirpation should be preferred to other procedures, unless the size of the growth or the age of the patient would make the operation more than ordinarily hazardous. In one of Volk- Fig. 1720. Sanguineous Cyst of the Neck. 1 Surg. Path., p. 413, 1870. 3 Lancet, Nov. 24, 1866. 4 Dublin Quart. Journ. Med. Sci., Nov., 1869. 2 Quoted by Paget, op. cit., p. 404. 4 Med.-Chir. Trans., vol. li. 6 Beitr. z. klin. Chir., Bd. i., H. iii. 768 INJURIES AND DISEASES OF THE NECK. mann’s cases the tumor extended to the base of the skull, and could not be removed. In other cases the cyst extends into the chest and is be- yond surgical intervention. Yolker has collected nine total extirpa- tions by German surgeons. I have performed the operation in three cases, without any untoward symptom at the time of excision and without subsequent complication. Hydatid Cysts.—Hydatid cysts of the neck are rare. In 1882 Rie- del could collect but fifteen cases. They were uniformly developed in the side of the neck between the mastoid process and the clavicle, and in relation with the large blood-vessels. Although the hydatid cyst may be superficial, it generally has a deep origin and grows toward the surface. In its progress it may entail much destruction of tissue. When the cyst is superficial and thin-walled it may be translucent, but when deep-seated even fluctuation may be indistinct. In not a few cases suppuration of the cyst has caused it to be taken for an abscess. The removal by puncture of the characteristic fluid of a hy- datid and of its booklets, determines the diagnosis. The treatment of a hydatid must aim at its destruction, which is best accomplished by free incision and drainage. The consequent suppura- tion, which in itself is curative, must be restricted. While primary enucleation of the sac may at times be successful, surgeons familiar with the disease do not recommend this as a practice to be adopted in many cases. Surgical Affections of the Thyroid Gland. Thyroiditis.—A vascular engorgement of the thyroid gland is often seen with menstruation, during pregnancy, and in young girls while the menstrual function is being established. In the latter the swell- ing is at times sufficient to constitute a form of acute goitre. Aside from the swelling and tenderness there are no evidences of inflamma- tion. The normal thyroid gland being enclosed in a firm capsule, hav- ing no excretory duct, and a low functional activity, is protected against the invasion of the organisms of inflammation unless intro- duced through its blood supply. True inflammations of the normal thyroid gland are therefore rare. In the goitrous gland the disease is more common. To designate this class of cases the term “Strumitis” is often used. With the exceptional facilities for observation offered in Switzerland, Lebert saw but nine cases. Thyroiditis is the result of infection from without or from within. Wounds of the gland, aspiration of cysts, interstitial injections with un- clean instruments, or extension by contiguity of morbid processes from larynx or trachea, are among the external causes. Infection of the gland from internal sources may occur during any of the acute infectious diseases. It has been observed after pneumonia, malaria, diphtheria, and relatively often after typhoid fever. In the puerperal state thyroid- itis may be the first and chief evidence of sepsis. As part of a pysemic process abscess of the thyroid has often been observed. Thyroiditis of rheumatic origin has been described by a number of authors. It may develop during the height of the articular disease, may precede, or may follow it. SURGICAL AFFECTIONS OF TIIE THYROID GLAND. 769 The previous existence of a goitre predisposes to inflammation of the gland. Lebert saw all of his cases in Zurich, where goitre is endemic, but none in Breslau. Ivocher 1 reports 24 cases of strumitis, in 11 of which aspiration, electrolysis, or interstitial injections had been prac- tised. In 6 of the remaining 13 cases some of the causes already men- tioned were found, and Kocher directs attention to mild catarrhal af- fections of the alimentary canal as predisposing to the disease in question. Of suppurative thyroiditis two cases have come under my observation; one acute, in a previously normal gland as a sequel of typhoid fever; the other chronic, and following the retention of the needle of a hypodermic syringe.2 Suppurative thyroiditis is always of microbic origin. Eleven cases examined in this regard showed the presence of eight different species of bacteria. Besides the ordinary pus formers found by Wolffler in 1883, the presence of the pneumococcus was demonstrated by Gerard and Marchant;3 of the bacterium coli commune by Brunner,1 and of the typhoid bacillus by Favel and Kummer.6 Non-suppurating thyroiditis may involve the entire gland, while the purulent form is generally limited to one lobe. Abscesses may be superficial or deep; single or multiple. In the latter cases intensely vascular gland tissue will be found between the foci. The tendency of thyroid abscesses is to point externally. Retention of pus beneath the cervical fascia sometimes leads to mediastinal inflammation. Perforation into the trachea is not very rare, but rupture into the oeso- phagus is less common. In fulminating cases of thyroiditis gangrene may develop, with retention of the gases of decomposition. Symptoms and Course.—The symptoms and course of thyroiditis are largely influenced by the cause, and by the previous state of the part. Developing in a hitherto normal gland, an inflammation of malarial, rheumatic, or typhoid origin is comparatively mild. Often inaugu- rated with a chill, the disease makes itself manifest through elevated temperature, rapid pulse, dry tongue, and anorexia. When, as is the rule in these cases, the entire gland is involved, a characteristic swelling appears in the place of the normal thyroid, on both sides and in front of the "trachea. The swelling may often be felt by palpation before the tumefaction becomes visible. In well-developed cases the tumor is as large as a peach, or a fist, and its lower border may then be beyond reach, extending below the sternal notch. The tumor, always tender, moves with the trachea. The overlying soft parts glide freely upon it. The size of the swelling determines the local symptoms, which are chiefly those of compression. Moderate dyspnoea from pressure on the trachea is common. There is usually some huskiness of voice or spasmodic cough from compression of the recurrent nerves. Pressure on the veins may produce a cyanosis of the neck and lower portion of the face. Epistaxis and haemoptysis have been observed. When the swelling is large, radiating pains may be felt in the course of the lower cervical nerves. The symptoms of compression are most marked in cases of strumitis proper. In the milder forms of the disease the conditions de- scribed are developed within from four days to a week; they remain ’Arch. f. klin. Cliir., Bd. xxiii., S. 113. 2 Annals of Surgery, October, 1894. 8 Cong. Chir. (France), 1891, p. 268. 4 Schweiz. Corresp.-Bl., 1892, Bd. xxii., S. 307. 5 Wien. med. Presse, 1891, Bd. xxxii., S. 1620. 770 INJUKIES AXD DISEASES OF THE NECK. stationary for another week and gradually subside. In rare instances a residuum of the vascular engorgement forms the basis of a goitre. When suppuration ensues, the general and local phenomena are those of suppuration elsewhere. The rapidity with which the presence of pus is manifested varies within wide limits. In the acutest forms agglutination of the overlying soft parts and perforation of the capsule ensue in from two to three weeks. Sloughing of the gland from excess of intra-capsular tension has been observed as early as the tenth day. When the “dosage” of infection has been slight, as from the use of unclean instruments, weeks and months may pass before the abscess perforates the capsule. Such cases may assume from their inception a subacute or even chronic course. The rapidity with which pus is evacuated also depends on the depth of the abscess. The ways in which it may travel have already been mentioned. The spontaneous or operative evacuation of the abscess speedily leads, as a rule, to permanent closure by the granulation process. In the more subacute cases, the capsule of the abscess, or that of an entire lobe thickened by prolonged vascularity, and the presence of flabby granulations within, may for a long time or indefinitely prevent heal- ing. There remains an obstinate fistula leading to the abscess, or if closure does ensue, retention with its usual concomitants follows. The prognosis of thyroiditis depends largely on its cause. Always of considerable gravity in suppurative cases, it becomes very grave as a complication of puerperal infection, pyaemia, or diphtheria. When suppuration develops in a goitre which by its size and attachments has compressed the trachea or blood-vessels, the increased pressure may speedily cause death. Other causes of a fatal issue are acute sepsis, hemorrhage, and exhaustion from prolonged suppuration. According to Lebert, suppuration ensues in over sixty per cent., and twenty-five per cent, of all cases are fatal. The treatment of thyroiditis in its beginning must he directed toward the prevention of suppuration. Internals, the salicylates and large doses of saline cathartics may be administered. Externally, leeches may cut short the attack, and Brieger reports cases of diphtheritic thy- roiditis thus aborted. The continued use of ice-bags may delay or even prevent suppuration. Kocher recommends the interstitial injection of carbolic acid. When pus is present operative interference is indicated. If the abscess is superficial, a free incision must be made and drainage secured. In deep-seated abscess aspiration may first be resorted to, lest the cutting through a thick wall of gland tissue should cause hem- orrhage which in the debilitated condition of the patient might prove fatal. Whether the abscess be superficial or deep, its evacuation will often be followed by bleeding profuse enough to demand tamponing the abscess cavity with gauze. When multiple abscesses exist they may generally be emptied through a single incision. In very acute cases suffocation may be threatened before an abscess has been formed. Tracheotomy must then be resorted to, and a cam nula of more than ordinary length must be employed. Excision of the abscess cavit\r, with the lobe of the gland in which it is contained, must occasionally be resorted to in chronic cases in which obstinate suppuration and recurrent hemorrhages threaten the life of the patient. SURGICAL AFFECTIONS OF THE THYROID GLAND. 771 Goitre.—This term has been and still is loosely used to designate all chronic enlargements of the thyroid gland. It should be, and in the following pages is, reserved for such enlargements as are primarily of epithelial origin, clinically benign, and except through their mechanical effects on contiguous parts devoid of serious consequences. Site.—Goitre may involve both lobes of the gland and the interven- ing isthmus. It may develop in one or other lobe, in the isthmus alone, or in an accessory lobule. Recent investigations into the de- velopment of the normal gland have shown that accessory lobules are often found, and that they vary in size from a lentil to a bean. The limits of their distribution are the mandible above and the aortic arch below, on either side of the sterno-mastoid muscles. Posteriorly they have been found between the trachea and gullet, and even be- hind the latter. Such accessory lobules are generally situated in close relationship to the normal position of the body of the gland, and are often connected with it. They are continued downward, toward or be- hind the sternum, in contact with the vascular and nervous trunks of the root of the neck. Through abnormal development, the gland may completely surround the trachea and form a partial or complete canal for the passage of the oesophagus. On the other hand, the accessory lobules may have severed all bonds and exist as independent islets of glandular tissue, far removed from the parent gland. Their existence accounts for the presence in rare cases of intra-laryngeal and sublingual growths of typical thyroid structure. Gruber and Madelung have at- tempted to divide these accessory glands into certain groups. To their presence is due the atypical situation of some goitrous tumors, and they modify the form of enlargements of the body of the gland. Pathology.—The normal thyroid is a lobulated gland contained with- in a vascular and fibrous capsule, from which connective-tissue septa penetrate the interior and separate the lobules from each other. The latter consist of the ultimate granules imbedded in a stroma of inter- stitial connective tissue, derived from the capsule of the gland. The granular follicle is a minute globular sac of basement membrane, lined and filled with nucleated cells of gland type. In the adult gland the centre of the follicle generally contains a deposit of gelatinous or colloid material. In addition to the elements contained within the follicles, Wolffler has found vestiges of epithelial embryonal cells in the stroma, between the acini of the gland, and believes that when stimulated to exuberant growth these masses of latent cells are productive of goitre. This view of Wolffler on the histogenesis of goitre has not, however, found general acceptance, and until further proof thereof is adduced, the doctrine of the intra-follicular origin of struma, as particularly enunciated by Virchow, may properly be retained. Every goitre is primarily epithelial, and the varieties are due to secondary changes consequent on cell metamorphosis, connective-tissue sclerosis, vas- cular hyperplasia, and hemorrhages. The shape, size, consistence, and surface appearance, in brief the clinical phenomena of a goitre, are determined by the variety to which it belongs, as is also the ques- tion of operative interference. Varieties.—(1) Follicular Goitre; Struma Hyperplastica Follicu- laris et Parencliymatosa.—This represents a growth of moderate dimen- sions. It is generally diffused throughout the entire gland or one of its 772 INJURIES AND DISEASES OF THE NECK. lobes; it is soft, often slightly lobulated, presenting to the touch islands of greater resistance within. On section it resembles macroscopically the normal thyroid tissue. This follicular goitre is essentially a prolifera- tion of the follicular cell elements, whereby the follicles themselves are enlarged and their number increased. Irregularity in the growth of the cell masses causes nodular or cord-like excrescences from the parent follicle, from which in their further development they become entirely separated. Stimulated to activity by the cell proliferation, the inter- stitial connective tissue provides a capsule for these isolated masses. New and larger follicles are thus produced. Irregularities in the growth of the new cell masses and follicles, the limitation of the pro- cess to one part of the gland, and the difference in age of the new formed tissue, will give a nodulated appearance to the follicular goitre. Whether single or multiple, the presence of the nodules of soft consis- tence is of sufficient clinical importance to warrant for follicular goitres containing them the term nodular goitre, or struma nodosa. The follicular goitre may continue as such indefinitely. As a rule, however, the follicular hyperplasia is followed by secondary changes in the stroma, the vascular supply, or the follicular cell elements them- selves, thus giving rise to further varieties of the disease. (2) Fibrous Goitre.—Responsive to the irritation of the proliferating follicles, the connective tissue of the follicular walls and of the stroma participates in the hyperplasia. The development of new interstitial tissue may proceed rapidly until the goitre is pervaded by fine inelastic masses of fibrous tissue. In places the follicular element is entirely supplanted by hard fibrous nodes, varying in size, of white or yellowish color, creaking under the knife, almost devoid of blood-vessels, and on section resembling the structure of the semilunar cartilages, and quite as firm. Hence the name formerly given of scirrhous or cartilaginous goitre. The sclerotic masses vary greatly in size and in number. From the size of a filbert they may grow to that of a hen’s egg. When single, they send fibrous prolongations toward the periphery; when multiple the}7 are joined together by similar bands. The fibrous node is often surrounded by a layer of proliferating vascular gland tissue. The fibrous goitre is generally nodular, limited to one or other lobe, or to part thereof, and by itself does not give rise to a tumor of large size. Occasionally, however, sclerosis of the entire gland is followed by dire results through compression of the trachea, although the goitre itself may appear quite small. (3) Vascular Goitre.—The influence of vascular engorgement on the size of the thyroid gland is manifested in certain physiological states, such as menstruation, sexual excitement, and pregnancy. An increase in the number and volume of its blood-vessels belongs to every goitre. It is only when there is a preponderance of vessels over glandular growth that the term vascular is applicable. The increase in the number and size of the vessels may affect the arteries or the veins. Following the lead of Virchow, writers speak of an arterial or aneu- rismal goitre, and of a venous or varicose goitre. In the former the arteries are uniformly dilated and their anastomotic branches greatly increased in number. There is no tendency to the formation of saccular dilatations. The vessels involved are chiefly those displayed on the SURGICAL AFFECTIOXS OF THE THYROID GLAND. 773 capsule of the gland, and those just within. They are elongated, assume a tortuous course, and very often present a corkscrew-like arrangement where they enter the parenchyma of the gland. In ex- treme cases the vascular condition resembles that of a cirsoid aneurism. It may be congenital (Haidenliain), or may form the important ele- ment of a goitre of adult life. The varicose goitre is more common than the variety just described. It affects the intra-capsular as well as the extra-capsular veins. In the soft nodular masses of the follicular goitre, irregular dilatations in the periphery of the nodules are far from common. As sources of hemor- rhage into, and consequent sudden enlargement of, the goitre, these dilated veins and the ampullar pouches connected with them are im- portant factors. It is, however, in the peripheral veins that the vari- cose condition is most marked. Here the vessels appear as sinuses, often as large as a pencil or the finger, winding in their course, and displaying numerous diverticula of varied form and size. Such vari- cosities are mostly observed in large goitres of long duration. (4) Colloid and Cystic Goitre.—This form of goitre follows a colloid degeneration of the epithelial cells of the follicles. It generally attains large dimensions. On section the gland presents one or more large cavities filled with a thick, gummy, yellowish, jelly-like material, re- moved with difficulty, and rich in albumin and sodic and kalic chlor- ides. Before extensive colloid changes have ensued the primary glan- dular structure is retained, the lobules appearing larger and containing within their centres a gelatinous mass. Even in larger cavities ves- tiges of cylindrical cells are to be detected. Similar masses of unchanged cells are often found within the gelatinous material, by proliferation of solid cell masses from peripheral layers. In this way smaller cysts are often formed within the larger. Primarily as large as a lentil, the gelatinous masses increase in size with the degeneration of the new- formed cells. The inter-acinous stroma and its blood-vessels atrophy from pressure, and thus contiguous cysts are fused. Through repetition of this process the number of cysts in the goitre may be reduced until only one large cyst remains, which by the imperfect septa within dis- closes its origin from many. The metamorphosis of some of the epithelial cells results in choles- terin production. This is often extensive enough to give the cyst con- tents a sebaceous character. Through deposit of lime salts they are in rare cases converted into calculi. The contents of large cysts often present a grumous appearance, of chocolate or even darker color, from the admixture of blood. The hemorrhages may result from the ero- sion by pressure of a varicose vein, from trauma, or as the result of a puncture. If the bleeding is abundant coagulation may follow, but otherwise the blood is diffused throughout the gelatinous material, causing it to resemble very closely the grumous contents of an ova- rian cyst. While from the foregoing account it is seen that colloid degeneration leads to cyst formation, a cystic goitre may develop in another way. Without the formation of colloid, an accumulation of an albuminous fluid occurs within the follicles, the cells undergoing usually a fatty degeneration. The single follicles increase in size, the connective tis- sue walls atrophy as above described, and many small cysts become 774 INJURIES AND DISEASES OF THE NECK. confluent. The increase in size is not altogether dependent on fusion,, the cyst wall itself yielding a copious serous transudation. After evacu- ation of a cyst by puncture it may refill within a few hours or days, and in this way the rapid growth of some goitres is explained. In the cystic goitre here described the contents, if unchanged, are aqueous, clear, highly albuminous, and slightly yellowish or greenish in color, much resembling the fluid of a hydrocele. Large and thin-walled cystic goitres are therefore translucent if the cysts are superficial and their contents unchanged. Gelatinous and cystic goitres are usu- ally large, and often are pendulous masses extending to the root of the neck, or over the sternum, to the line of the nipple or as low as the abdo- men. According to the number of cysts, the tumor presents a smooth or lobulated surface. The varieties of goitre described are those ordinarily encountered, and in small tumors they exist separately. In those of many years’ standing, however, there is often an admixture of the various secondary changes, giving to the mass, on section, a great diversity in appear- ance. While one form may and usually does predominate, the others are represented. Surrounding the glandular or fibrous nodules, and the cysts of various form, is a layer of connective tissue called the capsule of the goitre. This is separate and distinct from the capsule proper of the gland, with which in superficial nodules it may become partly fused. On the outer surface of the capsule there is often, even in comparatively superficial nodules, an atrophied layer of gland tissue. As the capsule grows in thickness it becomes poor in blood-vessels. In very rare instances it is so extensively infiltrated with salts as to resemble osseous tissue. Ac- cording to Virchow 1 true bone is never found in the goitrous capsule. In justice to the extensive researches on the pathology of goitre made by Wolffler, and above alluded to, I append the varieties of goitre as given by him in his most recent publication.2 (a) Hypertrophy of the thyroid gland, present at birth and develop- ing at puberty or during pregnane)7, uniformly enlarging the entire gland. It is smooth on the surface. There are no nodules within. The normal contour of the gland is retained. Tumor is soft, and if very vascular, compressible. (h) Vascnlar goitre, purely a clinical name, depending on the num- ber of the vessels and in no relation to the glandular element. This goitre can often be emptied like a sponge. It pulsates visibly, vascular bruits are audible, and a thrill can often be felt. (c) Foetal Adenoma.—This is represented by a circumscribed tumor existing from birth or puberty. It is generally firm in consistence and movable, and often the tumors are multiple. (id) Adenoma gelatinosa, or colloid goitre, often develops late in life, and appears as a soft, nodular, more or less fluctuating tumor of very slow growth. Occasionally the colloid material increases fast. Thence the cystic goitre. Etiology.—The main data are given in Sir G. Macleod’s article.3 It should be added that the disease preponderates in women. Lay cock found only 26 men affected in 551 cases, and Baillarger has tabulated 1 Krankli. Gescliw.. Bd. iii., S. 41. 2 Arch. f. klin. Chir., Bd. xl., S. 171. 3 Vol. V., p. 204, supra. SURGICAL AFFECTIONS OF THE THYROID GLAND. 775 13,090 cases of which 8481 were in women. In Billroth’s clinic only twenty-six per cent, of the cases occurred in males. In women the goitre develops usually about the period of puberty, or during preg- nancy. It may be congenital and develop rapidly at these periods of sexual activity. In the endemic goitre of mountainous regions, affecting animals as well as human beings, the bad quality of the drinking-water seems to play an important part. Quite recently Lustig 1 has proclaimed goitre an infective disease produced by a specific germ found in the water, and claims to have isolated the germ and to have produced goitre in animals by giving them the infected water of the Aosta valley. Symptoms.—Except for the physical deformity entailed, goitres often produce no marked symptoms. These depend largely upon the struc- ture and situation of the tumor. Small fibrous goitres which closely surround the trachea, extend between the trachea and the oesophagus, or grow beneath the sternum and press upon the vascular and nervous trunks, give rise to more serious phenomena than very large and de- forming goitres which hang as pendulous masses from the neck and cover the chest. Pressure upon the trachea, if unrelieved, may pro- duce death from long continuance of dyspnoea, or from sudden collapse of the windpipe. Sudden deaths have overcome goitrous subjects, particularly often during sleep. According to Rose,2 fatty metamor- phosis and absorption of the cartilaginous rings make a compressible membranous tube of the trachea, which then easily collapses; but, ac- cording to most authorities on goitre, this danger is rare. Dysphagia is not a common symptom. When present, in ordinary cases, it indi- cates the existence of a retro-tracheal or retro-pliaryngeal growth. In malignant goitre, on the other hand, oesophageal stenosis is very often produced. The large vascular and nervous trunks of the neck ordinarily escape compression by lateral displacement. Nevertheless the return of blood through the jugular is at times interfered with, and marked evidences of cerebral congestion are occasionally seen. Compression and irritation of the recurrent laryngeal nerve often in- duce paralysis of the vocal cord with aphonia, violent seizures of cough- ing, and at times very serious asthmatic attacks. The sudden death of goitrous subjects has been charged to the sudden bilateral paralysis of the vocal muscular apparatus. A very interesting complication of goitre is the tachycardia due to irritation of the sympathetic fila- ments contained within the goitre itself. Since in true Basedow’s dis- ease exophthalmos is often absent, the distinction between the surgical Basedow’s3 disease and the former maybe difficult. In 1869 Eulen- berg. sought to differentiate the two conditions. As a result of uni- lateral goitre he observed exophthalmos, mydriasis, and elevation of the temperature on the side of the goitre. Stenocardial attacks, psychic phenomena, tremors, insomnia, and epileptic seizures belong to true and not to secondary Graves's disease. The diagnosis of goitre ordinarily presents no difficulty. The posi- tion of the tumor, its lateral mobility imparted to the trachea, and its ascent during deglutition, are sufficiently characteristic. In excep- tional cases, however, the goitre develops in abnormal places from ac- 1 A. Lustig and A. Cade. (Quoted in Giorn. di R. Acad, di Torino, Agosto, 1890, p. 689.) 2 Arch. f. klin. Cliir., 1878, Bd. xxii. und xxiii. 3 Gauttier, Lyon Sled., 1888, No. 22. 776 INJUKIES AND DISEASES OF THE NECK. cessory portions of the gland, or by its weight is drawn away from its original position, and retro-pharyngeal and retro-tracheal goitres are often difficult of diagnosis. Movable goitres, described by Wolffler, may sink or by aspiration be drawn into the mediastinum, behind the sternum or clavicle. Ketro-sternal goitres may exist with or indepen- dently of a tumor of the normal gland. An accessory goitre may be mistaken for an enlargement of a cervical lymphatic gland, for a san- guineous cyst, or if situated in the median line for a ganglion. Owing to its inherent vascularity, or to its relation to the large blood-vessels, a thyroid tumor must sometimes be differentiated from an aneurism. A study of its relations, the mobility of the tumor, and the character of the pulsation, will exclude the possibility of error. Treatment.—The internal therapy of goitre is restricted to the use of the preparations of iodine and of ergot. In very vascular tumors the internal use or interstitial injection of ergot has a beneficial influence in restricting the development and reducing the size of the growth. In parenchymatous goitres uniformly affecting the gland, of rapid growth and of recent date, iodine internally administered often pro- duces rapid diminution of the tumor, and even in recent cases may cause its total dissipation. The external application of iodine and of ice-poultices, when long continued, appears to hasten the absorption of recent hypertrophic goitres. In the colloid and cystic goitres of older date, internal medication and embrocations are altogether useless. In the nodular form of goitre parenchymatous injections of iodine, iodo- form, or alcohol, are frequently followed by induration and rapid di- minution in size. Not more than from five to ten drops of alcohol or tincture of iodine are to be used for each injection. Of a solution of iodoform in ether and olive oil (1-7-7), Mosetig Moorhof injects from lo minims to 1 drachm. Intra-thyroid injections necessitate certain precautions. The syringe should be sterilized and the needle strong. The patient being in the recumbent position, the tumor is seized and well fixed with the left hand, while, carefully avoiding superficial veins, the needle is driven to its hilt into the growth. The injection must be slowly made, to avoid the asphyxia or syncope which would certainly follow the injection of the entire dose should a vein perchance have been punctured. To avoid this possibility very careful operators first puncture the tumor with the needle of an empty syringe and aspirate the growth, the filling of the syringe with blood showing that a vessel has been entered, and necessitating a change in the position of the needle. If no blood enters, the barrel of the syringe is charged and the injection is completed. Injections into the thyroid are not gener- ally painful, though momentary pains in the jaw, or under the ear, and a metallic taste are often experienced. The injections produce tempo- rary increase in the size of the gland, but this reactionary swelling is rapidly followed by induration and diminution. The injections are to be repeated at intervals of from two to five da^ys. That parenchymatous injections are not devoid of danger has often been shown. The methods of aseptic surgery and haemostasis having removed the chief danger from capital operations, intra-glandular injections are not now so much resorted to as even a decade ago. More radical operative procedures have supplanted them. Neverthe- less, the mere existence of a goitrous tumor does not justify an opera- SURGICAL AFFECTIOXS OF THE THYROID GLAXD. 777 tion, the indications for which may be summarized as follows: 1, Great deformity. 2, Suffocative attacks or continued dyspnoea. 3, Dyspha- gia. 4, Very rapid growth of the tumor. Many variations of classical operations for thyroid enlargements have been devised by different surgeons. In the very elaborate article of Van Arsdale,1 nine methods are described. Total and partial extirpation, resection, amputation, enucleation, and ligature of the afferent vessels, comprise the procedures from among which the proce- dure adapted to the individual case is to be chosen. Total extirpation should be reserved for malignant disease of the thyroid gland. In the ordinary varieties of goitre it can no longer be considered justifiable, though not because of the immediate mortality of the operation, for this has steadily decreased. Thus, according to Wolffler, 50 thyroidec- tomies prior to 1850 were attended by a mortality of 41 per cent. Of 119 patients operated on before 1877, only 19.6 per cent. died. Of 250 cases reported by Kocher, the mortality was only 2.4 per cent., includ- ing all cases; or, excluding those of malignant disease and five of exophthalmic goitre, less than one per cent. My, coedema ; Cachexia Thyreo-priva.—The danger of total thyroidec- tomy depends on the removal of all thyroid gland tissue, and the conse- quent induction of a condition known as myxcedema operativa, or cachexia strumipriva. The first contribution to this subject was made by Reverdin, of Geneva, in September, 1882, and about the same time Kocher noticed the development of this condition in patients whom he had subjected to total extirpation of the thryoid gland. Thyroid cachexia does not, however, develop in every case after thyroidectomy. Among 34 patients operated on by Kocher, the cachexia existed in a more or less marked degree in 24. According to Trombetta, only twenty-seven per cent, of thyroidectomies are followed by myxcedema. It is probable that in many cases in which the patients remain well after the operation, portions of gland tissue with normal functions have not been removed, or that accessory glands have assumed the physio- logical work of the gland proper. It is also worthy of note that most of the cases hitherto reported have come from Switzerland, whereas the patients operated upon bjr Billroth, Crede, Wolffler, and others, have for the most part remained well. It is possible, therefore, that a primary climatological influence may weigh as an etiological factor in the development of operative myxcedema. The report to the Clinical Society of London contains 277 cases of total thyroidectomy, in 22 of which the goitre returned, or development of accessory glands ensued. These cases remained free from symptoms. In 186 there were no traces of cachexia, although the goitre did not recur and compensatory en- largements were not found. Only in 96 cases were the symptoms of myxoedema more or less pronounced. In only one-per-cent, of partial thyroidectomies has the cachexia developed in consequence of a reflex atrophy of the remaining portion of the gland. Ordinarily insidious in its beginning, the disease progresses until in from three to six months after the operation the cachectic condition is well established. While on the one hand the condition may develop with foudroyant manifestations immediately after the effects of the operation have passed off, on the other hand symptoms may be delayed 1 Annals of Surgery, vol. xii., p. 161. 778 INJURIES AND DISEASES OF THE NECK. for a year or more. The condition is usually ushered in with a sense of weariness and of weight in the extremities, accompanied by more or less pain. Fibrillary muscular contractions, diminished precision, par- ticularly of the more delicate movements, and impaired muscular power follow. Cardiac palpitation, difficulty of speech, loss of memory, and gradual depreciation of the intellect supervene in rapid succession. The cachectic condition is made manifest by intense pallor of the skin, accom- panied by a pseudo-oedema affecting chiefly the face and hands. The skin is hard and dry. The function of the sweat glands may be en- tirely lost. The integument and superficial fascia become doughy, but there is no pitting on pressure as in true oedema. Myxoedema may likewise affect the palpebral and oral mucous membranes. The entire facial expression is changed as the disease progresses, until in extreme cases the physiognomy of idiocy is established. Epilepsy is occasion- ally developed, as is a condition of tetany which may speedily cause death. When the disease occurs in the young, there is a marked arrest of physical growth. Myxoeclema operativa, like its analogue idiopathic myxoedema. first described by Sir William Gull in 1873, runs a slow but progressive course. It may last from six to twenty years, and usually ends in death from some intercurrent affection. According to Koclier there is never any amelioration of the symptoms, when the disease is once es- tablished, but on the other hand Reverdin and Julliard have seen im- provement and almost complete recovery ensue after an unquestioned cachexia had existed for many months. According to the investiga- tion of 109 cases by the M}’xoedema Committee of the Clinical Society of London, improvement occurs in about* fifty per cent. One condition is common to all cases, namely, some destructive change of the thyroid gland, commonly consisting in the substitution of a delicate fibrillar tis- sue for its normal granular structure. Observation of the disastrous results of total thyroidectomy and the investigation of idiopathic myxoedema have thus established the impor- tance to health and growth of the thyroid gland. Physiological inves- tigations by Schiff and von Eiselsberg, Wagner, Zesas, and Horsley, have definitively elevated the gland to a position of almost vital impor- tance. What its precise function is, has not yet been determined. It would be out of place here to consider the many theories advanced. It is probable, however, that the gland prevents the accumulation of mucin in the system, not by a process of elimination, but by converting it into a harmless and probably useful substance. Enough has been estab- lished to make total thyroidectomy an operation to be performed only for malignant disease. Fortunately the therapy of myxoedema is far from hopeless. By successfully grafting portions of the excised thy- roid gland into the peritoneum, von Eiselsberg saved two animals from myxoedema. Horsley and Collins, with moderate success, have trans- planted sheeps' thyroid into human subjects. In 1891 G. R. Murray suggested the use of the thyroid extract by hypodermic injection. Many methods of administering the gland have since been tried by nu- merous writers, with almost marvellous results. The improvement is constant whatever the method of administration adopted, and speedily follows the beginning of the treatment. The best, because the most con- venient, method is by the administration of a dry extract of the gland. SURGICAL AFFECTIONS OF THE THYROID GLAND. 779 Operations for Goitre.—The operations to be considered are: (1) Partial extirpation of one lobe. (2) Intra-capsular enucleation. (3) Evacuation, or eviclement, of Ivocher. (4) Resection or amputation. (5) Ligation of the afferent arteries. (1) Extirpation.—An ample incision is made either in the median line or along the inner border of the sterno-cleido-mastoid muscle, from the jugulum to the cricoid cartilage. The median incision may bo curved outward (Kocher's method) for a varying distance over the bor- der of the muscle. Superficial veins are avoided or divided between double ligatures. The deep fascia is next divided along the entire length of the external incision, and all muscles presenting over the face of the tumor are treated likewise. The sterno-hyoid, sterno-thyroid, omo-hyoid and sterno-mastoid must be held aside or divided. The superior thyroid artery as well as the veins in its immediate proximity are now sought for, isolated, and ligated. Next the division of the ex- ternal capsule of the gland is proceeded with, and by blunt dissection this is stripped off the tumor and the latter is turned out of its bed, working from above downward. Gradually the position of the inferior thyroid artery is approached; it is to be isolated with its accompanying vein, and ligated as far outside of the tumor as possible, taking care in this manner not to include the recurrent laryngeal nerve. By blunt dissec- tion the isthmus is now lifted from the trachea and included in two or more ligatures, when the tumor, en masse, is removed; it is perhaps better to cut through the isthmus and secure separately any bleeding vessels (Tillmann). (2) Enucleation (Socin,s Operation).—This owes its origin to the nodular character of many goitres, and to the fact that these nodules have a distinct though often very thin capsule surrounding them. The operation is begun by laying bare the tumor just as in extirpation. Instead of ligating the vessels, however, the individual nodules are now sought out. It is important in doing this to thoroughly recognize the capsule of the nodule; in the case of those which are superficially situ- ated this is easy, but it is often necessary to cut through a layer of vascular parenchyma before the capsule is reached. The capsule, hav- ing been recognized by its grayish tint, is carefully cut through and the nodule shelled out. The hemorrhage during this operation is not great unless a thick layer of gland tissue be cut through in order to reach the nodule, and even in this case it is not usually excessive. The chief merit of this operation lies, of course, in its avoiding the necessity of ligating the thyroid arteries and veins, and in its placing the recurrent laryngeal nerve beyond jeopardy. (3) Eviclement or Evacuation (Kocher’s Method).—This differs from enucleation, as just described, principally in being more rapid of execu- tion. Instead of carefully isolating the capsule of the nodule, it is at once bisected with the knife, when the two halves are emptied with finger and scoop, or curette. It is, like enucleation, indicated only in cases of nodular goitre. (I) Resection or Amputation.—It is evident that any quantity of thyroid tissue may be cut away by the use of ligatures en masse, or, as was formerly practised, by the thermo-cautery. It was really on this principle that Mikulicz developed into a method the plan of so-called “resection,” although it is said to have previously been done by others* 780 INJURIES AXD DISEASES OF THE NECK. It is claimed that this method precludes injury to the recurrent laryn- geal nerve, but this has been denied. The incision may be in the median line, with an angular extension upward and outward at the level of the hyoid bone, or it may be along the anterior border of the sterno-mastoid, as in extirpation. The surface of the gland is then bared as in the operations already de- scribed, and the affected lobe is freed by blunt dissection. The supe- rior thyroid artery and veins are next ligated, as well as any others which may enter the gland above its inferior cornu. The isthmus is then divided as in extirpation. The only portion of the lobe now ad- herent is the lower cornu, with the inferior thyroid artery and recur- rent laryngeal nerve. This portion is ligated in several divisions and cut off, leaving a “piece the size of a horse chestnut.” By making a second angular extension of the incision toward the other side, giving the whole incision a y-form, the other lobe of the gland may be pro- ceeded with in the same manner as the first. (5) Ligation of the Afferent Arteries of the Thyroid.—This is per- haps technically the most difficult operation practised upon the thyroid gland, and it is not very frequently employed. Its performance as a therapeutic measure has been justified by Wolffler after experiments on dogs. He has shown that where all the afferent arteries of one lobe of the gland are ligated, there follows a necrobiosis with consequent ab- sorption, not accompanied by an\T more rapid death of tissue. Recur- rence is however possible after this operation by the free development of collateral anastomoses. The operation is begun by tying the superior thyroids. The superior thyroid artery is found in the superior carotid triangle, and the operation is practically the same as for exposing the external carotid at the place of election. The incision is made over the anterior border of the sterno-mastoid with its centre opposite the upper border of the thyroid cartilage. The artery is found immediately after dividing the pla- tysma. When the thyroid is greatly enlarged upward the relation of the parts is somewhat changed, so that the artery should then be sought at the anterior border of the omohyoid muscle. Care should be taken not to include the superior laryngeal nerve, which closely accompanies the artery. To tie the inferior thyroid, an incision is made over the anterior bor- der of the sterno-mastoid on a level with the cricoid cartilage, and is extended to the clavicle. The sterno-mastoid is drawn outward, as are the carotid and accompanying vein when exposed. The inferior thyroid will be found as it passes from behind the carotid artery, slightly below the transverse process of the sixth cervical vertebra, which can be felt through the wound. By placing the ligature close to the carotid it will be easier to avoid the recurrent nerve. In very large goitres it may be advisable to seek the artery by an incision along the outer border of the sterno-mastoid. Drobink and Rydygier have successfully operated many times after this method. Resume of the Different Operations.—That combinations of two or more of these operations, and variations of all of them, should be made by various operators might be expected; thus Kocher has described an operation as “resections-enucleation,” intended as an im- provement upon the resection of Mikulicz. Hahn begins by ligature of SURGICAL AFFECTIONS OF THE THYROID GLAND. 781 the superior thyroid arteries and compression (with forceps) of the inferior; he then makes a bloodless evidement. Wolff, on the other hand, adopts no preliminary ligation whatever, relying upon “methodi- cal compression” for control of the hemorrhage. The indications for the different procedures will he briefly mentioned. Generally speaking, it may be said that, where it is possible, enucleation is the best operation, as best avoiding injury to important organs of the neck and to whatever of sound thyroid tissue there may remain. Partied extirpation is indicated when there is diffuse hypertrophy of the gland, especially if there be left some sound tissue; also when there exist a very large number of small nodes. Enucleation is the operation to be chosen when the goitre is cystic, and in the case of large nodes in simple goitres. Evidement may be used for any nodular goitre when dispatch is of importance; also in “struma nodosa” when the nodes are soft and yielding. Resection may be employed when it is impossible to do one of the previous operations as planned, when the nature of the tumor is un- certain, or when in a case of diffuse h}Tpertrophy there is no sound tissue to be left, and especially when it is desired to operate upon both sides without making the extirpation total. Ligation of the arteries is an operation which by itself is seldom called for. The principal indication for it would be the presence of a “struma vasculosa.” Since the introduction of more rapid and safer methods, large cystic goitres are now rarely treated by the older procedures of tapping, injection of medicinal fluids, the seton, incision, or drainage. For these goitres enucleation may be said to be the only proper operation. Ordinarily the cyst is surrounded by a very dense capsule, which de- prives its enucleation of technical difficulties. The hemorrhage, which is usually slight, comes from the divided overlying normal gland tissue. As in the removal of cysts from other parts, every effort should be made for its enucleation as an unbroken mass. When before the opera- tion injections of iodine, oft repeated, have caused adhesions to form about the sac, this may be impossible. Should rupture occur under these circumstances, the sac must be split in its length and carefully dissected away. Goitres once removed do not ordinarily recur. Nevertheless, after operations short of total extirpation, recurrence has been noticed in somewhat less than ten per cent, of cases, either on the side operated upon or in the opposite lobe. It is interesting to know, too, that operations on one lobe of a diseased thyroid have often been followed by diminution in size of the remaining half of the gland. Simple divi- sion of the isthmus, in two cases reported by Sydney Jones,1 were fol- lowed by atrophy and permanent cure. Malignant Goitre.—Carcinoma and sarcoma occasionally develop in the thyroid gland. As a rule, malignant disease is grafted in an already existing goitre, or invades the gland from some neighboring organ—the oesophagus or larynx. Primary carcinomata of the gland are very rare, occur chiefly late in life, and considerably oftener in men than in women. Primary carcinoma usually presents the cylindri- 1 Lancet, 1884, yoI. ii., p. 367. 782 INJURIES AND DISEASES OF THE XECK. cal type of epithelial cell; secondary carcinoma presents the flat cell of oesophageal or laryngeal epithelioma. Of the sarcomata all varieties have been found in the thyroid. The chief clinical characteristics of malignant disease of the thyroid gland are rapidity of growth and extensiveness of adhesions, impediment to respiration and deglutition often out of proportion to the size of the tumor, early involvement of the lymphatic glands of the neck and mediastinum, and marked tendency toward metastatic dissemination. In very many cases of successful extirpation of malignant goitre, un- suspected deposits have been subsequently found in the lungs, liver, or spleen. The treatment of malignant goitre is most unsatisfactory. To relieve urgent dyspnoea it may be imperative to perform tracheo- tomy, an operation which under these circumstances is singularly fatal. Langenbeck reported seventeen cases without a recovery. In total ex- tirpation of the malignant growth lies the only hope of the patient. Exophthalmic Goitre.—In 1869 Eulenburg called attention to the development of the symptoms of Graves's disease as a consequence of goitrous growths. Tachycardia, liuskiness of voice, and muscular tremor may be considered a result of mechanical irritation of the sym- pathetic and recurrent nerve filaments. Since Tillaux’s first extirpa- tion of the thyroid for Graves's disease in 1884, the term surgical Graves’s disease, as distinguished from the idiopathic form of exoph- thalmic goitre, has properly found acceptance. In all forms of Graves’s disease surgical treatment has been re- sorted to. Enucleation, partial extirpation, and resection have been practised in many cases without a death from the operation. Accord- ing to the recent tabulation of Freiberg,1 the symptoms were relieved by operative treatment of the surgical goitre in 9 out of 10 cases. Of 11 cases of true morbus Basedowii, T were reported cured by operation. In 9 of the cases, total or partial extirpation of the tumor was prac- tised. The fact that partial extirpation of the goitrous gland in true and surgical Graves’s disease is practically devoid of danger, has been established. Not so, however, the certain curability of the disease by operation. That many patients have been greatly improved cannot be questioned. In what proportion permanent and absolute relief has been given, cannot as yet be determined, since many cases have been reported within from only six weeks to six months of the operation. Only in a few cases, as in one of Riedel’s (three years), has sufficient time elapsed since the operation to allow the result obtained to be designated as perfect and permanent. 1 Medical News, 1893, p. 225. INJURIES AND DISEASES OF THE AIR-PAS- SAGES AND OF THE (ESOPHAGUS. BY W. C. GLASGOW, M.D., OF ST. LOUIS. (Edema of the Larynx. (Edema of the larynx occurs in the form of: Acute Inflammatory (Edema; Chronic Inflammatory (Edema; Simple Serous (Edema; Angeio-Neurotic (Edema; Solid, or Lymphoid (Edema. Acute Inflammatory (Edema.—This occurs as a result of an acute phlegmonous laryngitis, or, in a limited number of cases, of a catarrhal inflammation of the larynx. In these cases the oedema may be the most prominent feature and the essential factor in causing the gravity of the lesion. Pathology.—Inflammatory oedema of the larynx consists essentially in an infiltration of the submucous areolar tissue with a serous, a sero- purulent, or a sanguineous fluid. It is found chiefly in those parts of the larynx where the attachment of the mucous membrane to the deeper structures is loose, thus affording sufficient space for the fluid to accumulate. This condition is specially marked in the ary-epiglot- tidean fold, the ventricular bands, the laryngeal surface of the epiglot- tis, and the posterior surface of the larynx. The mucous membrane of the vocal cords is to a great extent closely attached to its underlying tissue, but toward its edge it is more loosely connected (Fournier), and this part may be the site of oedema. (Edema of the infraglottic region is not infrequent. When it occurs in connection with acute phlegmonous laryngitis it is associated with intense inflammation of the mucous membrane, and with hypersecre- tion of the muciparous glands. The mucous membrane becomes swol- len and cedematous, and shows a pallid appearance. The parts involved stand out in marked relief, in contrast with the surrounding membrane. When the ary-epiglottidean folds are involved the oedema is usually bilateral, and the swollen folds appear as two grayish pyriform swell- ings. When the oedema is great it may largely occlude the glottis and produce more or less dyspnoea. In oedema of the ventricular bands the glottis is greatly constricted. The vocal cords are completely covered 783 784 INJURIES AND DISEASES OF THE AIR-PASSAGES AND (ESOPHAGUS. by the bilateral swelling, and an almost complete closure of the glottis may occur. In infraglottic oedema the mucous membrane of the upper part of the trachea appears as two swollen tumors, largely blocking up the lumen of the trachea, and producing more or less dyspnoea, ac- cording to the amount of the tumefaction. In oedema of the epiglottis this part assumes a rounded, swollen appearance. The natural contours of the epiglottis are lost, and it appears as a grayish swollen tumor. When the oedema is excessive it may largely close the larynx, and if this occurs in conjunction with oedema of the ary-epiglottidean folds, respiration may be almost entirely prevented. Etiology.—Acute inflammatory oedema occurring in phlegmonous laryngitis must be considered in connection with the primary disease. Like other diseases of the air-tract the most frequent cause is exposure to humid cold and the vicissitudes of the weather. A weakened con- dition of the system is an undoubted factor in favoring the development of the disease. It occurs rarely as a primary condition of the larynx; more frequently it is consecutive to a phlegmonous inflammation of the pharynx. Occasionally it is seen as a secondary affection in a sub- acute inflammation of the larynx, due to tuberculosis, syphilis, or can- cer, but in these diseases the chronic form of the affection is more common. It has occurred as a complication in erysipelas, small-pox, and typhoid fever. Occasionally it results from traumatism, either by a foreign body or by some external penetrating wound. The swal- lowing of caustic fluids and the inhalation of irritating vapors have been known to produce it. Chronic Inflammatory (Edema.—Chronic inflammatory oedema is seen most frequently in connection with diseases of the larynx which have a constitutional origin. Laryngeal phthisis, tuberculosis, and syphilis are most frequently the causes, and it adds largely to the dis- tress and gravity of these affections. It also occurs in connection with diseases of the cartilaginous articulations, especially in the crico-arytenoid joint. Its extent rarely is as great as that of acute oedema, and is frequently limited to the tissues about the affected joint. It may arise as a primary condition, or may be connected with necrosis'or caries of the cartilage. The oedema in these cases is caused by a sero-purulent infiltration of the tissue. Simple Serous (Edema.—A simple serous oedema, or oedema in which the mucous membrane and connective tissue are infiltrated with pure serum, is always secondary to conditions which interfere with the venous circulation. It is found in all those conditions in which dropsi- cal effusions occur in different parts of the body. It has been observed in acute and chronic Bright’s disease, in heart disease as a result of weakened or dilated right ventricle, and also in cases in which pressure is exerted on the laryngeal, thyroid, or innominate veins, or on the de- scending cava. De Barv (Gottstein) notes a case of scarlet fever com- plicated with nephritis, and B. Frankel cites one in which laryngeal dropsy was the only evidence of effusion. McKenzie considers it very rare in Bright’s disease, as, after having examined two hundred cases, oedema of the larynx was not found in a single instance. (EDEMA OF THE LARYNX. 785 Angeio-Neurotic (Edema.— Angeio-neurotic oedema may be de- scribed as a circumscribed oedema, due to a vaso-motor neurosis. There is no appearance of inflammation, and in the acute form the oedema is caused by an infiltration of the tissues with pure serum. In the chronic form the infiltration seems to be due to the exudation of the cellular elements of the blood. The swollen part gives a hard brawny feel to the touch; it does not pit on pressure, and the line of demarcation between it and the healthy tissue is distinctly marked. The tendency to this form of oedema may continue for years. The swelling may continue for weeks, but then subsiding, it again recurs at irregular intervals. Quincke1 has fully described it, as it appears on the skin in circumscribed cedematous swellings, and it has been further noticed by Ruhl,2 Strubling,3 Gottstein,4 and Osier.6 On the skin it appears as a circumscribed swelling in various parts of the body, and it is frequently accompanied by symptoms of intestinal disturbance, such as vomiting, colic, and diarrhoea. Strubling has drawn attention to its occurrence in the mucous membrane of the upper air-passages. He claims to have seen it after exposure, or the inges- tion of irritating substances, and from causes which have hitherto not been explained. It involves the mucous membrane of the palate, especially the palatine arches, and thence extends occasionally to the larynx. In acute cases, the parts affected have the transparent swollen appearance of a serous oedema. It appears suddenly, con- tinues for a few hours and disappears as rapidly. In its chronic form, the tissues are densely infiltrated, resembling more a solid than a serous oedema. In some cases it has been noted that its disappear- ance from the throat has been followed by oedema of the skin of the face, and of the thorax. Strubling claims to have seen oedema of the larynx that followed a similar condition of the skin. The symptoms vary with the part affected. When in the upper part of the pharynx there is a feeling of fulness. When the larynx is involved there also appear the signs of laryngeal obstruction. There is no pain, and no febrile symptoms have been noticed. Cases have been noted in which the condition has proved fatal in a few hours. Strubling believes that angeio-neurotic oedema is dependent on an irritation of the mucous membrane, followed by dilatation of the blood-vessels with a transuda- tion of serum. Ruhl considers angeio-neurotic oedema to be due to some disturb- ance of the vaso-motor system having a central origin. In support of this view he cites the sudden occurrence of oedema of the skin, with dis- turbance of the intestinal canal and the general symptoms of drowsi- ness and oppression; also the frequent and sudden change of the site of the swelling, and the fact that it has been known to disappear through psychical influences. I believe that the oedema of the fauces and larynx which has been seen to follow the *use of certain drugs, notably iodide of potassium, may be classed as an angeio-neurotic oedema. It may appear as the only symptom of iodism, and it may be produced by the smallest doses. 1 Monatshefte fiir practische Dermatologie, 1882. 2 London Medical Record, December, 1887. 3 Monatschrift fiir Olirenbeilkunde, No. 10, 1886. 4 Die Krankheiten des Kehlkopfs. 6 American Journal of the Medical Sciences, April, 1888. 786 INJURIES AND DISEASES OF THE AIR-PASSAGES AND (ESOPHAGUS. Fournier relates four cases in which the dyspnoea became so great that the patients were only saved by a prompt performance of tracheotomy, and two others in which death occurred owing to delay in resorting to the operation. Groenow 1 relates two cases in which oedema of the larynx was caused by the same drug. In one case, after a succession of trials, tolerance was established, but in the other even minute doses continued to produce the oedema. I have seen a case of acute angeio- neurotic oedema arising from the use of quinine:— Mre. J. T., a lady from Texas, was given, for general debility, teaspoonful doses of an elixir of iron, quinine, and strychnine. One-half hour after tak- ing it she experienced a feeling of swelling in the throat, accompanied by a sense of suffocation, with stridulous breathing, which was most distressing. When I saw her, two hours subsequently, she was partially relieved, the stridor had disappeared, and only a sense of fulness remained. On inspection, the pillars of the left side of the palate presented the appearance of an elongated bag of water, swollen, and seeming almost translucent. The right side of the pharynx was normal. The epiglottis was oedematous, as well as the posterior part of the larynx, but in a less degree. The swelling had evidently largely subsided, and in three hours had entirely disappeared. She said that in the preceding year her physician in Texas had given her a dose of quinine for malarial fever, and that she had then had a similar attack. The following is a case illustrative of the chronic form of oedema:— Miss S. has for five years been troubled with a recurrent swelling of the upper lip, which caused a most uncomfortable sensation and interfered with speech. I saw her first in 1894, when she complained of difficulty in breathing. The upper lip was at this time greatly swollen, the tumefaction involving the skin and a limited portion of the mucous membrane. The palate was rigid and infiltrated. The epiglottis was swollen, especially on its under surface, and it largely ob- structed the laryngeal orifice. Two distinct swellings of a pyriform shape were seen over the arytenoid cartilages, closely resembling the pyriform swellings of laryngeal phthisis. The oedema subsided, but recurred several times after expo- sure and fatigue. Solid or Septic (Edema of the Larynx; Influenza (Edema.— This condition was first described by myself in notes read before the Medico-Chirurgical Society of St. Louis in 1886, and was fully described in a paper read before the American Laryngological Society at its eleventh annual congress, in 1889 (Septic (Edema of the Air-Passages). My observations were confirmed in a paper read by Dr. J. Solis Colien at the succeeding congress in 1891 (The Symptoms and the Patholog- ical Changes in the Upper Air-Passages in Influenza), and the condi- tion has also been observed by Carl Seiler, De Lostalat, and Bavacki. Septic or solid oedema is closely connected with the epidemic of in- fluenza or grippe which has been prevailing during the past years. The cases seen from the year 1886 to the year 1890 may strictly be re- garded as sporadic cases, and may be considered as illustrating one of the protean forms of this disease. Septic oedema, or lymphoid oedema as it has been called by J. Solis Cohen, is the result of an infiltration of the mucous membrane and connective tissue of the air-tract by a cellular material, with a stasis of the venous and lymphatic systems. The local condition of the upper air-passages is secondary to and char- 1 The Practitioner, June, 1890. OEDEMA OF THE LA11YXX. 787 acteristic of the morbid state of the blood existing in influenza, and is similar to the condition found in the mucous membrane of the bronchi and in the walls of the air-vesicles. This solid oedema may involve any part of the air-tract. It is seen in the nasal, post-nasal, pharyngeal, laryngeal, and bronchial mucous membrane, and in the walls of the air-vesicles. It is most frequent in the palate and in the lateral walls of the pharynx. More rarely it in- volves the larynx, and then constitutes a grave form of disease. To the eye the membrane has a swollen, cedematous appearance, and is paler than the normal mucous membrane. The veins are enlarged and may be visible. The membrane appears dry and pale, although in many cases a viscid secretion is present, and when artificial light is thrown upon it this may present a sparkling appearance. To the touch it gives a solid feeling, with an entire want of its normal elas- ticity, and it does not pit under pressure. When the larynx is involved we may find the mucous membrane of the ventricular bands, the true cords, the epiglottis, and the posterior sur- face of the larynx affected. More frequently we find the oedema limited to one of these parts, the other portions remaining normal. When the true cords are involved we find them, on inspection with the laryn- geal mirror, swollen, pale, and glistening. This swelling is especially noticeable at the edges of the cords. When the ventricular bands are affected the oedema is generally bilateral. The bands are symmetrically swollen, and may cover the true cords to such a degree as to produce a most complete stenosis of the larynx. CEdema of the epiglottis changes this organ into a symmetrically swollen tumor. In small children it may be so much enlarged as to almost entirely close the glottis. With this swelling there is no sign of inflammation, and secretion may be entirely absent. In many cases, in addition to the swelling, we notice a paresis of the true cords due to imperfect action of the adductors. The symptoms of septic oedema of the larynx depend upon the part involved. When the true cords are the site of the oedema there is an impairment of the voice, which is especially noticeable in singing. In many cases the voice fails completely and the greatest effort does not suffice to produce a tone. This condition usually comes on sud- denly. This loss of the singing voice may be present, although the voice of ordinary conversation may appear normal. When the ven- tricular bands are affected the symptoms will depend upon the amount of tumefaction. If slight there may be no special symptoms. When great, however, the larynx may be almost completely closed. This condition is especially a dangerous one, for there is always a tendency to spasm of the glottis which may be quickly fatal. A minor oedema or swelling of the ventricular bands may cause a certain degree of hoarseness or huskiness of the voice. (Edema of the epiglottis rarely causes symptoms in the adult. In infants it produces the symptoms of spasmodic croup. In oedema of the ventricular bands and of the epi- glottis in children, there may be marked stridor in both inspiration and expiration. This is persistent, and at times becomes greatly intensified when the element of spasm is added to the obstructive lesion. The constitutional symptoms of septic oedema are those of influenza. 788 IXJURIES AXD DISEASES OF THE AIR-PASSAGES AXI) (ESOPHAGUS. There are more or less prostration, languor, and drowsiness. A slight degree of fever may be present at the beginning, and there may be varied and fleeting pains in different parts of the bod}T, or any of the various symptoms seen in this disease. The condition usually arises suddenly and in some cases subsides very rapidly, but in others may continue for months. Diagnosis.—The diagnosis of septic oedema must be made with the laryngoscope. It may be confounded with a catarrhal inflammation of the larynx. The bilateral character of the swelling and the absence of all signs of inflammation will be important factors. In chil- dren, when laryngoscopic examination is not possible, the differential diagnosis from catarrhal or membranous croup will be difficult. The absence of the general symptoms of membranous croup and the rapid increase of the laryngeal obstruction will aid the diagnosis. The inter- missions of the laryngeal stridor, both on inspiration and expiration, and the remissions of catarrhal croup, are entirely foreign to this dis- ease. The laryngoscope will in most cases distinguish between these conditions, and this may be used in the youngest infant. Prognosis.—The prognosis of solid oedema is usually favorable under proper treatment. In some cases, however, when the spasmodic ele- ment is added, it causes grave anxiety. The spasm of the glottis occurs at unexpected times and from unknown causes, and unless prompt measures are taken it may prove fatal. Treatment of (Edema of the Larynx.—The treatment of oedema of the larynx will depend upon the cause. In acute inflammatory oedema scarification of the part affected will be the first indication. This may be done with the laryngeal knife, or even in an emergency with a long curved bistoury, the incision will promptly allow the fluid to escape, and will thus reduce the tumefaction. Insufflation of tannin has been highly recommended, but the knife will accomplish the de- sired effect much more satisfactorily and properly. General measures to promote the action of the skin and the secretions will be of benefit. The application of hot cataplasms to the neck, and the use of ice in- ternally, will aid in reducing the swelling. After the parts have been punctured the use of hot gargles and drinks will promote the discharge of the fluid. In some cases the application of an ice bag, or of a Leiter coil with iced water, has been of benefit in the early stages. All of these measures aid in allaying the primary inflammatory condition, but they cannot take the place of scarification. In cliromc inflammatory oedema the treatment must be largely directed to the primary disease. If this can be relieved, the oedema will disappear by the aid of such simple means as the use of ice and the in- sufflation of tannin. Occasionally, however, when the swelling is great, scarification will be necessary, as occurs sometimes in laryngeal phthisis, when great tumefaction of the part may prevent the taking of food, not only through the obstruction but by the pressure causing pain. A few punctures with a lancet will often relieve the local con- dition, but when this fails tracheotomy will be the only resource. In snnpte serous oedema attention must be given to the disease which causes the effusion. The action of the skin, the bowels, and the kid- neys must be promptly and vigorously increased. Gottstein has LYMPHOID HYPERTROPHY OF THE VAULT OF THE PHARYNX. 789 reported most favorably of the hypodermic use of pilocarpine in these cases. Scarification, although giving temporary relief, will not replace the measures needed to overcome the prevailing venous engorgement and obstruction. Acute angeio-neurotic oedema usually subsides in a short time with- out the use of remedies, although the nervines will be theoretically in dicated. When grave symptoms are present the use of the knife is im- perative. In the chronic form, arsenic and the bromides are useful. I have obtained excellent results from the use of ichthyol, as recom- mended by Unna in urticaria and by Hardaway in this form of oedema. Morrow advises the use of pilocarpine. The treatment of solid septic oedema will be the treatment of in- fluenza. I have found in the benzoate of sodium in large doses (twenty grains every two hours for the adult), a most useful drug in promoting a reduction of the cellular infiltration. The spray, or local applications with a cotton pledget, of carbolized iodine in strong solu- tion will reduce the swelling and give relief to the distressing dry- ness. When, however, the oedema remains in spite of these measures, and when it affects the ventricular bands in a marked degree, trache- otomy should be employed. The tendency of the oedema to sudden increase from atmospheric or unknown causes, and the great frequency with which it becomes associated with spasm of the glottis, render this condition exceedingly grave. Many cases of the laryngeal oedema of influenza might have been saved by opening the trachea as soon as the spasmodic element was added to the obstructive, or when the ventric- ular bands were so swollen as to close the respiratory portion of the glottis. This is especially the case with children. The condition is entirely different from that of spasmodic or membranous croup. In both of these diseases the great obstruction is from spasm of the glottis, which shows a remission at certain periods. In membranous croup tem- porary relief will come from expulsion of a portion of the membrane, but in solid oedema the ventricular bands and the vocal cords are solidly infiltrated and the obstruction continues without change. The persist- ence of this obstruction in the larynx eventually leads to a mechanical congestion of the lungs with resulting heart failure, through acute dilatation of the right ventricle. The longer the operation is postponed, the less chance will the patient have for recovery. I believe from experience that when this condition has been verified by a laryngoscopic examination, and the signs of laryngeal obstruction have been present in a marked degree for two hours, or when the spasmodic element has become evident, the trachea should be promptly opened. The tracheal tube must be worn until the oedema has entirely subsided, which may be for weeks or even longer. In a case known to myself the tube was worn by an adult for nine months before it could be removed. Lymphoid Hypertrophy of the Vault of the Pharynx. Meyer, of Copenhagen, in 1868, first drew attention to the existence of a mass of so-called adenoid tissue in the pharyngeal vault as a cause of disease. Since then it has been widely studied, and a series of phe- nomena producing more or less derangement of the general health, and 790 INJURIES AND DISEASES OF THE AIR-PASSAGES AND (ESOPHAGUS. especially disturbance of the respiration, have been ascribed to its presence. According to Luschka, adenoid tissue is always present in the vault of the pharynx. It is apparent at the earliest age, and has been said to be congenital. During childhood it has a tendency to hyperplasia and growth, so that at times it becomes a pathological tissue. Luschka describes it as extending across the vault of the pharynx, between the fossae of Rosenmuller. The hypertrophied mass is found most fre- quently in the back and upper part of the vault. It may consist of simply a fringe-like mass projecting downward, located at the top of the vault of the pharynx, or it may fill the greater part with a hard, solid growth. Most commonly this mass is composed almost entirely of lymphoid tissue, with a minimum amount of connective tissue. In some cases, however, the connective tissue is more developed, and we find the mass presenting the dense, hard appearance of fibrous tissue. As a rule, however, the tumor is soft and friable, especially in young children. In adults I have seen a hard, smooth mass occupying the upper part of the vault which seemed to be formed of well-developed fibrous tissue. The growth of lymphoid tissue assumes its greatest proportions dur- ing the years of childhood, and there is a notable tendency to retrogres- sion or disappearance after the tenth year, and between the fifteenth and twentieth years. At least it is not found as a lymphoid growth, and in some cases, where the development of fibrous tissue is excessive, we find a disappearance of the lymphoid tissue, but the fibrous growth remains, and this may continue indefinitely. In growths, however, in which the connective tissue is imperfectly developed, the whole mass may disappear between the tenth and the fifteenth year. The lymphoid growth in this respect repeats the his- tory which we so often see in the faucial tonsil. In some individuals the disappearance of the adenoid tissue takes place sooner than in others. This subsidence of lymphoid hypertrophy has been called an atrophy, but I should rather consider it an absorption or retrogression. Many causes have been assigned by writers for the development of this lymphoid hypertrophy. Some have claimed that it is due to improper sanitary surroundings, while others attribute it to malnutrition and imperfect assimilation. I cannot agree with either of these propo- sitions. Most of the cases which have come under my observation have been in children whose surroundings from a hygienic point of view have been good, and whose general physique has been that of good health, save as it may have been modified by the mechanical obstruc- tion of the growth itself. I would rather ascribe its occurrence simply to the tendency which is generally acknowledged to be present in child- hood to growth and hyperplasia of lymphoid tissue. Usually this hy- pertrophy is not confined to the vault alone, but may in some cases be found involving the faucial tonsil to a greater or less degree. Al- though the constitutional condition known as struma develops a special tendency to hypertrophy of the lymphoid structures, still in the major- ity of these cases we fail to find the other and varied manifestations of this condition, and hence I cannot strictly connect the lymphoid hy- pertrophy with the strumous diathesis, but would rather ascribe it to the special tendency in the years of childhood to lymphoid hyperplasia, LYMPHOID HYPERTROPHY OF THE VAULT OF THE PHARYNX. 791 aided by some form of local irritation which has been the inciting cause. This local irritation will be found in many of the diseases of childhood and infancy, notably in the exanthemata, and especially measles. It will also be found in certain conditions of the nasal mucous membrane, in which respiration is imperfectly performed through the nose, and in which a subacute catarrhal inflammation of the poste- rior naso-pharynx has resulted. It maybe due likewise to such atmos- pheric conditions as would produce a naso-pharyngeal catarrh in the adult. Symptoms.—The symptoms of lymphoid hypertrophy of the vault of the pharynx will depend upon the situation of the growth and its toler- ation by the individual; that is, upon whether it has or has not set up a series of secondary phenomena which produced certain symptoms. These may be described as nasal, post-nasal, or aural, and as disturb- ances of the respiratory act. To these must be added the secondary symptoms resulting from a long continuance of the hypertrophy, which produces impairment of the bodily vigor, growth, and nutri- tion. Reflex disturbances of the nervous system, especially those relat- ing to the larynx, must in some cases be considered secondary symptoms of this lymphoid hypertrophy. The predominating nasal symptom is obstruction of the nares. The obstruction may be partial or complete, depending upon the extent of the growth in blocking up the posterior extremity of the nasal canal, and upon the amount of tumefaction of the nasal mucous membrane which may be the result of this obstruc- tion. The imperfect ventilation of the nares in such cases tends to produce a hyperaemia of the whole length of the nasal canal, with an ultimate hyperplasia of the structures known as hypertrophies. The pos- terior obstruction may also produce a further obstruction in the anterior portion of the canal by the contraction or drawing in of the walls of the nose with each attempted inspiration. This, however, is not peculiar to hypertrophied growths, as it may be present in any case of partial occlusion of the posterior end of the nasal canal. A purulent discharge from the nostrils is frequently seen. This originates in the posterior nares and occurs either through the nose or into the naso-pharynx. The patients are usually of a strumous constitution and the discharge re- sults from an acute inflammatory condition. Slight hemorrhages may occur. This is frequently seen at night, when the pillow may be found stained with blood spots. A special deformity of the nose arises in cases of long-continued obstruction. The sides of the nose become flat- tened and pinched. This, with a constantly open mouth and curvature of the upper lip, presents a picture of facial deformity which is pathog- nomonic of the disease. Mouth breathing is always the sequence of long-continued obstruction of the nasal passages. In cases where the amount of obstruction is small, this takes place mostly during sleep, the self-control of the child being sufficient to keep the mouth closed during the day, although the obstruction of the nasal passage is insufficient for respiration. In cases of great obstruction the mouth remains open and the respiration is performed entirely through it. Tiie post-nasal symptoms are chiefly the constant discharge of a muco-purulent secretion. Sometimes this exists in great quantities and and it is occasionally found mixed with blood. In older individuals complaint is sometimes made of a feeling of fulness in the upper part of 792 INJURIES AND DISEASES OF THE AIR-PASSAGES AND (ESOPHAGUS. the throat, or a sense of irritation is experienced in the naso-pharynx. An annoying sensation of contraction in the posterior nares was experi- enced by a young adult; this seemed to be due to the presence of an elongated fibrous band extending along the summit of the pharyngeal vault. In recent years aurists are holding these lymphoid growths of the pharynx responsible for a number of diseases and disturbances of the ear, notably chronic otitis media both simple and purulent. The exact relation between aural disease and the presence of lymphoid hyper- trophy has been a matter of discussion, but the fact has been clearly established that a large number of children suffering with enlarge- ment of the pharyngeal tonsil show a varying degree of deafness, no- tably the result of a chronic catarrh of the Eustachian tube, or middle ear. Some writers claim that the aural complication is the result of an impingement of the lymphoid tissue on the mouth of the Eustachian tube, preventing the proper ventilation of the aural cavity. In practice, however, we rarely, if ever, see the growth occluding the Eustachian orifice, and still, in many of these cases, aural disease is present. Others consider that the mere presence of the lymphoid hypertrophy in the vault interferes with the necessary renewal of air in the aural cavity, thus exciting aural disease, employing the same argument which is used to connect nasal hypertrophy with disease of the middle ear. Still others believe that aural disease is the result of a simultaneous catarrhal inflammation of the two regions, or of an extension of in- flammation from the naso-pharynx to the Eustachian tube and middle ear. It is a well-known fact that children with lymphoid hypertrophy of the nasal pharynx are especially prone to inflammation of the mucous membrane of this region. It is natural and in accordance with the history of catarrhal inflammation that the mucous mem- brane of the Eustachian tube should be involved through contiguity. A slight degree of deafness, with symptoms of Eustachian catarrh, may arise simply from a swelling of the mouth of the tube. In favor of this theory is the fact that deafness and the Eustachian symptoms are temporarily improved through simple treatment of the naso- pharyngeal space, with the necessary inflation of the tube, although the great body of the growth still remains. Chronic purulent catarrh of the middle ear may arise through great intensity of the inflamma- tory process, or in individuals specially prone to this form of inflam- mation. In the production of voice tones, both in speaking and singing, the importance of a clear naso-pharynx has been fully established, and the presence of this lymphoid hypertrophy in the vault exercises a pro- nounced and disturbing effect. The resonating quality of the voice will be more or less impaired according to the extent of the growth, and, thus losing in a measure its tone, it will become dull and muffled. According to Loewenberg, in the speaking voice the resonating con- sonants N and M will be replaced by D and B. This marked effect can only occur, however, when the size of the growth entirely precludes the possibility of nasal respiration. In recent years the presence of the pharyngeal tonsil has been made responsible for many of the laryngeal disturbances of childhood. Laiyngismus stridulus and false croup are claimed by many writers to LYMPHOID HYPERTROPHY OF THE VAULT OF THE PHARYXX. 793 be due to this cause, and, indeed, Lennox Browne makes the assertion that almost all, if not all, subjects of laryngismus stridulus or false croup will he found to be mouth-breathers. I cannot agree to this state- ment, for although many reflex neuroses depend upon some point of irritation in the upper air-passages, many children with enlargement of the pharyngeal tonsil show no tendency to reflex disturbance in the larynx. On the other hand, when a child is forced to breathe through its mouth through an obstruction of the nostrils or posterior nasal space, we should naturally expect that pathological conditions of the lower throat would result. The respired air is no longer filtered and warmed as when it passes through the natural respiratory passage, and the unnatural efforts of the child in mouth breathing will have a ten- dency to develop any neurosal tendency which may exist. The pres- ence of a neurosal tendency or habit will be a necessary factor in producing the disturbance, and when this exists, the lymphoid hyper- trophy of the pharyngeal tonsil, especially when it is the subject of catarrhal inflammation or hyperaemia and thus presents a sensitive surface, may well be the provoking cause of the laryngeal neurosis. The same explanation may be given of those cases of asthma which have been ascribed to this pathological condition of the naso-pliarynx. That the obstruction of the nostrils, especially when it is great and continued for a long time, has a most unfavorable effect on the develop- ment and growth of the body, has been fully established. It is especially in the earlier years that we find evil resulting from this continuance. In infants, mouth breathing is an unnatural, persistent effort. An insufficient amount of air enters the lungs, and they are not distended to their full capacity. The bony framework of the chest suffers through inaction, and there is a constant tendency to thoracic deformity. The antero-posterior diameter is flattened, and in some cases there is sink- ing in of the sternum. With an insufficient amount of air respired, the general growth and development must suffer, and we find many of the general symptoms referable to malnutrition, and especially to the tendency to develop any neurotic habit which may have been inherited. Diagnosis.—The diagnosis of lymphoid hypertrophy of the pharyn- geal vault will be easy when the development of the growth occludes the nasal passages. The open mouth and facial deformity indicate the disease. When the amount of lymphoid tissue is not sufficient to en- tirely close the nasal passages the diagnosis is less easy, and the con- dition must be differentiated from obstruction of both the anterior and the posterior nares. Various methods have been given by which this can be accomplished. A rhinoscopical examination, if possible, will at once settle the diagnosis. Anterior examination of the nostrils is not so satisfactory, as frequently hypersemia of the membrane and hyper- trophy are concomitant conditions. The application of cocaine will reduce the hyperaemia, but has no effect upon the hypertrophy. It is proposed by some to examine the posterior pharynx by means of the finger. A soft earth-worm feeling is given to the finger when soft growths are present, and the hard, tumor-like growths can be at once de- tected. If this was always possible or advisable, no other "measures, for the purpose of diagnosis, would be necessary. Any one, however, who has had a short, thick finger introduced into the mouth and through the 794 INJURIES AND DISEASES OF THE AIR-PASSAGES AND (ESOPHAGUS. pharyngo-nasal space has found it a disagreeable and painful proce- dure. With larger children it may readily be done, but with younger children it should be avoided if possible. The terror and intense ner- vous disturbance of the child thus produced render the employment of further remedial measures most unsatisfactory. I believe that we have a measure which will largely replace the use of the finger in small children, and which will give almost as satisfactory results. In young children the hypertrophied tissue is almost always of soft consistence, and through their fulness the blood-vessels bleed readily when touched, while bleeding from the normal membrane will be the exception. A light probe wrapped with cotton can easily be introduced into the naso- pharynx of the child, and the different parts of the vault can be lightly rubbed. If the soft growths are present the cotton will be found stained with blood, and this, in my opinion, will justify the diagnosis. This may be an unpleasant procedure, but it does not produce the in- tense nervous shock which follows the introduction of the finger. In some cases the probe may be passed through the nostril into the naso- pharynx. The use of the spray or the douche through the nostril often fails to establish the diagnosis. It is stated that if the naso-pharynx is blocked the spray or fluid will fail to return through the opposite nostril, as it would in health. This is true; but the same result will be obtained in cases of posterior hypertrophies, although naso-pharyn- geal hypertrophy may be absent. Treatment.—In the treatment of lymphoid hypertrophy a certain difference of opinion will be found to exist, even among those who have had large experience. Some assert that whenever the presence of the hypertrophy can be verified it should be totally eradicated. Others, believing that the presence of the lymphoid tissue in the naso-pharynx is physiological, and that it is designed for some purpose, although its purpose has not so far been satisfactorily explained, contend that even if hypertrophied it should not be interfered with, but should be left to the absorption which Nature will accomplish in time, unless, through its size, it produces symptoms and disturbances which may be injurious to other organs, or may impair the growth and development of the body. Under the latter circumstances the hypertrophy must be reduced or removed by surgical measures. The simplest operation is to tear the growth with the finger-nail, a plan which is only applicable to soft growths. I do not believe that the whole mass need be re- moved. I have found that when a soft growth has been well rubbed with the finger-nail, the crushing and the resulting hemorrhage bring about a process of absorption which removes the obstruction. Instead of the finger I have used a stiff probe, to which a piece of sponge or pledget of cotton has been firmly attached. With this the naso-pharynx can be well rubbed and the growth broken down. It is much more agreeable than the finger, and equally effective. In some cases the probe may be introduced through the nostril, but in the ma- jority it must be passed through the mouth. When the growth is firm and dense it must be removed by the post-nasal forceps, the post- nasal curette, or the wire snare. The forceps must be so shaped that it may be used in the naso-pharynx without injuring the posterior surface of the palate. The forceps of Juratz has given the best results RETRO-PHARYNGEAL ABSCESS. 795 in my hands. The curette, preferably that of Gottstein, will accom- plish a great deal. In using both the forceps and the curette care should be taken not to injure the Eustachian orifice. The wire snare may be used in a certain number of cases when en- trance can be obtained through the nostrils, and occasionally it may be used to advantage when introduced behind the palate. When it is possible to use the wire snare, and the growth is hard, I believe this to be the preferable means of removal, especially with large children, who can aid the operator. The snare cuts quickly through the growth, and the operation is rapidly performed. The question of the use of chloroform or ether is a debatable one, but the weight of opinion is in favor of their employment, especially with small children. With a state of partial anaesthesia, the operation can be more thoroughly and satisfactorily performed. In older children, especially if they have courage, anaesthesia may be dispensed with to their advantage. Retro-pharyngeal Abscess. Aii inflammatory swelling, generally in the posterior surface of the pharynx, is known by the name of retro-pharyngeal abscess. The inflammatory process involves the underlying connective tissue with the lymphatic glands, and usually tends to suppuration. The pus may collect in a circumscribed sac, or it may burrow downward in the line of connective tissue to the posterior mediastinum, perforating the trachea, oesophagus, or pleural cavity. In a case of my own the pus burrowed into the subcutaneous cellular tissue and perforated the skin, forming a fistula near the cricoid cartilage. It was formerly said that retro-pharyngeal abscess was most frequently due to caries of the vertebrae, but later and more extensive observation has proved that this view must be modified. A large number of cases result from caries of the vertebrae, but others are due to a less formidable cause. The strumous diathesis, with its tendency to pus formation, is the primary cause in a number of instances. Retro-phaiyngeal abscess may occur as the result of a catarrhal inflammation in which the inflam- matory process has invaded the submucous and cellular tissue, which is loose and which has a lax attachment to the mucous membrane of the pharynx; or it may be the result of a true phlegmonous inflam- mation in which the tissues are intensely inflamed and which passes rapidly into the suppurative stage. A large number of cases arise from inflammation and suppuration of the lymphatic glands in the pos- terior portion of the pharynx. In these the inflammation follows the usual course of strumous glandular inflammation, and terminates in a circumscribed abscess. A traumatic abscess may be the result of wounds of the pharynx pro- duced by foreign bodies. Abscess of the pharynx has also been observed as a sequence to diphtheria, scarlet fever, measles, and cerebro-spinal meningitis. Nelaton has reported a case due to metastasis in connec- tion with perineal suppuration. In a certain number of cases no con- situtional or traumatic cause can be discovered; the abscess seems to be simply the result of exposure to irritating atmospheric influences which have produced an inflammatory condition of the pharyngeal 796 INJURIES AND DISEASES OF THE AIR-PASSAGES ANI) (ESOPHAGUS. mucous membrane. During the late epidemic of influenza an unusual number of pharyngeal abscesses have been observed. Symptoms.—The symptoms of pharyngeal abscess vary according to the portion of the pharynx affected. When seated in the upper or middle pharynx, dysphagia is often the sole symptom. This often exists to such an extent as to preclude the taking of solid food. When situ- ated in the lower pharynx there is often an interference with respira- tion, and we find dyspnoea added to the dysphagia. In a case seen by myself, in which the abscess occurred low down in the pharynx and involved the epiglottic folds, the dyspnoea was accompanied by great stridor. The constitutional symptoms vary greatly in individual cases, and depend largely upon the cause of the suppuration. In some they are entirely absent. In others they resemble the ordinary symptoms accompanying a suppurative inflammation. In children, according to Bokai, convulsions frequently accompany the disease. In acute in- flammatory cases pain may be the predominating symptom, and it may be so intense as to prohibit the taking of food. In the subacute or chronic abscess pain may be entirely absent, and the sole symptom may be the dysphagia or dyspnoea. When the pus burrows in the lines of connective tissue, the symptoms will depend upon the point invaded and the subsequent glandular inflammation involved in the process. When the vertebrae are in a condition of caries, there is a tendency on the part of the patient to keep the head in a fixed position, inclining backward. When the abscess is laterally situated, the head is inclined to the sound side. A characteristic act of swallowing is seen when the subacute or chronic abscess is laterally situated. As the food or liquid is projected below the palate, through a movement of the tongue, with a sideway upward jerk of the head, the patient seeks to bring it to the free side. Retropharyngeal abscess may occur at any age, but is seen most frequently in children. Bokai, in the Children’s Hospital atPesth, who has studied the disease through a period -of twenty-six years, reports the occurrence of 204 cases. This is the largest number reported by a single individual, as very few writers have seen more than from four to ten cases. Diagnosis.—Simple inspection of the pharynx, with the tongue well depressed, will reveal the condition when the abscess is situated in the upper part of the pharynx. Illumination with the laryngeal reflector will render it more evident. When the abscess lies in the pharyngo-larynx the laryngeal mirror will bring it into view7. In the greater number of cases palpation with the finger will detect the rounded fluctuating swelling. A gummatous tumor in a state of degeneration, or a growth of the posterior pharynx, might possibly mislead the care- less observer. A gumma, however, never gives the peculiar fluctuat- ing feel of an abscess, and the hardness of the malignant growth is a marked differential point. A lymphoma or lympho-sarcoma will also be characterized by slowness of growth. In one of my cases an os- teo-sarcoma of the pharynx produced the same difficulty of swallowing that is seen in retropharyngeal abscess, but a hard solid tumor could be felt low down, a little above the larynx. In this case the marked constitutional condition, with the hardness of the tumor, rendered the diagnosis certain. RETRO-PHARYNGEAL ABSCESS. 797 In small children an abscess may be mistaken for croup, when situ- ated near the larynx. This will especially be the case when it is situated in the laryngo-pharynx, in which case the stridulous breathing will resemble that seen in croup. There is, however, this difference: the dyspnoea and stridor of the abscess are constant and are not subject to the remissions which are usual in laryngeal croup. The voice also re- tains its tone, although it may be husky, and croupy cough is absent. Difficulty of swallowing will also be a marked symptom in abscess which produces stenotic symptoms, and this would be wanting in croup. Various other pathological conditions of the larynx, including laryn- geal oedema, inflammation, and growths, may simulate a pharyngeal abscess, but an inspection with a laryngeal mirror will establish the diagnosis. The differential diagnosis between abscess from caries of the vertebrae and that which results from idiopathic phlegmonous inflammation or from suppuration of the lymphatic glands, will be found in the history of the case. Idiopathic abscess due to phlegmonous inflammation usu- ally runs a rapid course, and suppuration is manifested in a few days. Abscess from lympliangeitis is somewhat slower, but its acute char- acter is manifest. In caries of the vertebrae tenderness of the affected vertebrfe is present, and the abscess is slowly developed, sometimes as- suming the characteristics of cold abscess. Prognosis.—The prognosis of retropharyngeal abscess depends strictly upon its cause. The idiopathic abscess, whether the result of phlegmonous inflammation or of glandular disease, will, in the vast ma- jority of cases, give a rapid recovery after incision and emptying of the sac, and spontaneous evacuation of the pus will be followed by an equally happy result. According to Bokai, out of 129 cases of pharyn- geal abscess only 5 proved fatal. In adults recovery is the rule, al- though a fatal result has been noted by some observers. Rupture of the abscess, with an entrance of pus into the larynx and air-passages, has been followed by pneumonia. Several writers have reported cases of rupture of the carotid artery and fatal hemorrhage. (Edema of the glottis may be the result of an abscess through extension of the inflammation. The prognosis in a case due to caries of the vertebrae is most unfavorable. Syme reports a case in which recovery took place after exfoliation of the greater part of the second cervical vertebra, and Gunther reports recovery after the removal of the third and fourth cervical vertebrae. Such recoveries must be rare. Roe makes a point which is worthy of further observation when he maintains that in certain cases of abscess associated with superficial caries of the ver- tebrae, the caries may be the result simply of pressure of the pus sac. In such a case evacuation should give permanent relief. An analogous condition is seen in caries of the vertebrae from the pressure of an aneurismal tumor. Treatment.—The treatment of retropharyngeal abscess consists in evacuation of the pus, as soon as the proper time for the operation has arrived. In the earlier stages, hot soothing drinks and the use of ano- dyne sedative inhalations give a certain amount of relief. A gargle of hot water with bicarbonate of sodium, and the application of a hot cataplasm about the neck are grateful. Some prefer the use of cold applications in the earlier stages, and advise the employment of small 798 INJURIES AND DISEASES OF THE AIR-PASSAGES AND OESOPHAGUS. pieces of ice, or ice cream, allowing these to melt in the mouth, with the application of an ice bag or a Leiter coil with iced water about the neck. As soon as the presence of pus is detected, the use of the knife is promptly required. An emetic will occasionally, in children, he suf- ficient to rupture the abscess, but such a procedure is not without dan- ger from the pus entering the larynx. Some writers advise the open- ing of the abscess with a trocar and canula, but if proper precautions are taken this will be unnecessary. The danger of the pus entering the larynx has, in my opinion, been largely exaggerated, for if proper precautions are taken such a result can hardly occur. An essential feature of the operation is to quickly lower the head, as soon as the incision has been made, so that the pus may flow upward to the mouth. An admirable plan is to place the patient on his stom- ach on a high table, one end of which can be raised to an angle of about forty-five degrees, with the head downward, projecting over the edge. This position is convenient for the operator, and more comfort- able for the patient than to allow the head and upper extremities to hang over the table with the head downward. As soon as the punc- ture has been made the pus gushes downward and out of the mouth. Children may be held on the lap and quickly reversed as soon as the cut is made. In abscess of the upper pharynx an ordinary bistoury may be used, but in deeper abscesses the pharyngotome is more advisable. It should have a more rounded curve than is usually given to the laryngeal lancet. The tumor is first covered by the finger of the left hand, and the knife is guided along the finger until the proper point has been reached. It is then inserted and a free incision is made. With a finger guard on the left forefinger the tongue may be depressed at the same time that the knife is guided, and in this way the use of a tongue depressor, which has been strongly recommended, may be altogether dispensed with. It has been advised by some to chloroform the patient, but this is not only unnecessary but even dangerous, as he will need his faculties to assist the operator. INTUBATION OF THE LARYNX. BY HENRY R. WHARTON, M.D., DEMONSTRATOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PRESBYTERIAN, METHODIST, AND CHILDREN'S HOSPITALS; ASSISTANT SURGEON TO THE UNIVERSITY HOSPITAL, ETC., PHILADELPHIA. The operation of intubation of the larynx consists in passing a spe- cially constructed metal tube through the mouth into the larynx, for the relief of dyspnoea resulting from laryngeal stenosis. Since the intro- duction of this operation by O’Dwyer, in 1880, it has been employed both in this country and abroad in many thousands of cases of obstruc- tive dyspnoea, and is now generally recognized as a valuable surgical procedure for the relief of that condition developing in cases of diph- theritic and membranous croup, or in cases of cicatricial stenosit of the larynx, oedema or spasm of the glottis, bilateral paralysis of the abduc- tors, or paresis of the cords from disuse. The indications for the opera- tion of intubation of the larynx in cases of obstructive dyspnoea are similar to those which are recognized as calling for the operation of tracheotomy for the relief of this condition. Prognosis.—The number of recoveries following the operation of intubation of the larynx is very similar to the number following trache- otomy. Ranke, in an analysis of 2500 cases of intubation, mostly from hospital practice, found that in the first year of life intubation gave apparently better results than tracheotomy, 13 per cent, of recov- eries in contrast to 5 .4 per cent, by the latter operation; in the second year intubation gave 32.3 per cent, of recoveries against 25.4 per cent, by tracheotomy. Ball, in a collection of 4217 cases of intubation gathered from American and European sources, found that there were 12S5 recoveries, or about 30.4 per cent. Ball’s statistics show that 60 cases under 1 year of age gave 11 recoveries, or 18.3 per cent. 258 “ “ 2 years“ “ “ 48 “ 19.0 “ “ 306 “ “ 3 “ “ “ “ 67 “ 21.9 “ “ 326 “ “ 4 “ “ “ “ 98 “ 30.0 “ “ 231 “ “ 5 “ “ “ “ 93 “ 40.0 “ “ 127 “ “ 6 “ “ “ “ 48 “ 37.8 “ “ Ranke’s statistics show that intubation gives better results than trache- otomy in the first and second years of life; from this age the difference between the two operations as far as recoveries go is not very marked. Too much reliance should not be placed upon these comparative statis- tics, for many operators perform intubation at a time when the dys- 799 800 INTUBATION OF THE LARYNX. pnoea is not extremely urgent, and when they would hesitate to employ tracheotomy; so that it is probable that the milder cases are treated by intubation, while tracheotomy is reserved for those which are more severe. Instruments Required for Intubation.—The instruments employed in the operation of intubation of the larynx are: Intubation-tubes of various sizes; an introducer; an extractor; a mouth-gag; a gauge; fine braided silk. The intubation-tubes are furnished for children and for adults; those for children are usually six in number, adapted to children from one to twelve years of age. The intubation-tube now generally employed con- sists of a metal tube which bulges near its centre, and is provided with a collar or head to rest upon the false vocal cords; it is irregularly quadrangular in shape, one angle resting upon the arytenoid cartilages, and its opposite angle bevelled to permit of the closure of the epiglottis over the aperture of the tube; the tubes are gold-plated, and each is provided with an obturator which has a blunt extremity. Just below the head, the tube? is of small diameter, to avoid injurious pressure upon the vocal cords. The wall of the tube is increased to its greatest diameter about the middle, which serves to maintain it in position dur- ing coughing, and increases the weight so that it is expelled with more difficulty. A small perforation exists at the edge of the collar on each tube, through which a strand of fine braided silk is passed, which gives the operator control of the tube, permitting him to remove it promptly if in its introduction it should be accidentally passed into the pharynx or oesophagus, instead of the larynx, or if after its introduction its withdrawal should be indicated by sudden obstruction by membrane. The introducer consists of a handle and staff, which is curved to a right angle at its extremity; at the end of the staff there is a screw by which it is attached to the obturator, and to it is attached a sliding- gear for detaching the obturator from the tube when it has been placed in the larynx. Mouth-gags of various kinds may be used; the one generally fur- nished with intubation sets is a self-retaining instrument. The extractor is also curved to a right angle, and has a small forceps with duck-bill blades at its extremity; these are made to separate and apply themselves to the inner surface of the intubation-tube with sufficient firmness to allow it to be withdrawn. A metal gauge also is provided, which is used to determine the size of the tubes to be employed for children of different ages. Preparations for Intubation.—The actual introduction of the in- tubation-tube should occupy as little time as possible, for as soon as it enters the larynx breathing is arrested until the obturator is removed; therefore all manipulations should be as rapid as may be consistent with accuracy. The time usually required for the introduction of the intubation-tube and withdrawal of the obturator is from five to ten seconds after the mouth-gag has been properly adjusted. The surgeon before undertaking the operation of intubation should select a tube of suitable size for the age of the patient, and should pass through the eyelet in the tube a strand of fine braided silk, about two POSITION OF PATIENT—OPERATION. 801 feet in length, and secure it with a knot. The tube should next be attached by means of the obturator to the introducer, and the operator should then see that it can be easily freed from the obturator by work- ing the trigger; this is very important, for if it does not work freely he may find that he cannot remove the obturator after the tube has been introduced into the larynx, and he may be compelled to remove the tube. The mouth-gag with the tube and introducer should be placed in a basin of warm water. The surgeon should now protect the index finger which is to be passed into the mouth of the patient to guide the tube in plafce, by wrapping it for an inch or an inch and a half behind the second joint with rubber or adhesive plaster, or by placing upon it a metal shield. This precaution is most important to prevent the finger being bitten in case the mouth-gag slips and allows the jaws to come together, for a bite from the teeth, which in diphtheritic cases are often very foul, might be followed by a disastrous result. Position of Patient for Intubation.—The child should be held erect upon the nurse’s lap, wrapped in a blanket which should cover it from the neck to the feet, and the nurse should secure the child’s elbows outside of the blanket and hold them firmly, but should not press them against the chest firmly enough to embarrass the respiratory move- ments. The legs of the patient at the same time should be secured by being held between the knees of the nurse. The patient’s head should next be secured by being held between the open hands of an assistant, placed one on either side of the head and cheeks; the assistant may at the same time hold the inouth-gag after it has been introduced, with the left hand. The patient should be held as erect as possible, and the nurse should take care not to allow him to lean so far back that he gets out of the reach of the operator. The erect position is the best one in which to place the child for intubation, but it is also possible to intro- duce the intubation-tube while the patient is lying down. I have on several occasions introduced intubation-tubes while patients were in the recumbent posture, in cases in which I did not think it advisable, from the condition of the circulation, to place them in the erect position. Operation of Intubation.—When the child has been placed as above described, facing the surgeon, who sits within easy reach of the patient, the assistant fixes the head, and the surgeon opens the mouth and introduces the blades of the mouth-gag between the molar teeth of the left side; the mouth is next widely opened by compressing the han- dles of the gag, and the assistant holds the gag with the fingers of the left hand. As soon as the mouth has been widely opened, the surgeon passes the index finger of the left hand, protected by means of the plas- ter or with a metal shield, into the mouth, and carries it back to the pharynx and feels for the epiglottis; when this is recognized it is hooked forward with the finger; the intubation-tube attached to the introducer is next passed into the mouth and carried back to the pharynx, the operator observing that in its introduction it hugs the base of the tongue in the middle line, and that the handle of the instru- ment is depressed well upon the child's chest; he should also see that the silken thread attached to the tube is not entangled in the instru- ment. When the extremity of the intubation-tube comes in contact 802 INTUBATION” OF THE LARYNX. with the end of the finger resting against the epiglottis, the handle of the instrument should be raised as this is pushed downward and forward into the larynx, and as it sinks into the larynx the finger is placed upon the head of the tube to fix it, and prevent its withdrawal when the obturator is removed. As soon as the tube has been pushed well down into the larynx respiration ceases, and further manipulations should be made with as much speed as possible; the trigger should be pressed to disengage the obturator and introducer from the tube, which is fixed in the larynx by the tip of the finger as before described. The introducer and obturator are now withdrawn from the mouth by depressing the handle of the instrument upon the chest, and before the finger is re- moved from the mouth the tube should again be pressed well down into the larynx. No great amount of force should be employed in pressing the tube down after it engages in the larynx; I think it may be given as a safe rule of practice, that no more force should be used than would be justi- fiable in passing a catheter or bougie into the urethra. If it is found that the intubation-tube is too large to be passed into the larynx with- out the exercise of considerable force, it should be withdrawn, and a smaller one should be attached to the instrument and introduced. Usually, as soon as the obturator has been removed, the child makes a deep inspiration, and at the first expiratory effort there is commonly coughed up false membrane or muco-purulent matter, and when the tube has been cleared of this the respiration is carried on quietly; if, however, upon the withdrawal of the obturator, the dyspnoea is not relieved by the expiratory efforts of the patient, the tube should be speedily removed by traction upon the thread and examined, and if it is found that no mass of membrane is occluding it, the canal being clear, and that dyspnoea is still present, it is evident that the obstruc- tion exists below the point to which the intubation-tube extended. Under such circumstances it is not likely that a second introduction would afford relief, and it is better to make no further attempt to in- troduce the tube, but to resort to tracheotomy. If, on the other hand, the respiration is carried on satisfactorily, before the mouth-gag is re- moved the index finger of the left hand should be introduced and carried back to feel that the tube is in place, and has not been disturbed by the expiratory efforts of the child. Some diversity of practice exists among operators as to the dis- position of the silken thread which is attached to the intubation-tube; some operators as soon as the tube is properly placed and the patient is breathing comfortabty, divide the loop of silken thread, and with the finger resting upon the head of the tube, pull upon the end of the loop and withdraw it; this is done to prevent the irritation of the fauces which the thread sometimes causes, and to prevent the patient from seizing it and displacing the tube. Other operators prefer to retain the thread in place for some hours or days, so that the loop can be brought out of the mouth and secured around the ear, and can he used to remove the tube, by traction upon it, in case it should become blocked with membrane and is not coughed out by the patient. To prevent the irritation of the fauces and the gagging which the thread sometimes eauses, it has been suggested that it should be passed through the pos- terior nares, and be brought out anteriorly and secured around the ear, accidents during and after intubation. 803 or to the face, by a strip of plaster. I usually allow the thread to re- main in place for from twelve to twenty-four hours, bringing it out at one angle of the mouth, and passing the loop around the ear, and securing the thread to the face by a strip of rubber plaster extending from the ear to the angle of the mouth; this prevents the child grasp- ing it and displacing the tube. To prevent the child biting the thread, where it is possible, I also pass the thread between the molar or pre- molar teeth. . In cases where a child has a tendency to grasp the thread, it is well to enclose the hands in mittens or stockings, and secure them to a band fastened around the waist. The most common mistake which is liable to occur in introducing an intubation-tube is to pass it over the epiglottis and into the pharynx, but this error is discovered as soon as the obturator is withdrawn, and the tube should then be removed by the attached thread and reattached to the introducer, and another attempt should be made to pass it into the larynx. This error I have often seen occur in the hands of both experienoed and inexperienced operators, and I think it is due to the fact that in introducing the tube they are not careful enough to hug the base of the tongue closely with its end, and to keep it strictly in the median line. The operator is less liable to make this mistake if he is mindful of the position of the index finger of the left hand, which should be held in contact with the epiglottis, and which serves as a guide to the opening of the larynx. Accidents During and After Intubation.—Accidents may occur during the operation of intubation, such as pushing a mass of mem- brane down into the trachea before the tube, or a too deep insertion of the tube may be made so that its head passes below the vocal cords; accidents of this nature have been reported, hut I personally have never had any serious accident occur during the operation. One of the most serious accidents is the pushing downward of a mass of membrane before the intubation-tube, which is likely to embarrass the respiration so seriously that in the violent expiratory efforts of the child the tube may he forced out of the larynx; if, however, this does not occur, the tube should be removed by traction upon the thread; and if, after its re- moval, respiration is still seriously embarrassed, tracheotomy ‘should be promptly performed. The too-deep insertion of the intubation-tube into the larynx, so that its head passes below the cords, is not likely to occur if a tube of the proper size and shape be employed; a tube which is too small may be readily forced between the vocal cords, or may be drawn down into the trachea by the inspiratory efforts of the child, after it has been introduced. If this accident should occur, and the respiration be seriously embarrassed or arrested, the tube can quickly be removed by traction upon the thread, but if it should occur after the removal of the thread it would be necessary to open the trachea to ac- complish the removal. Several cases of this nature have been reported in which it was necessary to resort to tracheotomy to accomplish the re- moval of a misplaced intubation-tube. It often happens that after an intubation-tube has been retained for a few days, it is coughed up, and upon being replaced the same accident occurs again. Under such cir- cumstances a larger tube should be tried, and if it cannot be tolerated by the larynx, and is displaced, if the dyspnoea is still present, further 804 INTUBATION OF THE LARYNX. attempts at intubation should be abandoned, and tracheotomy should be resorted to. It sometimes happens that the intubation-tube from which the thread has been removed is displaced from the larynx by coughing, and passes into the pharynx, and is swallowed. This seems like a serious accident, but I have never known of a fatal result to fol- low the occurrence, as the tube is usually passed through the alimen- tary canal without difficulty. Personally, I have never seen any serious accidents happen during the operation of intubation, or while the intubation-tube was in place, but I always bear in mind the possi- bility of such accidents occurring at the time of operation, and during the period the tube is worn, and always have at hand my tracheotomy case so that I may promptly open the trachea if necessary, and would advise all operators who make use of intubation to be similarly prepared. After-Treatment of Gases of Intubation.—A patient who has had an intubation-tube introduced should be under the care of a nurse, who should be instructed as to the management of any emer- gencies which may arise while it is in place. If dyspnoea suddenly develops from obstruction of the tube by a piece of loose membrane too large to pass through it, and the tube is not displaced by the violent expiratory efforts of the patient, the nurse should be instructed to attempt its removal by traction upon the thread, if this has been left in place, or if the thread has been withdrawn she should invert the child, when by striking over the posterior portion of the chest, or by pressure upon the larynx from below upward, she ma}r be able to dislodge the tube. A case has been reported recently in which a nurse saved the patient’s life by this manipulation. In the after-treatment of cases of intubation, I have the patient inhale a spray of Parker's soda solution, applied by means of a hand or steam atomizer. The solution I refer to contains Sodii carbonatis 3 i.- 3 ij. Glycerin® f § i. Aquae q. s. ad f 3 vi. I also often employ a spray of peroxide of hydrogen diluted one-half with water, both being efficient in dissolving membrane and liquefying secretions. I usually have the spray used every half-hour, or more frequently if there is little tendency to expectoration. The use of the soda spray is most important in what are commonly described as dry cases. Feeding of Patients after Intubation. —The feeding of the patient is the most difficult portion of the after-treatment of cases of intuba- tion. The act of deglutition is often seriously interfered with by the presence of the tube, as from the imperfect action of the epiglottis liquids are apt to pass into the larynx, causing choking and setting up coughing, which interferes with taking a sufficient quantity of nourish- ment; and this interference with the proper nourishment of the patient constitutes, in my mind, one of the most serious objections to the opera- tion of intubation. I find, as a rule, that patients wearing intubation- tubes have difficulty in swallowing liquids, but some are occasion- ally met with who swallow liquids without difficulty; therefore it is REMOVAL OF INTUBATION-TUBE. 805 well to make a trial as to the feeding before special diet is ordered for any individual case. Some patients wearing intubation-tubes will learn to swallow with the tube in place; I have seen children who at first were unable to take liquid nourishment, in a few days change their manner of swallowing so that liquids could he taken without discom- fort. Where marked difficulty is experienced in swallowing liquids, I order a diet of semisolids, such as corn-starch, mush, milk-toast, curd, or soft-boiled eggs, and as patients soon experience thirst, I order pieces of ice to he swallowed, or give enemata of water, an ounce to an ounce and a half, to be repeated at intervals. In the case of infants, for whom a milk diet is essential, it will often he found that the child can swallow well if fed from a nursing-bottle or the breast, the head being dropped over the nurse’s lap so that it is lower than the body; this lat- ter expedient was suggested by Casselberry, of Chicago. In some cases where the above expedients fail as regards the feeding of patients, it will be found necessary to resort to the introduction of food by nutritious enemata or by means of a stomach-tube. Removal of Intubation-Tube.—The intubation-tube usually re- mains in place for four or five days, but it is often coughed out before this time as the swelling of the laryngeal tissues subsides, and if there be no dyspnoea it need not be replaced; the surgeon, however, should bear in mind that for a few days dyspnoea is liable to return, so that the reintroduction of the tube may be necessitated, and he should he within reach of the patient during this time; if, however, it has not been coughed out, and the child’s general condition is improving, the tem- perature having a tendency to reach the normal mark, the tube may be removed at the end of three or four days, and if there is no return of the dyspnoea it need not be reintroduced; but the case should he kept under careful observation, for the patient is not safe for several days more. If, on the other hand, dyspnoea is present after the withdrawal of the tube it should be promptly replaced, and no further attempt should he made to dispense with it for a period of two or three days. In from five to ten days the tube can ordinarily be definitively with- drawn, although I have had recently under my care a case in which it could not be permanently removed until the fifteenth day. After the removal or expulsion of the intubation-tube, if the breathing is carried on satisfactorily. I continue for two or three days the use of the soda spray, and have the patient carefully watched so that he is not exposed to cold. In all cases in which recovery has followed intubation of the larynx I have noticed that there has been a considerable amount of hoarseness of the voice, which, however, usually disappears in a few weeks. As the same intubation-tubes may be used in many different cases, it is most important that they should be thoroughly sterilized by boiling for a few minutes after their removal, and thoroughly cleaned and polished before being again employed. More difficulty is often experienced in removing an intubation-tube than in its original introduction. For removing the tube the patient should be placed in the same position as that already described. The mouth-gag should be used to separate the jaws; the index finger of the left hand should be protected, and should be passed into the mouth and 806 INTUBATION OF THE LARYNX. placed on the head of the tube. The extractor should be next intro- duced, and, with the finger on the head of the tube as a guide, the blades should be passed into the opening of the tube. By pressing the lever which separates the blades, the tube is grasped by them, and is withdrawn by depressing the handle upon the patient’s chest. In passing the forceps into the opening in the intubation-tube, difficulty is sometimes experienced, but if the finger is placed upon the head of the tube as a guide this should not occur. During the withdrawal the blades may slip, losing their hold upon the intubation-tube which may then pass into the pharynx and be swallowed. This accident may be prevented by following the tube by the finger as it is withdrawn from the larynx, when if it becomes detached from the extractor it can be hooked forward by the finger and removed. In the treatment of dyspnoea resulting from diphtheritic or mem- branous laryngitis, or from oedema or spasm of the glottis, intubation of the larynx has proved a valuable surgical procedure; cases of membranous or diphtheritic laryngitis, where obstruction comes on rapidly and is probably largely due to oedema of the mucous membrane, are in my judgment the most favorable for intubation. Statistics show that children under two years of age are better subjects for this operation than for tracheotomy. Intubation of the larynx seems to me also to be especially well suited for cases of dyspnoea due to oedema of the laryngeal mucous membrane from burns or scalds, from the swallowing of corrosive liquids, or from the inhalation of irritating gases, unless there is at the same time marked oedema of the epiglottis and fauces. Cases of diphtheria in which the dyspnoea is largely due to great swelling of the tonsils and fauces, with profuse deposit of membrane in these situations, as also those in which the dyspnoea comes on very slowly, pointing to a gradual deposit in the larynx of a 'well- organized membrane, are unfavorable cases for the operation of intu- bation. The operation usually relieves the urgent symptoms, is practi- cally free from danger, is a bloodless procedure, and the consent of the parents for its performance can usually be obtained without difficulty; the inspired air, too, enters the lungs warm and moist, and if it fails to relieve the patient it does not preclude a subsequent tracheotomy; these are the principal advantages claimed for intubation over the latter operation. It is stated by some authorities that the prognosis in cases of tracheotomy after intubation is not favorable, but my personal ex- perience does not agree with this statement; for I have opened the trachea in a number of patients in whom a fair trial of intubation had failed to relieve the dyspnoea, and the results following the operation have been in nowise less satisfactory than those in which tracheotomy has been resorted to as a primary operation. Intubation in Chronic Stenosis of the Larynx.—The operation of intubation has been successfully employed to relieve the dyspnoea resulting from chronic stenosis of the larynx, and it has been found that an intubation-tube can in these cases be worn for a considerable time without inconvenience. It has been employed in cases of chronic syphilitic stenosis, cicatricial contraction, bilateral paralysis of the ab- ductors, paresis of the cords from disuse, and in cases where there is difficulty in permanently dispensing with the tracheotomy-tube from INTUBATION" IN CHRONIC STENOSIS OF THE LARYNX. 807 the presence of granulations in the region of the tracheal wound, or from the dread of having the tube removed; in such cases the manipu- lations for the introduction of the intubation-tube are similar to those employed in acute cases, with possibly the difference that more force is justifiable in the introduction. In these cases the tube should he changed at intervals of a few days, a larger-sized tube being required from time to time. Little difficulty usually occurs in feeding the pa- tient, as liquids are commonly taken without trouble after the tube has been worn for a short time. INJURIES AND DISEASES OF THE CHEST. BY RICHARD H. HARTE, M.D., DEMONSTRATOR OF OSTEOLOGY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE PENN- SYLVANIA HOSPITAL AND TO THE EPISCOPAL HOSPITAL; CONSULTING SURGEON TO ST. MARY’S HOSPITAL AND TO ST. TIMOTHY’S HOSPITAL, PHILADELPHIA. Contusions of the Chest. Contusions of the Thoracic Wall.—By the peculiar mechanism of the chest, all forces received upon its walls are distributed over twenty or more elastic springs. By this means, and especially when the lungs are distended with air, an astonishing amount of resistance is offered to external violence, without any serious injury being sus- tained by the thoracic wall or by its contained viscera. As the result of its elasticity, especially upon its anterior portion, ecchymosis and circumscribed blood-tumors are seldom met with, as on the head and buttocks, although over the scapular region occasionally large sanguin- eous collections will be found as the result of direct impact. Another common form of chest contusion is by indirect force, where the body is caught and squeezed, or rolled, between two unjuelding bodies, as be- tween a cart and a wall. In this class of contusions the external evidences of injury are negative, and in case of death an autopsy throws but little light upon the subject. The principal symptom is pain, aggravated by movements of respiration, coughing, or sneezing, and by pressure. Although the pain may be very severe, it is less than when the contusion is complicated by fracture of the ribs or by rupture of the viscera. In this class of injuries the pain is more liable to be persistent than in ordinary contusions, owing to the fact that not in- frequently at the articular ends of the ribs, both at the heads and tuber- cles, the ligaments are stretched, and synovitis of many of these small joints is set up, causing even slight respiratory motion to be accom- panied by pain. The most common injury to the chest is fracture of the ribs, the broken ends of which not infrequently wound some of the deeper struc- tures. Much of the disability which follows what are regarded as simple contusions of the chest is really due to a fracture of one or more ribs which has not been recognized, the diagnosis being often much more difficult than might be supposed, from the fragments being held on both sides by the unyielding chest-wall and intimately attached muscles. 809 810 INJURIES AND DISEASES OF THE CHEST. The chief symptom of these injuries is pain, which is especially marked upon forced respiration, as in coughing or sneezing, and may be elicited by firm pressure made along the course of the injured rib by the end of the finger; whereas with diffused pressure, made with the flat of the hand, the pain will often be overlooked, except one hand be placed over the sternum and the other over the vertebral ends of the ribs, with firm pressure and counter-pressure, when the injury may be located with a fair degree of accuracy. Again, the pain may be due to a bruising or laceration of the muscles, especially the pectoralis major, as might follow a similar injury in any other part of the body. Treatment.—The chief indication in the treatment of these cases is to procure as nearly absolute rest as possible, which can only be done by immobilizing the injured side so as to limit its motion during respira- tion. This is best effected by the use of carefully applied strips of adhesive plaster, two inches wide, of sufficient length to extend from the sternal border of the sound side to the vertebral border of the same. The strips should be applied firmly, commencing at the lower margin of the ribs, in extreme expiration, and should be carried up, each strip overlapping one-lialf of that previously applied, to the axilla. When this point is reached, the scapular and subclavicular spaces must be covered in the same manner by applying the strips obliquely, thus covering in and immobilizing completely the injured side. The appli- cation of a tight broad bandage over the strips of plaster, as is often advised, is undesirable, as it tends to interfere with the action of the sound side. Contusions Involving the Thoracic Viscera.—The deeper struc- tures of the thorax do not always escape, even if the external injury is slight. There may be a rupture of the great vessels of the lungs, or a rupture of the heart or pericardium. Less severe contusions may involve the pleura or parenchyma of the lung, causing hemorrhage, which may he followed by pneumonia or by gangrene. Pleural and lung wounds are caused in many instances by the sharp ends of fractured ribs, in cases in which little or no contusion of the viscus has existed, and in which extensive emphysema often follows. One of the most characteristic signs of rupture of the lung, not dependent upon fracture, is emphy- sema making its appearance at the root of the neck or in the epigastric region. Rupture of the lung in the true sense implies extensive hemor- rhage into the chest and bronchi, with expectoration of blood and frothy mucus. The heart and pericardium have also been ruptured, and the heart torn from its attachments. These extreme injuries are usually the result of crushing forces causing fracture of the sternum or ribs. The heart appears to experience the result of concussion much in the same manner as the brain, and fatal results have followed when an autopsy has failed to reveal any apparent alteration in the cardiac structure. When these severe contusions are received on the lower portion of the chest, occasionally the liver or kidney may be ruptured; injury of the latter viscus may escape detection until revealed by post-mortem in- spection. The prognosis in these cases depends largely upon the pres- ence or absence of serious injury to the viscera, grave lesions of which are, as a rule, accompanied by much shock. WOUNDS OF THE CHEST. 811 Wounds of the Chest. Non-penetrating Wounds.—Wounds of the chest are conveniently divided into non-penetrating and penetrating wounds. The non-pene- trating variety comprises all punctures and lacerations involving the soft parts about the chest-walls. They are rarely of a serious charac- ter, except when a large artery is severed, such as the subscapular, which may bleed freely for a time, but is easily controlled. The great- est care must be exercised in the examination of deep, non-penetrating wounds, that they are not needlessly converted into penetrating wounds, especially in attempting to locate the missile in cases of gunshot injury. In most cases the diagnosis may easily be made if the character of the vulnerating body is known. Emphysema is often present, and is due to the sucking of air into the cellular tissue around the wound by the bellows-like action of the chest-walls, and its presence is not in any way pathognomonic of wounds of the lung. I am familiar with a case in which extensive emphysema occurred, involving the regions over the perineum, buttock, and abdomen, up to the axilla, as the result of a perineal abscess opening into the rectum. Care must be taken to differ- entiate between emphysema and gaseous cellulitis. A case of the latter is reported by Dungern,1 in which this condition followed extirpation of the rectum. Dungern believed the presence of air to be due to gas- producing bacilli which were found in abundance in the cellular tissue. Treatment of Non-penetrating Wounds.—If foreign bodies are lodged or embedded in the ribs, they must be removed, and the bleed- ing controlled as soon as possible. If muscles are divided, they must be accurately united by buried catgut sutures. If the deeper layers of fascia are opened, drainage must be secured from the most dependent portion, and dressings should be applied as to like wounds in other parts of the body, care being taken to immobilize the chest-walls as much as possible, as their movements will have a tendency to delay union. The more remote dangers are those due to septic absorption— tetanus, erysipelas, gangrene, etc. The possibility of pleurisy or pneumonia following, with their sequelae, must not be overlooked. In rare cases peritonitis or pericarditis may be developed in an unlooked- for manner, probably as the result of septic embolism. Penetrating Wounds of the Chest.—These may be subdivided into those opening into the cavity of the thorax and those implicating the viscera. They may be of the most varying character, from the slightest puncture, as by a knitting needle, to the greatest destruction of substance, as by the end of a wagon pole. These wounds are danger- ous from the accompanying hemorrhage, destruction of lung tissue, entrance of septic material, etc. In penetrating wounds of the chest, no matter from what cause, the lung is usually injured, and the two most characteristic signs will be bleeding and the presence of pneumothorax with emphysema. Hemor- rhage may occur into the bronchi, when the expectorated matter may consist of pure blood, or of a frothy light-red mixture, which in a few 1 Munch, med. Wochenschr., Bd. xl., 8. 747, 1893. 812 INJURIES AND DISEASES OF THE CHEST. days becomes rusty or black; or the blood may escape into the cavity of the pleura, and be slowly expelled with each respiratory act through the external wound, or may remain until it distends the cavity (hcemo- thorax) and compresses the lung against the back. In rare cases, when the air vesicles alone are torn, without injury to the pleura, air may escape into the cellular tissue of the lung and make its way along the outside of the bronchi to the mediastinum, and so gain the root of the neck; or, which is most common, it may find its way into the pleu- ral cavity {pneumothorax) and from thence enter the cellular tissue, causing surgical emphysema; or, if the wound he large, it may he sucked in and out of the chest during respiration {tromatopnoea), being more or less mixed with blood. Dyspnoea is always present to some degree, and if the lung rapidly collapses it is extreme. The shock in such injuries is severe and often fatal, even when but little hemorrhage has occurred. If the lung has escaped, the diaphragm may be para- lyzed from injury to the phrenic nerve; or, if the heart be feeble and tremulous in its action, injury to the pericardium or its nerve supply, or simple concussion of the heart may be suspected. In penetrating wounds of the chest extensive hemorrhage may take place without the lung having been injured, especially in gunshot wounds involving the intercostal artery or the internal mammary. I once saw fatal hemor- rhage follow wounding of the vena azygos major by the blade of a small knife, the nature of the injury being revealed by post-mortem examination. The bleeding in these cases is often internal or concealed, and the treatment varies with the nature of the case. If the source of hemorrhage can be located with any degree of accuracy, the wound should be carefully enlarged and the bleeding point sought for, even if resection of several ribs should be necessary. Injury to the Heart and Pericardium.—In comparison with the lung the heart is seldom injured, except in suicidal attempts, and even then it frequently escapes owing to the popular opinion that this viscus is entirely upon the left side of the chest. In rare cases the pericardium, or the surface of the heart, may be injured and yet the patient recover, but as a rule these cases are fatal. Occasionally the heart has been wounded by the entrance of fish bones or pins driven through from the walls of the oesophagus. Recovery in non-penetrating wounds of the heart is said to take place in about fifteen per cent, of all cases, but this estimate is undoubtedly too high. Penetrating wounds of the heart are, as a rule, fatal, although death is not always immediate, especially if the wound is made with a sharp instrument, which does not produce much concussion. I had under my care a patient who lived for nearly four hours after a penetrating wound of the left ventricle, one and one- half inches in length, made by the blade of a butcher’s knife. Death takes place in these cases largely from the effusion of blood into the pericardium, slowly but effectually embarrassing the heart’s action. The diagnosis of heart wounds, where external signs are absent, may be made by noting the extreme shock, dyspnoea, and almost instant failure of the circulation. The heart sounds are usually inaudible, but occasionally splashing or other abnormal sounds may be heard. In the treatment of these cases absolute rest should be enforced. External cold over the pericardium, and opium internally, may be found of service. The external wound may be closed, this being best done by WOUNDS OF THE CHEST. 813 packing it firmly with sterilized gauze. If closed by sutures, concealed •hemorrhage into the chest is liable to continue. The great vessels of the thorax may he injured in cases of penetrat- ing wound, and as a rule accidents of this kind are often more rapidly fatal than lesions of the heart itself. The thoracic duct may be injured as the result of deep penetrating wounds. A case has recently come to my notice in which the duct was wounded in the removal of some deep cervical glands. If the wound is within the chest, large quantities of a milk-like fluid will be poured into the pleural cavity during the process of digestion, until the sac becomes quite distended with chyle. The pi'ognosis in these cases is most unfavorable, as starvation is inevitable. In the case above referred to rapid emaciation ensued. The diaphragm may be injured in a variety of ways; thus it may be ruptured by extreme compression, punctured by stabs or gunshot wounds, or torn by fragments of ribs after fracture. Frequently some of the neighboring viscera may be injured, or some of the abdominal contents may be squeezed up through the opening into the thorax, causing great pain and dyspnoea and giving rise to a diaphragmatic hernia; if the rent be small, immediate strangulation may result. Treatment of Penetrating Wounds of the Chest.—This depends upon their character and extent. In grave cases, as of wounds of the large vessels, which are nearly always rapidly fatal, surgery has but little to offer. Where the danger is not so immediate, the surgeon is warranted by the persistence of hemorrhage in seeking for the bleeding point, enlarging the wound, and if needful even resecting several ribs. When the bleeding is from the internal mammary artery, a strong silken liga- ture should be carried around the vessel with a curved needle, and all the tissues, including the artery, should be firmly grasped within its loop. The intercostal vessels are seldom the seat of much hemorrhage, provided that they are cut across and can retract into their sheaths. If partially severed or punctured, the opening in the vessel will remain patulous and troublesome bleeding may result, requiring a ligature which if necessary may be carried around the adjoining rib. External hemor- rhage is much better controlled by plugging with gauze than by closing the wound with sutures, which might be followed by concealed bleeding. It is important to remember that needless exploration with the probe, especially in gunshot wounds, should be avoided, as little can be thus learned which could not otherwise be ascertained, while by probing blood-clots are broken up and septic material may be introduced. The control of hemorrhage, the thorough cleansing and disinfection of the wound, and immobilizing the chest-walls, must be carefully attended to. The judicious administration of opium and diffusible stimulants is commonly indicated, and the wound must be carefully dressed with antiseptic precautions. The amount of destruction which may follow what appear to be simple wounds will be illustrated by the following case: T. S. was admitted to the Pennsylvania Hospital with a pistol-shot wound, 32 calibre, of the lower chest, the ball entering between the eighth and ninth ribs in the anterior axillary line. The patient suffered from shock, but lived twenty hours. Post-mortem examination revealed the track of the ball as follows: En- tering at the left interspace between the eighth and ninth ribs, it had pierced 814 INJURIES ANI) DISEASES OF THE CHEST. the diaphragm at its attachment to the ninth rib and had crossed the upper por- tion of the abdominal cavity, piercing the left crus of the diaphragm, and rest- ing in the areolar tissue in front of the spine. In its passage it entered the epiploic appendages of the colon, penetrated the jejunum about three feet from its be- ginning, cut off almost the entire tail of the pancreas, and removed a wedged- shaped piece from the upper border of the left kidney. The abdominal cavity was filled with blood-clots. In this case enlargement of the wound and careful exploration had failed to give any definite information as to the course of the ball. Complications of Chest Wounds and their Sequels.—Hernia of the lung, or pneumocele, is produced by a portion of the lung insinu- ating itself through the lips of the chest wound. This may be immedi- ate, or it may follow after several months, the protrusion overcoming the resistance of an insufficient cicatrix. The cause of this rare con- dition, as suggested by Agnew, is possibly the unusually deep fissures in the lungs of some persons, leaving a pendulous portion or edge which finds its way through an external break or opening in the chest- walls. Primary pneumocele is easily recognized by its crepitating character. When the hernia is secondary, and covered by integument, a marked change will be noticeable during respiration, the tumor alternately increasing and diminishing in size. In an unusually large hernia of the lung under my care the tumor was compressible and markedly crepitant, with a distinct, clear percussion note, and on auscultation gave an unusually loud rasping murmur. If an acute pneumocele is non-adherent, it should be thoroughly cleansed and, if possible, restored to the chest-cavity and retained there by suitable compresses. When adherent and projecting through a wound, it is likely to become strangulated by the entrance of blood and air, in which case it will soon slough off. It will be found best to anticipate this occurrence and transfix its base with a double ligature, as deeply as may be found necessary. In secondary pneumocele the swelling may be protected with a suitable shield retained by a bandage. Emphysema has already been referred to several times. By this term is meant the presence of air in the cellular tissue outside of the chest- wall. If no external wound is present, it is diagnostic of injury of the lung. As before stated, in external wounds it is frequently seen with- out wound of the lung, but usually to a limited extent except when the costal pleura is opened, when the air enters through a valve-like opening in the skin, and is then forced back into the cellular tissue. The emphysema in thoracic wounds may be of such an extent as to extend all over the body, rendering the features unrecognizable, the scalp and the palmar and plantar surfaces of the extremities alone being exempt. The looser and more delicate the skin the more distended it becomes; it remains soft and is not discolored, and when touched there is a soft, crackling sensation under the finger as the bubbles of air are driven through the meshes of the areolar tissue. The same thing is met with in the early stages of gangrene when decomposition has begun. Emphysema is not dangerous, except when it is so extensive as to inter- fere with respiration, or if the air be infected, when it may give rise to cellulitis or erysipelas, or even gangrene. Emphysema generally re- quires no treatment, as the air is soon absorbed, passing into the blood and through the skin by osmosis. When it is very extensive and 815 TUMORS or THE CHEST. interferes with respiration, the air may he permitted to escape by a number of small punctures in the skin. All penetrating wounds of the chest are liable to be followed by pleurisy, and if the lung be implicated, by pneumonia. These trau- matic inflammations are also common after fractures of the ribs and severe contusions, but, as a rule, are self-limited a*nd tend to sponta- neous cure. If foreign matter finds access to the lung, as in gunshot or other large wounds, decomposition may be excited, causing intense inflammation and abscess, which may open into the bronchi, or into the external wound. The physical signs, when they are not masked by pleuritic effusion or thickening, are similar to those of ordinary croupous pneumonia, and the prognosis depends largely upon the amount of lung involved and the general condition of the patient. In fractures of the ribs and severe contusions, blood and serum are often poured into the pleural sac, causing hcemothorax or hydrothorax, and subsequently, by the entrance of air or other foreign substance, the effused material may become purulent, causing pyothorax or empy- ema. When this occurs, the suppuration may be ushered in by a violent chill and high fever, or may come on slowly, the effusion gradually increasing and becoming more and more purulent, as when empyema succeeds a serous pleurisy. When an intrathoracic effusion becomes purulent, the first thing to be done is to insure perfect drainage, so that the pus may not he pent up and become decomposed. The serous effu- sion which accompanies simple fracture, when not absorbed, may readily be removed by aspiration. If from the presence of blood-clots or other causes the contents of the pleural sac cannot be evacuated by the aspi- rator, the cavity must he drained. If this he done before the pleura has had time to thicken and contract, the lung will expand and become adherent to the chest-walls. Tumors of the Chest. Parietal Tumors.—Tumors unconnected with the circulatory sys- tem are occasionally met with involving some portion of the thoracic wall. Of these the most common are exostoses or enchondromata, springing from the ribs or costal cartilages. They may be pedunculated in shape and may attain considerable size. Mediastinal Tumors.—Malignant growths in the thorax are, as a rule, found involving the mediastinal spaces, usually assuming the character of a carcinoma or of a sarcoma. From a large number of cases collected and carefully analyzed by Hare, carcinoma appears to be the growth most frequently met with. Malignant growths in this region have certain peculiarities in their development, viz.: not select- ing any one or two tissues, but invading whatever comes in their path, following the course of least resistance, and invading the heart, peri- cardium, and great vessels; nerve filaments become affected, as mani- fested by various functional derangements which soon end in death, es- pecially when the pneumogastric nerve becomes involved. The oesoph- agus and trachea are frequently perforated by pressure or become involved in the disease. The diaphragm may be pressed down, caus- 816 INJURIES AND DISEASES OF THE CHEST. ing distortion of the sternum and ribs, or these may become perfo- rated, allowing the disease to manifest itself externally. Little or no light has been thrown upon the etiology of these growths, which ap- pear to occur more frequently in the male than in the female. The symptomatology of mediastinal growths is by no means clear, as they may be simulated by other conditions, some writers going so far as to state that a diagnosis cannot be made during life; nevertheless, by exclusion, a fairly accurate diagnosis may be arrived at, provided that the presence of the growth is not entirely masked by the occur- rence of more prominent symptoms in other parts of the body. In a certain number of cases, pressure on important nerve trunks may bring on a long train of obscure and dangerous symptoms as regards respira- tion, circulation, deglutition, digestion, and speech. Growths in the mediastinum are liable to be confounded with aneu- risms, abscesses, pleuritic and pericardial effusions, and chronic pneu- monia, and can only be differentiated after most thorough and sometimes repeated examination. In pleurisy with effusion, and in pneumonia, there will be dulness on percussion, while in mediastinal carcinoma this sign does not appear unless the growth has encroached upon the chest-wall; even then considerable force must be exercised before any change in the percussion note will be observed. Cachexia rarely appears in mediastinal cancer unless the growth be secondary, so that no dependence should be placed on the absence of this sign. In many instances patients remain fat and well-nourished to the end. Bare cases will be found where sudden and great emaciation may take place by a growth involving the post-mediastinal tissues, and pressing upon and occluding the thoracic duct, thereby preventing the escape of chyle into the circulation. Other rare growths, such as lymphoma and lymphadenoma, may be found in the mediastinum, but their true char- acter can only be revealed by post-mortem examination. Treatment of Thoracic Growths.—When the tumors involve the tho- racic parietes, and are in a position to be easily attacked, their removal is to be advised, even if the section of several ribs should be found necessary for the purpose. Growths involving the thoracic contents for the most part lie outside of the domain of operative surgery. Never- theless, dermoid or hydatid cysts may occasionally be removed when found lying immediately below the sternum. Mediastinal Abscess. Abscesses affecting the mediastinal spaces are fairly common, and have long been recognized. About twenty-five per cent, of persons suffering from diseases in this region will be found to present lesions of an inflammatory or suppurative character, which appear to be more frequent in the male than in the female, and usually occur in those of a strumous diathesis. Cold, contusions or other injuries in this region of the body, and recent attack of measles or typhoid fever, appear to be predisposing causes. The abscess may be of either the acute or the cold variety. The pain is deep-seated, and pressure-symptoms may simulate those of tumors in this region. In the acute variety all the OPERATIONS ON THE LUNGS. 817 symptoms of ordinary inflammation may appear;, sometimes the pain is of a pulsating character, similar to that caused by abscess in other parts. In cold abscess the percussion note may vary according to the position of the body. The diagnosis in obscure cases may be cleared up by the introduction of a small aspirator or exploring needle. The prognosis is always more favorable than in cases of morbid growth. The acute variety may run its course in three or four days, bursting into the trachea or oesophagus, or may go on for as many weeks. The treatment depends upon the patient's physical condition. If the abscess points externally, it should be freely opened and drainage pro- vided for. If the pus collection is extensively diffused, as in cold abscess, only a portion should be removed at first, lest the sudden relief from intratlioracic pressure should cause fatal syncope. If the abscess does not point on either side of the sternum, but appears to be involving its substance, the trephine may be employed and the abscess evacuated through the opening. A sufficient number of successful cases have been reported to warrant the procedure. Operations on the Lungs. Undoubtedly the surgery of the lung is still in its infancy. The experimental researches of Gluck, Wills, Willard, and others, have thrown much light upon the subject, showing that large portions of the lung may be removed in certain cases, and that it is not only possi- ble but judicious to attack abscess cavities in the pulmonary tissue. In some forms of abscess, however, surgical interference is inadmissi- ble ; nothing could be hoped for in attacking a lung riddled by numerous tubercular cavities, or by multiple gangrenous foci the result of embolic pyaemia. Those cases in which surgery may he and has been attempted with a fair degree of success ma}7, be thus classified: (1) Well-defined and circumscribed tubercular cavities; (2) cavities resulting from gan- grene of the lung; (3) cavities caused by the bursting into the lung of a collection of pus or other irritating matter from without; (I) bron- chiectasis resulting from whatever cause, including the presence of a foreign body in the air passages. The subject of operations on the lung is not entirely new to the minds of surgeons, for Barry1 in 1726, and still earlier Baglivi in 1714, advo- cated the opening and draining of pulmonary abscess cavities, saying that the operation might be performed without danger, as adhesions were sure to exist which would tend to shut off the pleural cavity at the point of incision. The medication of tubercular cavities with various antiseptics has been frequently resorted to, the remedy being introduced either through the mouth, or directly, by the medium of a thin canula or hollow needle inserted through the chest-wall. By these procedures little is to be gained except in very small foci which cannot be punctured with any degree of accuracy. Cavities resulting from tuberculous disease, except in rare cases, as following catarrhal pneumonia at or near the 1 A Treatise on a Consumption of the Lungs, p. 217. Dublin, 1726. 818 INJURIES AND DISEASES OF THE CHEST, base of the lung, offer but little hope from surgical interference, and as a rule are much better let alone. Gangrenous cavities resulting from the entrance of a foreign body or a punctured wound, and the similar condition seen as the result of croup- ous pneumonia where there is no tuberculous element present, consti- tute decidedly the best class of cases for operative interference, especially if this be not too long delayed. Bronchiectasis.— Another and totally different variety of pulmonary cavity, due to a dilatation of some part of the bronchial tree, is met with in two forms, the cylindrical and the sacculated. These dilatations may follow the entrance and lodgment of foreign bodies, such as pieces of wood, grass, etc., which find their way into the bronchi from above. Such foreign bodies usually select the right bronchus, which is almost a direct continuation of the main stem, the bifurcation taking place at a point a little below the fourth dorsal spine. The recognition of this fact may be of practical value in attempting to remove obstructions through an opening in the trachea. When foreign bodies have lodged, and it is impossible to remove them, they tend to produce dilatation of the bronchus. These dilatations, unfortunately, are usually multiple; when single (a rare occurrence) thejT offer a much more favorable field for operative interference. On the other hand, if several adjoining tubes are dilated, but little hope of benefit can be entertained, and an operation should be avoided. To use the language of Mr. Godlee,1 the state of our knowledge as to operations upon lung cavities may be summed up in the following words:— 1. Gangrenous cavities should always be sought for, and if possible opened. The prognosis of the operation, if successful, is not bad. 2. The same may be said in regard to abscesses caused by rupture of purulent collections from other parts into the lungs, at least as regards the pulmonary complication. 3. Abscesses connected with foreign bodies must be opened; the body, if not found and if of any size, probably lies near the median line. If possible, these cases should be treated early by tracheotomy and incision. 4. Bronchiectasis, when single, may be cured by operation; when multiple, the results are unfavorable. 5. Tuberculous cavities should not be opened except in cases where the cough is harassing and the cavity single. The Operation.—The anaesthetic to be employed is preferably chloro- form, and it should be administered very slowly, so as to cause as little irritation as possible. The position of the cavity should be accurately determined, and its location verified by the introduction of an aspirat- ing needle, which may be left in situ as a subsequent guide. After a free incision, about two inches in length, has been made in as dependent a position as possible, the intercostal space is opened up. If sufficient room is not obtainable, a portion of a rib may be resected, giving better exposure of the lung. The next step of the operation is the opening of the cavity, which may be done by the introduction of a trocar and canula, and subse- quent dilatation with a sinus forceps, or by carrying the point of a Paquelin cautery slowly through the lung tissue, leaving a seared track 1 Lancet, vol. i., 1887. SURGICAL TREATMENT OF PLEURITIC EFFUSIONS. 819 behind. The cavity should be thoroughly opened, and, if possible, ex- plored with the finger, and all necrotic tissue should be removed. A long, good-sized drainage tube should be introduced and firmly secured. In the great majority of cases the lung will be found adherent to the chest-wall, thus obliterating the pleura at the point at which the tube is to be inserted. Should no such adhesion exist, Mr. Godlee advises the preliminary introduction of stitches and the fixation of the lung to the external wound. This procedure is not a very easy one, owing to the constant motion of the lung caused by the act of respiration. After the introduction of stitches no attempt should be made to open the cavity for at least a week, and then the manipulation should be gentle, lest the rather delicate adhesions should be torn asunder. If the pleura should become infected from the escape of purulent matter, it should be treated on the same lines as empyema. As a rule, the bleeding is not troublesome, but if severe hemorrhage should occur, the wound should be packed with gauze. After-Treatment.—The cavity should be regularly washed out with a mild antiseptic solution, such as carbolized water or Thiersch’s fluid, and the tube should be retained until all discharge and expectoration have ceased, as serious relapses have followed its too early withdrawal. Rest, liberal diet, and fresh air will all be factors in insuring an early convalescence. Hydatid cysts of the lung, though rare in this country, occasionally demand surgical interference. They usually contain daughter-cysts and often attain considerable size, sometimes reaching the proportions of a child’s head. They are attended with considerable pain, increased by lying upon the affected side, and are accompanied also with dyspnoea. Unless they suppurate, their course is feverless. Careful observation will reveal undue prominence of the chest-wall and widening of the intercostal spaces, and if not too deeply seated, fluctuation may be detected. Hydatids which primarily have begun in the liver may rupture into the pleura and perforate the diaphragm. The diagnosis should he verified by aspiration, but the withdrawal of the cyst con- tents will afford but temporary relief. Injections of iodine may in some cases effect a cure, but the most satisfactory results will be ob- tained by free incision. The steps of the operation are the same as those for the evacuation of abscesses in the lung substance. When the cyst-cavity is reached, Gardner advises the attachment of the cyst- wall to the external wound by means of sutures. Then, with a wound of sufficient size to allow the introduction of one or two fingers by the side of strong catch forceps, the surgeon is able, with a little manipu- lation, to deliver the mother-cyst entire. During this process many of the daughter-cysts may escape and may be washed out afterward. A large drainage-tube should be introduced, and the wound should be treated in the way already described. Surgical Treatment of Pleuritic Effusions. Collections of fluid in the pleural sac are frequently met with as complications of chest injuries, and also as either primary or secondary 820 INJURIES AND DISEASES OF THE CHEST. results of pleuritic inflammations. From whatever cause, the effused material will not always partake of the exact characters of either serum or pus. When it is of traumatic origin, the fluid is more or less stained with blood, which in nearly all cases is at first poured into the pleura. When of purely inflammatory origin, the fluid is almost colorless, or of a light straw color, often containing flocculent masses of lymph. The pus in an empyema is not like the healthy pus discharged from an abscess. It is rather puriform, containing masses of unhealthy lymph, often stained with blood and of a very offensive odor, and its escape is not infrequently accompanied by the discharge of offensive gases. The rapidity with which serum may he poured into the chest is remarkable, twenty-four hours being sufficient time to allow the pleural sac to be- come distended with serum after an acute pleurisy, while equally rapid effusion will often be noticed in the daily discharge from an empyema which has been drained. On the other hand, collections of fluid may accumulate so quietly and gradually as to cause no uneasiness or distress until the chest-wall has become distended and the lungs compressed. In this class of cases the disease is usually of tubercular origin, and is accompanied with great thickening of the pleura, which is occasionally encrusted with lime salts, transforming it into a cartilaginoid or bone-like substance. A pleuritic effusion may suddenly become purulent by the rupture of a pulmonar}’ or hepatic abscess into the pleural sac. The rational signs of fluid collections within the pleural sac are dysp- noea, often accompanied with a short grunting sound—the patient usu- ally resting upon the affected side—and rapidity and weakness of the pulse, which is greatly accelerated by the slightest exertion. The physical signs are enlargement of the affected side, with bulg- ing of the intercostal spaces; a dull percussion note over the seat of effusion, most marked at the base of the chest, continuing up to the level of the fluid collection with the patient in the erect posture, and varying according to changes in his position. If the fluid be sufficiently thin, a sudden jar to the thorax will cause a distinct splash, which may be heard and felt. Displacement of the heart to the right side is fre- quently noticed if the opposite side is affected. All respiratory sounds are greatly modified or entirely lost; absence of vocal resonance is among the most prominent of the physical signs. The diagnosis may readily be verified by the use of the aspirator or exploring needle. In carrying out this simple operation the strictest antiseptic precautions must be taken, as many serous effusions have become purulent by their neglect. Treatment.—In dealing with large, serous effusions, too much de- pendence is often placed upon the power of a diseased pleura to absorb a large quantity of fluid, and in consequence the practitioner is too backward to puncture the chest for these collections, since a large quan- tity of fluid cannot rest within the pleura without causing serious com- pression of the lungs, and if on the left side, displacement of the heart and great vessels. For the removal of fluid collections within the pleural cavity the operation of paracentesis is performed, either for diagnostic purposes or to relieve the tension, permitting the lung to expand. There is little doubt that many of the unsatisfactory results following this operation are caused by waiting for a diseased and thickened pleura to 821 SURGICAL TREATMENT OF PLEURITIC EFFUSIONS. absorb a large amount of fluid which has rested for months within its cavity. Consequently, on the removal of the fluid contents, the long compressed lung is unable to recover its former position in relation to the chest-walls, leaving tissues previously accustomed to pressure now entirely free and in a partial vacuum. With this absence of pressure the conditions are more favorable for the escape of serum from the dis- eased pleura, and reaccumulation rapidly occurs. Many empyemas, too, result from protracted serous collections which have compressed the lung, and the evacuation of which leaves a large pleural cavity which soon becomes infected and purulent. Paracentesis Thoracis.—The operation of paracentesis may be per- formed in a variety of ways. To Bowditch, of Boston, is due the credit of the first evacuation of serous effusions by suction, a method now universally employed by means of the modern aspirator, in which the fluid is received into a previously prepared vacuum. In the absence of suitable apparatus siphonage may be employed, attaching several yards of rubber tubing to a hollow needle or canula. In default of all mechani- ical devices, and in extreme cases, the chest-wall may be opened with a bistoury while the patient lies on his side in a warm bath, the pleura being emptied of its serous contents, and the wound closed, while he is still in the submerged position, thus preventing the entrance of air. For the mere purpose of exploration a large hypodermic syringe may be employed. It must be thoroughly cleansed by boiling and soaking in a strong alkaline solution in order to remove all particles of oil, and the needle should be passed through an alcohol flame to insure the removal and destruction of any septic matters which may have collected within it. It is very easy, by means of repeated punctures, to convert a serous effusion into an empyema. The locality selected will usually depend upon the physical signs; the thinnest part of the chest-wall is preferable, and the seventh or eighth intercostal space, near the mid-axillary line, is the point usually selected. The skin should he thoroughly cleansed, and as carefully as for a cutting operation. A local ansesthetic such as the ether spray may be employed if the patient is very nervous, but is rarely necessary. At the place selected, the skin is drawn either up or down, and the point of the aspirating trocar is then carried close to the upper margin of the rib, leaving on its with- drawal a valvular opening through which there is little danger of air entering. The semi-recumbent is the most convenient posture. Syn- cope, due to the pressure of the effusion, sometimes follows if the pa- tient attempts to lie upon the sound side. A similar result may follow the too rapid withdrawal of the fluid, or the removal of too great a quantity, owing probably to the viscera being unable to accommodate themselves to the altered conditions. The operator should accurately locate the point of proposed puncture, so that the trocar, carefull}r guarded by the finger, may be carried through the tissues with a firm thrust, thus causing less pain and insuring its passage through the pleura without danger of its penetrating too far, since with a dull trocar, slowly inserted, the costal pleura might be separated from the chest-wall and carried in front of the instrument, which would then fail to reach the cavity. The quantity of fluid to be removed depends upon the conditions of the individual case. No attempt should be made 822 INJURIES AND DISEASES OF THE CHEST. to remove all the fluid at once if the pulse becomes feeble, if blood is found in the tube, or if the patient becomes weak from coughing; the canula should under these circumstances be immediately removed and the opening closed with gauze and collodion. Not infrequently the flow will suddenly cease, owing to the occlusion of the canula with lymph, which may be disengaged by inserting the blunt rod which is provided for that purpose. Rarely do any serious consequences follow the with- drawal of pleural effusions, except an attack of syncope, which may readily be relieved by placing the patient in the recumbent posture. Perfect rest should be enforced for a number of hours after the oper- ation. Should the lung persistently refuse to expand after repeated tappings, it is hardly worth while to pursue this method of treatment, and tonics and change of air will often prove a more satisfactory means of dealing with these recurrent cases. The prognosis in acute effusions following traumatic pleurisy, in non- tubercular cases, and where the lung expands, is favorable; but if the fluid is purulent, and if after several tappings no improvement is noticed, through drainage of the cavity will usually be the best method to pursue. Drainage of the Pleural Cavity.—This is seldom required, ex- cept for empyema. Simple aspiration for the relief of a purulent effu- sion, except where it is of traumatic origin or in children, is not a very successful operation, and only in those cases in which the compressed lung re-expands on the receding of the fluid and re-occupies its normal position, should it be used. One difficulty in the attempted cure of empyema by aspiration is the inability entirely to empty the pleural sac. After the operation a certain amount of pus is apt to be left, and its absorption really never takes place. The early recognition of puru- lent change in a pleural effusion is important. In addition to the physical signs denoting fluid in the pleural sac, the presence of pus will be indicated by chills, hectic, and the other phenomena which accom- pany pus formation. It should always be suspected in children, espe- cially after the eruptive fevers or any serious illness where convalescence is unaccountably delayed, when the patient, instead of improving, begins to fall back. If, under such circumstances, there are any in- dications of fluid within the pleural sac, its character should imme- diately be verified by using the exploring syringe. The spontaneous cure of an empyema is a rare occurrence. If left to itself, the pus tends to increase in quantity, and will either rupture externally or into the lung, and be discharged through the bronchus. In a case which came under my care, it burrowed down behind the diaphragm and opened into the intestine. Moullin states that it sometimes follows the course of the psoas muscle and points in the groin. Death may occur suddenly from syncope, due to the rapid escape of the fluid following a rupture; the heart and lung being displaced from prolonged pressure and capable of working only to great disadvantage, the least exertion suddenly turns the scale, and death results from asphyxia due to oedema of the opposite lung, or to pus being discharged into the bronchi in such quantities that it cannot be coughed up. I have seen a case in which the discharge through the bronchi was so profuse that by placing the body in a favorable position—that is, by laying the patient on his sound 823 SURGICAL TREATMENT OF PLEURITIC EFFUSIONS. side with the hips well elevated and the head low—a continuous stream of pus flowed from the mouth for almost a minute. Death in empyema may also result from septic absorption or from amyloid degeneration. Sometimes, in children, where the lung has been long compressed, the rather yielding chest-walls will fall in after evacuation of the fluid, encroaching upon the lung and occluding the pleural space, causing a lateral spinal curvature on the affected side with compensating curves above and below. It occasionally happens that the cavity will be occluded by the adhesion of the two pleural sur- faces. The unyielding upper chest-walls, however, often fail entirely to contract, leaving a sinus which keeps on discharging a small amount of pus, with little or no inconvenience to the patient, though the pro- longed drain in time may tell upon the general health and lead to amy- loid degeneration. Preparatory to the operation for draining an empyema the patient should be in the recumbent position, and as nearly as possible flat on the back. It is more convenient for the surgeon if the patient be rolled over on the sound side, but such a position is apt to embarrass the breathing, especially when the patient is under the influence of an anaesthetic. Chloroform is preferable to ether for these cases, as it induces much less bronchial secretion. The site of incision must be in- fluenced by the physical signs afforded by the collection of matter within the pleural sac. If pus is actually pointing, or if an old sinus exists, that spot should be selected, and, if necessary, a secondary opening may be made elsewhere to insure complete drainage. The usual site, how- ever, is the seventh or eighth interspace in the mid-axillary line in front of the latissimus dorsi muscle. If for any reason a more anterior open- ing should be decided upon, the fifth or sixth interspace posterior to the costal cartilage may be selected, the chest-walls being thinner here than elsewhere. It is well to raise the arm up to a right angle, as its movement displaces the skin, and the incision should then be made so far above the spot selected that when the arm is brought to the side a direct opening into the thorax will be made, and not a valvular one, the skin wound and the deeper wound corresponding. An incision from one and one-half to three inches in length should be made trans- versely over the upper margin of the rib, down to the intercostal mus- cles; then with a firm steel director an opening is made into the cavity beyond. This opening may then be enlarged with the finger or with a pair of sinus forceps. In ordinary cases a drainage-tube as large as the space will admit should be inserted. If for any cause it is found that a second opening is advisable, a steel vesical sound may be introduced through the opening, and its beak made to project at the desired inter- space, where it is easily cut down upon with a knife. If two openings are made, the tube (which should be flexible and not too rigid) may be attached to a curved probe, carried through one opening and out of the other, and retained with two safety pins. In this w’ay there is little risk of the tube slipping into the chest or being removed with the dress- ing, which should be of some absorbing material, such as cotton or oakum, in large loose folds, covered with rubber tissue or wax paper, and retained by the turns of a broad bandage. The dressing should be changed frequently. If from any cause the intercostal artery should be wounded, it should be completely severed and allowed to retract into 824 INJURIES AND DISEASES OF THE CHEST. its sheath, as much more serious bleeding will result from a punctured than from a severed vessel. Failing in this, pressure by plugging with gauze for a short time will usually suffice to control the bleeding. After the pus has slowly drained away and the cavity has been emptied, it is unnecessary to wash out the pleura with an antiseptic, as absorp- tion ceases and the temperature falls as soon as perfect drainage is established. When, however, the discharge has subsided a little, and especially when the escaping matter is offensive, with a tendency to a nightly rise of temperature, the cavity may be washed out by allowing several gallons of a warm, mild antiseptic solution, such as Thiersch's fluid, to run slowly through it from a vessel held at a slight elevation. Sometimes, especially in operating on cases in which a sinus has existed for some time, permitting partial escape of the fluid, and in which the chest-wall has contracted so that the ribs overlap, as the slates on a roof, thus reducing greatly the size of the interspaces, it may be neces- sary, in order to obtain a sufficient opening for the tube and to prevent its being compressed, to excise a small portion of one or two ribs. This is easily done after exposure of the rib through the above-described incision. The removal of the periosteum is effected by a periosteotome or curved raspatory, the ribs being steadied by a pair of strong forceps, and they are then divided in two places by a small but firm saw, care being taken that this does not puncture the lung. In children cutting forceps may be employed instead of the saw, but in adults the latter is the preferable instrument, the use of the bone forceps having a tendency to unduly crush and splinter the rib. After the resected portion of the rib has been removed, and the thickened pleura cut away with scissors, the cavity should be gently explored with the finger, as an accurate knowledge may thus be obtained of its extent, and the large masses of curdy material which are often met with may thus easily be detected and extracted. Sometimes, too, the finger will break down adhesions and open up localized cavities which might otherwise have remained unopened for a length of time. This procedure is not to be advocated in all cases. If the ribs are wide enough apart, as in a well-formed chest, sufficient drainage may be obtained by incising an interspace. It seems wiser to avoid ex- cising a portion of the rib, if possible, when the pus is fetid, as absorp- tion of putrid material is said to be more likely to take place when the bone is cut across; I have, however, never seen any ill results from the procedure. On the other hand, if the ribs offer any interference to drainage, a portion should be immediately removed. The drainage- tube in all cases should be retained as long as any discharge appears; and if, after its removal, there are signs of re-accumulation—such as increased discharge, showing externally, rise of temperature, general discomfort, and thoracic pain—no time should be lost in dilating the sinus and reintroducing it. If this be delayed, the newly formed adhe- sions will give way and much time will be lost. Thoracoplasty; Estlander’s Operation.—Not infrequently, in old cases of empyema, the lung is so bound down by adhesions as the result of prolonged compression, that no amount of aid which it may receive by even perfect drainage and the partial collapse of the chest-walls will enable it to expand and allow obliteration of the cavity. This con- SURGICAL TREATMENT OF PLEURITIC EFFUSIONS. 825 dition is nearly always due to neglect, so that a spontaneous perforation has occurred leaving a thoracic fistula, which discharges at times hut a small amount of pus, and at others a much larger amount, and which if uncured, is sure sooner or later to lead to amyloid disease. Even if the cavity is widely opened by the ordinary method, it is impossible for it to heal, since the lung cannot expand from within nor the chest-wall collapse from without. The ribs, acting like parallel hoops, preserve a cavity which every effort on the part of nature fails to close. It is in these cases that the operation of Estlander, or thoracoplasty, has ren- dered such signal service. It is based on the theory that the unyielding outer walls of the chest-cavity must he made to collapse and meet the lung, and consists in the resection of the ribs which overlie the cavity, the results depending largely upon the completeness with which the two surfaces are brought in apposition and the cavity obliterated. It is almost needless to say that this operation should never be performed except when obliteration of the chest-cavity cannot he obtained in any other way. The state of the heart, of the other lung, and of the kid- neys, must also be taken into careful consideration. Phthisis and ad- vanced amyloid degeneration, if distinctly present, are insurmountable objections to operative interference. The preparation of the patient is the same as for ordinary resection of the ribs. Chloroform is probably the best anaesthetic. The cavity to be treated must be thoroughly explored, if possible with the finger or vesical sound, and its margins accurately mapped out upon the chest with an aniline pencil. It will as a rule be found that the cavity is in the upper and central part of the pleural sac, rather than in its lower portion. No definite rule can he laid down for all cases, as it is impossible to determine beforehand how many or how much of the ribs will have to be resected. The success of the operation depends here, as it does in operations on other hone cavities, on the removal of the anterior por- tion of the bony wall, thus permitting the soft tissues to fall in and occlude the exposed space. The ribs usually removed are from the second to the seventh inclusive. The amount removed may vary from one inch to nearly the entire length of the rib. Various plans and incisions are proposed for exposing the costal walls. Estlander makes an incision along the costal space, and through this wound resects the two adjoining ribs. If six ribs are to be resected, three incisions will be called for. Jacobson advises two or three inci- sions, two being usually sufficient, and raises several flaps comparatively small in size. Mr. Godlee, one of the highest of English authorities, in his Brompton Lectures, advises a large V-shaped or U-shaped flap com- posed of all the soft parts. This makes the operation one of considerable severity, as it involves a large wound and possibly much hemorrhage. Gould recommends a longitudinal incision over the central part of the cavity, each rib being exposed in turn and stripped of its periosteum. If a considerable length of rib has to be removed, it is better to cut it away piecemeal. If the cavity extend far hack toward the spine, it will be found convenient, after removing the anterior portion of the rib, to remove the posterior part from the inside, peeling the thickened pleura from the bone and applying angulated cutting bone forceps from within the chest, thus simplifying the operation and disturbing 826 INJURIES AND DISEASES OF THE CHEST. the soft parts less than by any other plan. The hemorrhage attending the operation is considerable, but is easily controlled. It has been advised, in dealing with large cavities, to attack the ribs from two points: in the usual position, and posteriorly at the inner border of the scapula; thus three or four ribs may be divided in front, and from three to seven behind. The operation is severe in itself, and leaves the patient with an opening through the chest. My own preference, if the cavity is not too extensive, is for the longitudinal incision of Gould, which under ordinary circumstances gives a very perfect exposure. If, on the other hand, the cavity is found to extend over a large space laterally, the exposure made by the incisions of Estlander over the in- tercostal spaces will prove most satisfactory. Having removed a suf- ficient length of a sufficient number of ribs, if necessary up to the first —which is never touched on account of its close proximity to the sub- clavian vessels—as much of the thickened pleura and periosteum is cut away with scissors as will leave a soft, pliant covering to fall in and rest upon the visceral pleura, thus obliterating the cavity. To accom- plish this, the cut ends of the ribs must correspond as nearly as possible with the anterior and posterior margins of the space which it is intended to close. It is important to remove enough periosteum, since the great rapidity with which bone is reproduced, if its ensheathing membrane is left, soon puts a stop to the process of contraction, and in some cases a mass of callus has been developed, forming a hard wall as incapable of yielding as the imbricated ribs which it has replaced. The operator has now an opportunity to thoroughly explore the cavity, and it may seem expedient to curette its inner surface with a spoon, to remove septic debris; this, however, really does but little good, and often does harm, as the sharp spoon may scrape over the surface of the pericardium, or in close proximity to branches of the pneumo- gastric or sympathetic nerves. If the cavity should be very large, it may be carefully mopped out with some antiseptic, or a mild antiseptic fluid may be injected with care, this often greatly adding to the com- fort of the patient. In my own experience I have never had an un- pleasant result from washing out an old empyema; but it must be re- membered that a considerable number of cases are on record in which an injection, which may have been frequently repeated without serious consequences, has led to sudden death or to the most alarming symp- toms, probably from the sudden increase of pressure within the cavity, caused by a partial closing of the outlet or by the use of too large a tube. The nature of the fluid employed can have had nothing what- ever to do with these results, as equally bad results have followed the use of pure water. A large drainage-tube is to be placed in the most dependent portion of the incision, and if necessary a special opening may be made for the tube, when the wound may be closed with sutures. Every provision should be made to insure reaction, as the operation is often accompanied by much shock. The dressing of gauze and cotton is to be retained by a broad bandage carried around the chest. Paracentesis Pericardii. Paracentesis pericardii is essentially a modern operation, although it was advocated nearly 180 years ago by Senac. The precision and ac- PARACENTESIS PERICARDII. 827 curacy with which fluid collections within the pericardium can now be mapped out upon the external surface of the chest, make it a much easier and more precise operation than when it was performed by Larrey. The older writers who have referred to the operation have contented themselves with either advocating or opposing it on purely theoretical grounds. Opening the pericardial sac may be required for the removal of fluid collections, either of a serous or purulent nature, and usually dependent upon prolonged attacks of illness, generally of a rheumatic origin, or occurring in the later stages of general dropsy. It is worthy of note that of 79 cases of purulent pericarditis reported by West, but one proved fatal as the result of the operation, the trocar in this instance having entered the right ventricle. The immediate result of the opera- tion in nearly every case was good, even if but a small quantity of fluid was removed, the mechanical interference with the heart’s action being obviated by the relief from pressure. Death, when it followed, ap- peared to be entirely the result of the original disease, rather than of the operation or of consequent pericarditis. Mode of Operation.—If it can be determined with any degree of ac- curacy that the effusion is of a serous character, and not purulent, its removal by means of the aspirator, observing strict antiseptic precau- tions, will usually prove the safest and easiest mode of treatment, as the puncture is small, and the entrance of air is readily prevented. If, however, the pericardial fluid is purulent* it is best dealt with as if the case were one of empyema, by free incision down to the sac, which should be lifted with forceps, incised with a pair of blunt-pointed scissors, and dilated with a pair of sinus forceps, allowing the free escape of the fluid. The quantity removed may be very great, and in Dr. West’s successful case as much as two quarts were removed with- out any bad symptoms, or even faintness, but, on the contrary, with immediate relief. The fluid contents of the pericardium might also be evacuated by means of a trocar and canula, and this would probably be a perfectly satisfactory method of treatment, if the question of drain- age with a soft-rubber tube and the washing out of the sac with some mild antiseptic solution, such as Thiersch’s fluid, were not to be con- sidered. Upon this largely depends the success of the operation. Trephining of the sternum has been suggested on theoretical grounds as a preliminary to tapping the pericardium, but this procedure is to be deprecated, as it exposes a very vascular bone to the risk of septic absorption and necrosis. The Place of Puncture.—The point to be selected is usually in the fifth intercostal interspace, about an inch to the left of the sternum, in order to avoid wounding the internal mammary artery which lies about one-half to three-fourths of an inch to its outer border. When the pleura is obliterated and adherent to the pericardium, the operation be- comes much simpler, as a spot can be safely selected near the nipple line without danger of opening the pleural sac. The results of the operation should be more favorable than those of empyema, as the walls of the cavity are better adapted to follow and contract on the receding fluid, and thus permit of complete obliteration. The after- treatment of these cases does not differ from the mode of dealing with purulent collections elsewhere. DISEASES OF THE BREAST. BY MAURICE H. RICHARDSON, M.D., VISITING SURGEON TO THE MASSACHUSETTS GENERAL HOSPITAL; ASSISTANT PROFESSOR OF ANATOMY, HARVARD MEDICAL SCHOOL. Our knowledge of diseases of the mammary gland has been extended chiefly in the line of malignant growths, especially carcinomata. The following article is devoted largely, therefore, to the principal advances made in this direction. A few observations of minor importance have been included upon other topics considered in detail by Professor Ann- andale in Yol. V. Where neither additions nor corrections have been made, it will be understood that the authorities of to-day differ in no material respect from those whose views were expressed so ably by the author of the article of 1884. Anatomy of the Breast. The boundaries of the breast exceed even the limits previously de- scribed by surgeons and anatomists. The importance of an accurate knowledge of the peripheral extension of the glandular tissue is very great, inasmuch as the modern operation for carcinoma requires the re- moval of the entire gland. For purposes of description, the breast is divided by S. W. Gross' into quadrants by two lines passing through the nipple, one vertical and one horizontal, intersecting each other at right angles. Stiles2 adds two oblique lines, reaching the circumference of the breast midway be- tween the vertical and horizontal ones. By ascertaining exactly the extremities of these lines, and connecting them, the true boundaries of the breast can be accurately determined. By this method Stiles describes the limits of the breast as follows:— “The vertical diameter extends from the lower border of the second rib to the sixth costal cartilage at the angle where it begins to sweep upward to the ster- num; the horizontal, from a little within the edge of the sternum opposite the fourth rib or interspace to the fifth rib or interspace opposite the mid-axillary line. The one oblique diameter extends from the upper border of the third cos- tal cartilage a little without the sternum downward and outward to the seventh rib a little in front of the mid-axillary line; the other oblique diameter passes 1 Am. Jour. Med. Sciences, March, 1888. 2 Edinburgh Med. Journal, June and July, 1892. 829 830 DISEASES OF THE BREAST. from the third rib a little beyond the anterior axillary fold downward and in- ward to the sixth costal cartilage midway between its angle and its sternal end. The circumference of the organ may be defined by connecting together the ex- tremities of all the diameters. When the arm is elevated, as for an operation, the nipple in a nullipara is placed opposite the fourth rib or interspace, and only about one inch within the axillary border of the pectoralis major, thus showing that the extent to which the breast overlaps the muscle is very considerable. The level of the breasts varies somewhat according to the configuration of the chest—thus tall women generally possess a low bust, while short, broad-chested women have usually a high bust. “ The inner hemisphere rests almost entirely on the pectoralis major; at its lower part it extends beyond the lower edge of this muscle, and slightly overlies the aponeurosis of the external oblique of the abdomen. The outer hemisphere has less simple relations, and must be dealt with in segments. The upper half of its upper quadrant rests on the greater pectoral, on the edge of the lesser pectoral, and, for a slight extent, on the serratus magnus, upon which, and under cover of the pectoralis, it extends upward into the axilla as high as to the third rib. Spence was in the habit of referring to this prolongation as the ‘axillary tail’ of the mamma. The circumference of this segment crosses the edge of the pecto- ralis major at the level of the third rib—that is, just where the muscle leaves the chest-wall to form the anterior axillary fold. The lower half of the upper quad- rant, and the upper half of the lower quadrant, rest almost entirely on the serra- tus, with the exception of a small area adjacent to the nipple, which overlies the pectoralis major. The lower half of the lower quadrant has relation to the digi- tations of the serratus and external oblique which arise from the fifth and sixth ribs, and the part near the nipple lies on the pectoralis major. It will thus be seen that about one-third of the whole mamma lies inferior and external to the axillary border of the pectoralis major. Of this portion the upper half overlies the lower part of the inner wall of the axilla, and is separated from its contents only by the axillary fascia, which is here very fatty, so that the lymphatic glands lying embedded in it appear to be in direct contact with the breast.” Heidenhain, quoted by Dennis,1 at the German Congress of Surgeons in Berlin, in 1890, pointed out the fact that the ligaments of the breast were often surrounded by projections of the parenchyma of the gland and might contain cancer cells. This is true of the so-called ligaments of Sir Astley Cooper as well as of those which are retro-mammary, and which bind the breast to the fascia. Stiles has demonstrated the fact that, by treating the breast with nitric acid, the tissues may be so modified that macroscopic changes are produced which permit the constituents of the gland to be seen in marked contrast with each other. This method, described under the operative treatment of mammary cancer, enables one to see the outlying bound- aries of the breast, its relations to the skin and deep fascia, and the manner and extent of cancerous infiltrations. Peripheral processes2 “springing from the anterior surface of the breast appear as triangular, tooth-like processes with fibrous prolongations (‘ligaments’ of Cooper) passing from their apices to the corium. The parenchyma is pro- longed into these processes, and in thin women reaches almost up to the corium. It follows, therefore, that the surgeon must either sacrifice a large amount of skin, or keep so close to it in dissecting it off the mamma as to run some risk of sloughing.” . . . Posteriorly the microscope “reveals the presence of outlying gland lobules, extending from the corpus mammae into the retro-mammary tissue, up to and be- 1 Trans. Am. Surg. Assoc., vol. ix., p. 220 et seq. 2 Stiles, loc. cit. AX ATOMY OF THE BREAST. 831 tween the layers of the pectoral fascia. In order, therefore, to remove all the parenchyma, the retro-mammary tissue and pectoral fascia as well as the breast must be carefully dissected off the muscle. Beyond the limits of the parenchyma the stroma of the peripheral processes becomes directly continuous with the con- nective-tissue framework of the circum-mammary fat.” . . . “ The surgical anatomy of the mamma would not be complete without a reference to the retro-mammary tissue and pectoral fascia; indeed, from the surgeon’s point of view these structures are no less important than the breast itself, and should be looked upon as part of it. In spare women the corpus mammae is separated from the subjacent muscles by a thin layer of loosely arranged, delicate connective tissue rich in elastic fibres; the deeper layers are more closely packed to constitute the pectoral fascia proper, which is very thin and gives off processes which penetrate between the fasciculi of the pectoral muscle. The presence in this retro-mammary tissue and pectoral fascia of out- lying lobules of the parenchyma has already been referred to. No separation can be made with the knife through this loose areolar tissue without the risk of leav- ing behind lobules of parenchyma. In obese subjects the retro-mammary tissue is laden with fat, which forms a thick layer separating the corpus mammae from the subjacent muscles. The fascia in such cases is so thin as scarcely to be recognized.” The course of the lymphatic vessels is of great importance. The evi- dence upon which our knowledge of the anatomical distribution rests is largely clinical. The main lymph current which sets toward the axilla along the border of the pectoralis major corresponds closely with the course of the arterial supply. Other instances show that lymph drainage extends through the space between the deltoid and pectoral muscles, or directly into the chest through the intercostal spaces; while the immediate communication with the lymphatics of the skin is shown by the frequent occurrence of rapid and extensive superficial invasion known as “ carcinome en cuirasse.” Stiles 1 looks upon the mammary lymphatic system as consisting of five sets of vessels which communicate freely with one another:— “ (1) A superficial or cutaneous set, including those of the nipple, areola and surrounding skin; (2) the sub-areolar plexus of Sappey; (3) intra-mammary lymphatics; (4) lymphatics of the circum-mammary fat; (5) retro-mammary lymphatics. “ The lymphatics from the inner part of the mamma accompany the perforating branches of the internal mammary artery to join the sternal glands placed along its trunk. The greater number, however, accompany the mammary branches of the acromio-thoracic, long thoracic, and external mammary branches of the axillary artery to open into the axillary glands. As many as twenty, thirty, or even more may not infrequently be counted when the axilla has been thoroughly cleared out. The reasons for the anatomical underestimation of the number of glands in the axilla are, that some measure not more than one or two millimetres in diameter, while others have undergone such an extensive fatty involution as to resemble closely an ordinary fat lobule.” W. Roger Williams2 regards the mamma as the homologue of a single sebaceous gland. Polymastism in the human subject occurs in certain definite positions, and corresponds almost invariably with the mammae of polymastic animals. He has found in fifty cases of fibro- adenoma of the mammary region that seven (14 per cent.) had origi- 1 Loc. cit. * Jour. Anat. and Phys., vol. xxv., pp. 225-304. 832 DISEASES OF THE BKEAST. nated in supernumerary mammary structures outside normal mammae. Of 132 cases of cancer he found 13 (9.8 per cent.) which had developed in the same manner, and others which seemed to have done so. He also cites cases of complete absence of both breasts, areolae, and nipples, in women otherwise well-formed. One case is recorded in which both breasts completely disappeared after lactation had ceased, and reap- peared in good condition with the next pregnancy. Inflammation of the Breast. Nursing from an inflamed breast is not without danger. Chaillou reports the case of a child nursing from the breast of a primipara affected on the ninth day with lymphangeitis. Death took place with convul- sions, coma, paralysis of the lower extremities, and partial paralysis of the left arm. The autopsy showed extensive foci of infection in the brain, spinal cord, and liver. The infecting material was supposed to have been absorbed through the intestines. Nursing from a breast in which the slightest symptoms of lymphangeitis exist is forbidden by most accoucheurs. Osteochondro-sarcoma op the Breast. Mr. Battles1 reports a case of this very rare form of mammary tumor. There had been a small lump on the inner side of the nipple for six years. It had been the size of a pea for two years, and was as large as a hazelnut three years later. When the patient was admitted to the hospital the tumor was the size of an orange, painless, and hard. The nipple was much retracted, but the skin was movable. The tumor was removed and the patient did well. Clarke2 reports a case of calcifying chondro-sarcoma of the female breast. Tuberculosis of the Breast. Tuberculosis of the mammary gland is a rare affection, though doubtless many cases are overlooked for want of accurate histological diagnosis. Very little has been written on the subject. In 1881 Dubar a published the first modern scientific studies in regard to it, and in the same yearLe Uentu 4 continued the investigation, to which Olnacker in 1883 added an able paper.6 The first reference to mammary tuber- culosis in English and American books on surgery was made by Ros- well Park in the American System of Gyaeecology, 1887-88. Since 1887 scattering contributions to our knowledge of this disease have ap- peared in periodical literature from Orthmann, Hering, Maudry, Roux, Campenon, Lane, Shattock, and others. An accurate and valuable summary of all the work done in this direc- 1 Lfincet, 1886, vol. i., p. 975. 4 Transactions Path. Soc. London, 1890. 3 Des Tubercles de la Mamelle, Th£se. Paris, 1881. 4 Revue de Chirurgie, 1881, tome i., p. 27. 5 Arcliiv f. klin. Chirurgie, 1883, Bd. xxviii., 8., 366. MALIGNANT DEGENERATION OF BENIGN TUMORS. 833 tion has been given by Powers,1 from whom the following statistics are taken. In the literature of this country but two cases could be found in which an accurate histological diagnosis was made, although several have been reported in which the diagnosis of tuberculosis rested upon the history and gross appearances alone. From the study of all avail- able literature only 35 cases have been collected, of which 34 were in women. The majority occurred during the years of active child-bear- ing and lactation. The relative frequency of the disease, until more data are available, is impossible to estimate, although it is safe to say that it is compara- tively rare. Bull, of New York, among 185 cases of tumor of the breast, in all of which the growths were examined histologically, found but one of tuberculosis. At the Massachusetts General Hospital no cases have been recorded. Pathology.—This disease usually manifests itself in the form of cold abscesses and chronic fistulse. The latter may involve the breast or the axilla. There may be a single large diffuse swelling of the breast, or several small fluctuant areas. The fistulas present the usual gross ap- pearances of tuberculous tracks. In another form one or more hard nodules may be found in the breast, which on section present the usual appearances of tubercles in different stages of caseation. The axillary glands may be involved, with or without the formation of tubercular abscesses, or they may not be affected at all. Disseminated tubercles may be found in the tissues around the breast. The diagnosis of tuberculosis can be confirmed only by bacteriological demonstration. A family history of tuberculosis, with evidence of the disease in the lungs or elsewhere in association with the local signs in the breast, though obviously very suggestive, is not sufficient proof of the identity of the disease, unless confirmed by a positive histological and bacteriological examination. Prognosis. —Presumably the general prognosis will depend on the existence of other tubercular foci, and on the extent to which the glands are involved, as well as on the constitutional condition of the individual. Very few of the cases reported have been followed up. Powers2 traced two cases after radical operation; both patients died of phthisis, one one year, and the other four years, after the operation. Treatment.—After the diagnosis has been made the only treatment to be considered is thorough excision of the disease both in the breast and in the axilla. Mammary tuberculosis is regarded as a particularly dangerous source of general tubercular infection. Malignant Degeneration of Benign Tumors. Gross3 recommends extirpation of benign tumors on account of their tendency to become malignant, and because tumors of the breast are always a source of anxiety. In one of my cases of diffused fibroma, Dr. Whitney found a spot of carcinoma. Dr. Cabot refers to a similar case. The question of malignancy in connection with benign tumors 1 Annals of Surgery, 1894, Yol. xx., p. 159. 2 Loc. cit. 3 Fibroma of Female Breast, Based upon the Study of One Hundred Cases. Med. and Surg. Rep., 1887. 834 DISEASES OF THE EREAST. has been discussed by Paget, Hutchinson, and others. Paget says that cancerous disease has never been observed to occur in adenomata of the breast, but Hutchinson,1 on the other hand, declares that adenoma of the breast, after existing for many years, may serve as a centre for scirrhous growth. This writer therefore questions whether it would not be better to remove all adenomata of the breast, and whether, in a particular case, if the adenoma had been removed any scirrhus would have developed. Patteson2 describes two cases of adenoma of the breast in children, and, speaking of this variety of tumor and its formation, remarks that while the epithelial proliferation remains intra-cystic, we have the comparatively benign proliferating cystic adenoma; but that if the epithelial development becomes extra-cystic, and crossing the basement membrane extends into the inter-acinous stroma, then we have the infiltrating adenoma, or early stage of adeno- carcinoma, with its rapid local malignancy, etc. Cystic tumors of the breast may be malignant or benign. The pres- ence of cysts has little bearing, therefore, on the question of diagnosis or prognosis. Butlin 3 reports sixty-six cases of cystic and sixty-six of connective-tissue tumors, nine of carcinoma, and one of adenoma. The solid constituents of these tumors, not their number or their size, in- fluence their history. Gaillard Thomas describes a method of removing benign tumors without mutilation. He advises their removal because patients with any form of mammary tumor are apt to be apprehensive, nervous, and gloomy. This method is inappropriate for malignant tumors, but has been applied to fibromata, lipomata, cysts, and adenomata, varying in size from that of a hen’s egg to that of a duck’s egg, or larger. The operation is thus performed: The patient standing erect, and the mamma being completely exposed, a semicircular line is drawn with pen and ink exactly in the fold which is created by the fall of the organ upon the thorax. As soon as it has dried the patient is anaesthetized, and with the bistoury the skin and areolar tissue are cut through, the knife exactly following the ink line until the thoracic muscles are reached. The mamma is now turned up on the clavicle, and the growth is dissected out from below. Sarcomata of the Breast. The prognosis after removal of the breast for sarcoma depends upon the class to which the tumor belongs. In some instances the malig- nancy exceeds that of carcinoma, especially in the melanotic variety. The prognosis is influenced by the invasion of the axillary glands. In the more rapidly growing and malignant forms of sarcoma the lymphatic glands of the axilla have been found early and extensively infected, and in such cases the recurrences have been rapid. At other times there have been remote metastases without perceptible enlarge- ment of the neighboring lymph-glands. The jiresence of swollen and tender glands in the axilla in connec- tion with sarcomata of the breast does not necessarily prove that they 1 Trans. Path. Soc. London, 1888, vol. xxxix. 2 Jour, of Anat. and Physiol., vol. xxvi., p. 509. 3 Lancet, July 12, 1884. TREATMENT OF MAMMARY SARCOMA. 835 are malignant—the glands may be simply irritated. The surgeon should err on the safe side, however, and should clear out the axilla in all such cases. Gross reports 92 cases.1 There were 42 local recurrences; in 8 there was repro- duction of the tumor with metastasis; in 3, recurrence with all evidences of general dissemination; 4 were characterized by metastases and 2 by presumed metastases without local reproduction—that is, 64.83 per cent, possessed malignant features. Of the reproductions 57.7 per cent, occurred in six months; after twelve months 28.8 per cent, and only 8.8 per cent, of the latter after two years. The latest reproduction occurred after four years. The patient’s chances are relatively good after two years. In 156 cases axillary glands were enlarged, and these were occasionally tender in 19, operations with subsequent examination indicating hyperplasia. Before the age of 35 the slow-growing sarcomata will not recur, but rapidly growing sarcomata are very apt to recur, especially the cystic variety. The round-celled growth is the most malignant, but metastases occur with the spindle-celled variety. The operation cures in some cases, and certainly pro- longs life. Ninety-one operations show 13.18 per cent, of the patients well after four years. If all recurrences are removed as fast as they appear, suffering is alleviated, life prolonged, visceral contamination averted, and, occasionally, a cure effected. Gross concludes: (1) that sarcomata of the mammary gland, including those of the cystic variety, which is a comparatively benign growth, are neoplasms of decided malignancy; (2) that surgical intervention prolongs life, and fre- quently results in permanent recovery, and that local reproductions do not mili- tate against final cure, provided that they are freely removed as fast as they appear; (3) that the subjects are absolutely safe from local and general repro- duction if four years have elapsed since the last operation. Gross’s statement that sarcoma of the breast does not usually affect the axillary glands, is confirmed by Butlin,2 only one of whose seven cases of cystic sarcoma had the axillary glands infected. In this case the glands were not removed, and four years afterward the enlargement had subsided completely. Heath3 regards sarcomata as about as malignant as carcinomata. A soft, rapidly growing tumor of the breast, unaccompanied by enlarged axillary lymphatics, is usually a sarcoma. This consideration does not affect treatment, but has an important bearing on prognosis. There is a great tendency to local recurrence. Treatment.—The treatment of mammary sarcoma by the injection of the products of erysipelas and other micro-organisms, as described by Coley, offers more hope of cure than in carcinomata. This method was very successful in one of my own cases of fibro-sarcoma of the ab- dominal wall, in which the diagnosis was confirmed by a microscopic examination by Dr. W. F. Whitney. In this instance there was com- plete disappearance of the growth after a few months’ treatment. This method should not, however, be used for growths which can be thoroughly extirpated by the knife. In carcinoma the results are not encouraging. After parenchymatous injections of pyoktanin and other chemicals the results are unpromising. This method I tried re- peatedly and thoroughly in a case of rapidly recurring myxo-sarcoma, after the operative treatment had included resection of the ribs and sternum. The cells were found deeply stained, but there had been no perceptible influence upon the growth. 1 Prognosis of Sarcomata. Trans. Amer. Surg. Association, 1887, vol. v., p. 288. 2 Lancet, July 12, 1894. 3 Ibid., 1891, vol. i., p. 1027. 836 DISEASES OF THE BREAST. Carcinoma of the Breast. Most of the published work upon mammary tumors has been done in connection with breast cancer, its etiology and operative treatment. In methods of operating the practice of ten years ago has been extremely modified, especially with regard to the extent and completeness of the procedure. A further improvement, common to all operations, has been in the thoroughness of aseptic details—as contrasted with an- tiseptic—with a marked diminution in the immediate mortality of the operation. The number of permanent cures has increased in an en- couraging ratio. Not that the results of the most thorough modern operation afford a large percentage of permanent cures, yet the re- mark of S. D. Gross, made thirty years ago, is no longer true,—that is, that nothing is more unpromising than surgical interference in cases of breast cancer, though life may be prolonged from six to eighteen months. Not only is life prolonged in recurring cases, but the per- centage of permanent cures is very much increased by the complete- ness of the operations now recommended. Diagnosis of Mammary Carcinoma.—Unless we follow the rule to operate in all doubtful tumors, it is very desirable to demonstrate by incision the exact nature of the growth. For purposes of exploration, Mixter, of Boston, has devised a small hollow punch, with a circular cutting edge, by means of which a small section of the whole thickness of a tumor may be withdrawn for microscopic examination. Yet the objection common to all simple explorations applies to this method—• the probability of overlooking a focus of malignancy in an otherwise benign growth. Tumors of doubtful nature, therefore, especially in women after the age of forty, should be investigated more thoroughly than can be done by a small incision or by an exploratory punch. The importance of “skin dimpling” in carcinoma of the breast is urged by Tiffany.1 This symptom may occur when the original focus of disease is so small that attention has not been drawn to it. It is almost pathognomonic of cancer, and is rarely multiple. The dimple is most commonly seen in fibrous carcinoma, and is due to shortening of the connective-tissue processes. This symptom, even with no other signs, justifies immediate operation. Enlarged glands in the axilla are usually regarded as demonstrating the malignancy of breast tumors, but Warren 2 calls attention to the occasional tumors of the sweat glands which may simulate enlarged lymph glands. Stiles3 speaks of fatty involuted lymph glands, imperceptible through the skin, which, when the axilla has been opened, resemble malignant glands. In stout women these glands resemble fat lobules, and may be overlooked. Prognosis of Mammary Carcinoma.—The immediate mortality from the modern operation has much diminished in the last decade. The objections formerly raised against extensive dissections no longer rest upon a large death-rate. The mortality as reported from different sources in the past ten years is shown in the following table:— 1 Maryland Med. Jour., vol. xxvi., p. 309. 2 Boston Med. and Surg. Jour., July 5, 1894. 3 Loc. cit., p. 33. CARCINOMA of the breast. 837 Table Showing Mortality After Operations for Carcinoma of the Breast. Jefferson College, Philadelphia (previous to 1887).. Konig (1875-85) Gross (previous to 1888) Butlin (collected cases) Lister Butlin Gross (collected cases) Terrillon (1880-90) Weir Dennis (previous to 1891) Gross “ “ “ No. of Cases. Mortality Per Cent. 58 3.7 152 7.2 45 4.44 605 15.859 37 (24 axillae) 5.405 40 7.5 1234 14.24 100 0. 125 0. 71 1.408 10 Lister (reported by Cheyne ; previous to 1891) Butlin (previous to 1891) Billroth (before 1888) Fischer (previous to 1891) Esmarch “ “ “ 8. 7. 23. 20. 10. K lister “ “ “ 14. Billroth (another list) Id. (still another list) Mass. General Hospital (1877-86) Do. (1819-71; Do. (1888-94) Hans Schmidt Warren Richardson \ (Since 1888) hosPital mcnaruson | „ 1890) priyate Halsted 68 274 290 215 228 (2 males) 47 38-U103 50 15. 6. 8.3 7.9 1.86 10.81 0. 0.98 0. Mortality.—The later writers regard the danger of complete extirpa- tion, with dissection of the axilla, as trivial. This great improvement in results is probably due to the aseptic methods now in use, by which the risks of infection are reduced to a minimum, and by which the patient is saved the danger of systemic poisoning from absorption of antiseptic chemicals. According to Dennis the death-rate is three-fold greater after the complete operation than after the incomplete. These figures include all pre-aseptic cases. In 71 operations by Dennis there was but one death, and that resulting from haemophilia. Butlin thinks that the completed operation doubles the mortality. Permanent Cures.—Gross believed that cancer began as a local af- fection, and that early and thorough excision jirolonged life and encour- aged the hope of permanent cure. Most writers agree with him. Accepting the three-year period of immunity as the standard by which permanent recoveries are to be judged, the operation up to 1888 definitively cured 11.83 per cent, of cases. In 45 cases of his own, Gross reported 22.5 per cent, of recoveries. Dennis takes a more favorable view, and gives a percentage of 25 cures in his own experi- ence. Schmidt1 has had permanent recovery in 21.5 per cent.; under a two-year limit 26.4 per cent. In Gross’s first series of 100 cases there was not a single permanent recovery.2 Weir, reporting 20 per cent, cured in 60 traced cases, deems the results of thorough operation encouraging. Terrillon 3 observed no cures in 48 cases of carcinoma with axillary infection. He regards this complication, therefore, as 1 Deutsch. Ztsclir. f. Cliir., 1887, Bd. xxvi., S. 189. 2 Med. News, November 26, 1887. 3 Bull, de Therapeutique, 1891, p. 385. 838 DISEASES OF THE BREAST. necessarily fatal. Warren thinks that we may hope for 20 per cent, of cures in the future; Butlin from 12 to 15 per cent. Less than 2 per cent, of patients who pass the three-year limit have recurrence (Dennis). With regard to the percentage of complete cures, in the majority of Billroth’s cases a simple amputation had been done (Korteweg). The same is true of the cases of Esmarch. There were cured (Korteweg):— 1 Billroth. Esmarch. Volkmann. Konig. Of 100 simple cases 10 14 17 36 Of 100 cases with glands 2 7 . 8 10 AVithin the years 1867-76 1868-75 1874-78 1875-85 This shows an increase in the number of cures in complicated as well as in simple cases. Recurrences.—In a very large percentage of cases recurrence takes place even after the most thorough operation. This reappearance of the original disease, according to some writers, depends upon a consti- tutional rather than a local cause. The weight of authority, however, decidedly favors the local nature and origin of carcinoma. Recurrences are generally regarded, therefore, as the result of incomplete excision. Dennis gives 27 per cent, more recurrences after the incomplete than after the completed operation, and regards 75 per cent., the general average of recurrence, as the result of some defect in operative technique, or of some unreasonable delay. Gross2 reported the results in 207 cases of cancer. Of the first 100 cases, 91.75 percent, were marked by local reproduction, and there was not a single permanent recovery. In these the axilla was not cleared out. In the second series of 107 cases 10 patients died without opera- tion. Local recurrence took place after 52.77 per cent, of the opera- tions, in an average period of seven months. The average life of the thirteen who died with recurrence was 32 months, varying from 2 to 94 months. The average period since the operation upon those who still survived without recurrence, was 3 years and 3 months, varying from 8 years and 3 months to 6 months. The average interval between the operation and the first obvious re- currence, in 46 cases noted by Williams, was 26 months.3 Halsted4 gives statistics of 50 cases operated on by him at Johns Hop- kins Hospital. They are especially noteworthy because of the fact that in only three cases did recurrence take place in the area of operation. Halsted uses the term “local recurrence” to mean recurrence in any part of the region attacked by the knife. “Regionary recurrence” he defines as the multiple recurrences in the skin at a distance from the scar. In 34 cases out of the 50 there was no recurrence whatever, and in these 34 cases 24 patients were living at the time of writing, the periods since the operations varying from three and one-half months to three and one-half years. In only three cases in which recurrence took place was it in the exact area of the wound ; in eight cases it was re- gionary; five patients were not heard from. All of the cases were oper- ated upon in a uniformly thorough manner, the large pectoral muscle 1 Archiv f. klin. Chirurg., Bd. xxxviii., S. 679. 2 Med. News, November 26, 1887; Boston Med. and Surg. Jour., vol. cxix., p. 248. 3 Lancet, January 12, 1889, p. 72. 4 Annals of Surgery, November, 1894. 839 CARCINOMA OF THE BREAST. being removed entire, and the axillary and supra-clavicular glands being extirpated. This series of cases is of distinct value as showing the possibility of thoroughly removing cancer as a local disease. In 62 cases (1877-87) at the Massachusetts General Hospital, the average period before recurrence was 14.2 months. Paget’s practice (Barker’s statistics) shows 14 months for scirrhous and 7 for medul- lary cancer. Sibley (Middlesex Hospital statistics) gives 53 months when the growth is removed, 32 when left to itself. Barker—scirrhus let alone, 43 months; operated upon once, 55 months. Medullary cancer —let alone, 20 months; operated upon, 44 months. Stiles has shown that in most of the specimens examined by him the surgeon’s knife had not removed the entire organ:— “Recurrence of the disease after operation is due to the non-removal of small and often microscopic foci of cancer, more or less remote form the main tumor and depending for their origin upon the arrest and growth of cancerous emboli disseminating more or less directly from the primary tumor along the lymphatics. The importance of removing all the retro-mammary tissue, pectoral and axillary fascia, axillary fat and glands, along with the breast in all cases of carcinoma, cannot be too strongly insisted upon or too often repeated. The anastomosis and intersection of the lymphatics are so free that it is impossible to say toward which set of glands the lymph from any given point in the breast will be con- veyed. I have seen cancerous lymphatic emboli at the axillary border of the mamma when the tumor was situated in the inner hemisphere, and vice versa. There no is doubt also that the lymphatics of the two breasts communicate to a certain extent through a median anastomosis of both the superficial and retro- mammary lymphatics. “In carcinomatous breasts the lymphatics may frequently be seen injected, as it were, with cancer cells, so that by a careful study—more especially of the spread of the cancer in the different tissues in and around the breast—one can gain a more satisfactory idea of their structure and arrangement than is to be afforded by chance and unsatisfactory artificial puncture injections. “The cancer cells invade first the lymph-spaces of the tissue, and, since they probably possess no independent or amoeboid movement, their entrance into the lymphatic vessels is more or less accidental. I have repeatedly seen lymphatic vessels containing cancer cells in all the situations in which Langhans has artificially injected them. “The lymphatics when cancerous are generally filled and distended with cancer cells, which may or may not have invaded their walls and involved the surround- ing tissue. Occasionally one may observe a lymphatic of large calibre which is patent, containing only a few cancer cells which appear to have been floating along with the lymph stream. In such a condition the endothelial lining of the lymphatic is very distinct and quite normal. I have never seen any appearances which indicate that the endothelium of cancerous lymphatics in any way partici- pates in the cancerous process. “The examination of a large number of carcinomatous breasts has afforded a demonstration of lymphatics containing cancerous emboli in one or more of the following situations, viz., in the connective-tissue processes radiating from the tumor into the surrounding breast tissue or circum-mammary fat; in the breast tissue, remote from as well as close to the tumor; in the connective-tissue septa, separating the lobules of the circum-mammary fat; in the so-called ‘ligaments of Cooper,’ where they often lead to small disseminated cancerous nodules in the corium; in the retro-mammary tissue and pectoral fascia. In the last-named situation they are large, and generally accompany the blood-vessels which pass to and from the deep surface of the mamma.” 840 DISEASES OF THE BREAST. Mr. Gibbes has demonstrated that carcinomatous cells lie in contact with the stroma; and it is inferred that these cells pass by amoeboid movement into the intra-fascicular lymph-spaces, whence the lymphatic capillaries carry them into the nearest gland. Eecurrences are dependent chiefly upon the inadequac}r of the opera- tion. The disease in many cases of attempted extirpation is too far advanced for the most wide-reaching operation to be permanently suc- cessful. Could such hopeless conditions be recognized beforehand and operation be thereby avoided, the ratio of recurrences would undoubt- edly be very much diminished and that of permanent cures corre- spondingly increased. If those cases in which foci of cancer are known to have been left untouched at the time of operation are excluded, the percentage of recurrences will be greatly lessened. If to these be added the cases in which the outlook is conspicuously unfavorable, even if there be no demonstrable metastasis or untouched nodule, the ratio of recurrences will be still further diminished. Furthermore, if we ex- clude all cases in which the disease has been known to be present for a long time, and limit, therefore, our observations to cases in which the operation is early and thorough, the prognosis, both as to recurrence and as to permanent cure, will be very much improved. The recurrence of carcinoma is influenced greatly by the histological character of the disease itself. The more typical the structure, the better the prognosis; the more atypical the structure, the more un- favorable the prognosis.1 Permanent cures are certainly influenced unfavorably by the existence of gland complications. When lymph glands are distinctly enlarged and easily felt in the axilla, complete removal of outlying cancer foci is often impossible, for the infected chain may extend beyond reach, or remote infection may already have been established. Moreover, the lymphatic invasion may have taken place by unusual channels, and wandering cells may have been swept into the supra-clavicular lymphatics, into the sternal glands, into the pleurae, or into the lymph-spaces of the corium; such complications, influencing unavoidably the prognosis, may exist without the slightest sign. Were the latter infections as universal as those of the axillary lymphatics, operations for the per- manent cure of breast cancer would be well-nigh hopeless. Even the most favorable reports show that the axilla is involved in the great ma- jority of cases, the glands being so enlarged as to be easily felt either be- fore or after the incision. That the axillary spaces are often infected by the cells of cancer, even when there is no perceptible tumor, cannot be denied, in view of numerous undoubted demonstrations of such compli- cations. In my own experience the ride has been, almost without ex- ception, that in all cases of cancer there is axillary infection, shown in almost every instance by macroscopic inspection, and confirmed by the microscope. In those rare instances in which the glands have seemed normal, malignant foci have been demonstrated by Dr. Whit- ney, either in the glands themselves or in the free spaces of the axilla. As a cause of recurrence axillary complications are of great im- portance. They are of such frequent occurrence that failure to remove the whole axillary contents is usually incompatible with permanent cure. Kiister failed in only 2 out of 117 cases to find unmistakable evidence 1 Dennis, ioc. cit. CARCINOMA OF THE BREAST. 841 of carcinomatous infiltration of the axillary glands, and Mr. Gibbes has proved that such infiltration may be present though it cannot be rec- ognized by ordinary means. Schmidt1 in 228 cases, including 2 oc- curring in men, found the glands affected in 97 per cent. The glandu- lar invasion had been recognized before operation in 71.77 per cent.; in 26.25 per cent, the complications were demonstrated only at the time of operation. These contradictory statistics are due to the greater number of metastases recorded in later reports. (Korteweg.) Simple Cases. With Axillary Inrolvment. Billroth (1867-76) 60 90 Esmarch (1868-75) 80 120 Volkmann (1874-78) 25 100 Ivonig (1875-85) 25 125 That recurrence takes place first in the neighboring glands is shown by the fact that in 128 autopsies of patients dying from carcinoma of the breast, in 90 per cent, it was found that the patients had had return of the disease in the axilla (Dennis). According to Weir 2 there are axillary complications in 97 per cent, of all cases. The great increase in the ratio of metastasis noted of late years is due to the fact that the earlier observers required more physical evidence of glandular implica- tion, the axilla being left untouched unless a tumor could be distinctly felt. Hence also the high rate of recurrence and the gloomy prognosis of that time. Wyeth 3 reports that of 48 patients operated upon be- tween 1880 and 1890, 42 died and the remaining 6 had recurrences. In rare instances it must be admitted that the disease appears in the scar of the operation, cle novo, from irritation, as it might in any other scar from a similar cause, uninfluenced except by a constitutional pre- disposition. The influence upon recurrence of the duration of the disease before operation has been much studied. The statistics on this point vary so much with the rapidity of growth and the degree of malignancy, and are so dependent on the patient’s own observations, that they are of doubtful value. Korteweg4 concludes from 322 cases in which the age of the tumor before operation was approximately known, that (1) the more malignant the cancer the earlier it comes to operation; (2) the more malignant the cancer the sooner recurrence leads to death. Time of operation after recognition of disease. Duration of Disease Before Operation. Length of Life After First Operation. 50 cases before end of 3 months . 16 months 14 months. 65 “ between 3-6 months... . 23 u 17 U 45 “ “ 6-12 months... 26 “ 17 “ 57 “ a little over 12 months. 32 “ 20 U 35 “ between 12-18 months . 42 u 25 a 37 “ a little over 24 months. 47 u 23 a 33 “ 322 “ over 24 months in all. . ... 58 u 22 u Small tumors, slowly growing, frequently exist for months and even years without exciting apprehension. Such tumors very rarely come to operation until the axilla is seriously infected. Could extensive dissec- tions be made in such cases it is certain that the above table would be much modified. 1 Deutsche Zeitschrift. f. Cliir., 1887. 2 Med. Record, December 31, 1892. 3 Trans. New York Med. Association, 1891, p. 481. 4 Loc. cit. 842 DISEASES OF THE BKEAST. Operation for Cancer of the Breast. The radical treatment for permanent cure of cancer of the breast is aseptic excision of the entire seat of disease. Palliative treatment is devoted to the relief of painful or ulcerating tumors, and to the pro- longation of life. Early and thorough extirpations are indicated in all tumors of the breast jvhicli are malignant, doubtful, or benign but troublesome (White). In some cases continuous pain justifies exploration, even if no tumor can be detected. One instance of this kind occurred in my own experience three years ago. A woman of forty complained of persist- ent pain in the breast. Nothing abnormal could be felt. Exploration followed by microscopic examination proved the presence of a small focus of cancer, which was removed with the infected axillary glands. There has been no recurrence up to the present time. The variety of cancer influences the question of interference. In far advanced cases of the more malignant and rapidly growing forms, one is not justified in operating: while in cancer of moderate malignancy extirpation may be attempted even in the face of the greatest diffi- culties. Cancer, especially of the medullary variety, which has involved rapidly the whole breast, and presumably the peri-mammary tissues, particu- larly the skin, and which is complicated by obvious axillary infection, does not justify extensive and dangerous dissection nor the hope of permanent cure. Large masses in the axilla, with swelling of the arm, or enlarged supra-clavicular glands; internal symptoms with progres- sive anaemia; incurable diseases of other organs—all contra-indicate radical operations. The field of operation must be prepared with the greatest care, for upon this precaution as much as upon the sterilization of the instru- ments and hands depends the immediate result. Preparation should be begun twenty-four hours before the operation by shaving the skin, including the axilla. The parts must next be scrubbed thoroughly with a brush in soap and water. A green soap poultice should then be applied, followed by washing in ether or alcohol. Finally a moist corrosive sublimate dressing (1-3000) should be put on and kept in position till the moment of operation, when it is well to wash in a fresh sublimate solution (1-1000). The field, having been irrigated with boiled water and dried with a sterilized towel, is then ready for incision. Authorities of the present day are practically unanimous in declaring that next to very early operative interference a permanent cure de- pends upon the thoroughness of the operation. The first consideration, therefore, is so to plan the incision that every vestige of the tumor may be extirpated without regard to the easy approximation of the skin. The closure of the wound thus made must be regarded from the outset as a minor consideration, to be met according to the circum- stances of the case. If the enormous and deforming wounds neces- sary for the removal of an extensive local recurrence had been made in the first instance, it is fair to say that recurrence might have been avoided. OPERATION FOR CANCER OF THE BREAST. 843 Incision for Removal of Mammary Cancer.—The usual cut has been double and elliptical, made parallel to the fibres of the pectoralis major and including the tumor and the nipple. The numerous recur- rences in the scar led S. W. Gross to suggest the ablation of the skin cov- ering the entire gland by a circular incision over the periphery. This method is unnecessary in many cases when immediate healing is desir- able, and often makes closure by first intention impossible, without diminishing the liability to recurrence; for if the seat of the tumor be at the breast margin, and if the skin is implicated, a broad space of sound tissue must be assured by making the cut far beyond the mammary circle. If the whole gland is clearly affected, the cut must include the skin be- yond the breast by a circular margin at least an inch in diameter, and the parts must be removed regardless of the difficulties of closing the wound. When the nodule is small, non-adherent, and movable, it is unnecessary to make the circular cut of Gross, though it is well to take as much skin as can he spared and yet have effectual approxima- tion. The error should lie rather in the direction of sacrificing too much than too little skin. The principle is “so to plan the incision as best to facilitate the removal of the entire organ, and at the same time of whatever skin is diseased or is at all likely to be so.” 1 Stiles recommends the following method, based upon his anatomical studies of the breast:— “In a simple case the old elliptical incision, if sufficiently large, is the best incision to employ, so far as the removal of the entire gland is concerned. It should be made parallel to the oblique diameter of the breast, its lower extremity reaching well down below the costal margin close to the ensiform cartilage, and its upper extremity terminating at the outer border of the pectoralis major opposite the third rib. The ellipse should be widest at the nipple, and should there measure at least four inches across. “ If the ellipse includes the whole of the skin over the tumor, the surgeon may at once proceed to reflect the flaps off the breast; but, if the tumor does not fall within the ellipse, the skin over it should be removed by a triangular incision (as recommended by Dr. Joseph Bell, Edinburgh Med. Journal, 1871), the base of which forms part of the ellipse. This plan should be followed not only when the skin is evidently involved, but even when it is freely movable and apparently healthy. It will be obvious that unless such a method be adopted, the ligaments of Cooper, containing lymphatics in direct continuity with those about tbe tumor area, and therefore liable to contain cancer cells, will be left, and consequently recurrence in the skin or subcutaneous fat will be liable to occur. I believe neglect of this procedure is often responsible for the superficial recurrent nodules which are not infrequently observed in and close to the cicatrix. A combination of these incisions will be most suitable in the majority of cases in which the tumor is peripheral—the result being a T-shaped cicatrix. The lower and outer flap should first be dissected off the breast, keeping as close to the skin as is consistent with the maintenance of its vitality. This dissection should be carried as low down as to the seventh rib in the mid-axillary line. The upper and inner flap is reflected inward beyond the edge of the sternum, and upward almost as high as the clavicle. It is to allow of this free dissection that we recommend that the axillary incision should be made at the same time as the ellipse.” The breast should now be dissected from the pectoralis major, and the fascia of that muscle thoroughly removed. The dissection should be carried far into the periglandular fat under the flaps in all direc- 1 Stiles, loc. cit. 844 DISEASES OF THE BliEAST. tions. If the tumor is adherent, the muscle itself should be removed. A knife or instrument that has come in contact with the open surface of the diseased tissue must be laid aside. The axilla should be opened by an incision along the border of the pectoralis major, and far enough down the arm, along the edge of the biceps, to expose fully the axillary contents. The scar from this cut in- terferes less with the movements of the arm than that from a cut made directly over the axillary depression, especially if in closing the wound the skin is stitched to the apex of the axillary space. While the axilla is being dissected the breast wound should be covered with dry steril- ized gauze, which keeps the parts warm and checks oozing. The excised breast may now be examined by the pathologist, either by making immediate frozen sections or by the method of Stiles, to de- termine whether the disease has been thoroughly removed. The prin- ciple of Stiles’s method is as follows:— 1. Mark the position of the breast by a slight incision extending both on the breast and on the skin to be left remaining. 2. Wash the mamma in water until all the blood is removed from its surface, —an important preliminary step, since the nitric acid coagulates and blackens the blood, and thereby obscures the appearances which the method brings out. 3. Submerge in a five-per-cent, aqueous solution of nitric acid. 4. Wash in running water to remove the acid. 5. Place in undiluted methylated spirit. The rationale of this treatment is that the nitric acid renders all the tissues opaque white, except the fat, through coagulation of their albuminous constit- uents. By subsequently washing in water, the connective tissue becomes trans- lucent, homogeneous, and somewhat gelatinous. Its consistence in bulk is firm, tough, and india-rubber like. The parenchyma, on the other hand, remains more or less dull, grayish-white, and opaque, due to coagulation of the more highly albuminous epithelial cells. The fat is unaltered. Cancerous tissue behaves in the same way as the parenchyma, and is rendered even denser and more opaque. In very cellular cancers the tissue resembles boiled white of egg, though of a grayish color. The characteristic arrangement of the parenchyma is generally sufficient to distinguish it from the cancerous tissue. If the examination of the frozen section, or if the tumor thus treated, shows any foci of disease remaining, the suspected parts must be further excised. The following method of procedure is rapid and effectual in clearing out the axilla. The dissection should he made with a sharp knife along the axillary border of the pectoralis major, as far as its insertion. All bleeding should he checked, and sponging should be made with a constantly renewed clean surface of dry gauze. The loose tissues of the axilla are thus kept free from the usual diffused staining by which all anatomical relations are blurred. Careful attention to this detail will enable the operator to work in a field in which the various structures are sharply defined. Leaving the pectoral border, the fascia which makes the axillary depression should first be incised. This lies directly under the skin, and once freely cut allows the deep structures to be brought immedi- ately and easily into view. The axillary vein should next be exposed and its tributaries tied, with the corresponding branches of the axillary ar- tery. An assistant lifting the elbow upward (and slightly forward if necessary), a good view can be had of the apex of the axilla as far as TREATMENT OF MALIGNANT TUMORS OF THE BREAST. 845 the first rib, to which point the dissection can be safely and intelligently carried. Having separated the mass high up in the axilla, along the pectoral border and along the axillary vein, the dissection should pro- ceed downward and backward until the outer border of the latissimus dorsi has been reached, when the whole axillary contents will have been completely separated. In the downward progress the fascia should be removed from the serratus magnus muscle. The intercosto-liumeral nerve is generally sacrificed. The subscapular nerves and the external respiratory should not be disturbed unless they are hopelessly entangled in the disease. If the extent of the disease demands more thorough extirpation, the pectoralis major should be entirely removed, except that portion aris- ing from the clavicle. The muscle should be divided close to its hu- meral and its thoracic attachments. The dissection of the axillary glands and fat can then be carried up to, or even beyond, the first rib. If necessary, the pectoralis minor may also be removed. Supra-clavic- ular glands, though regarded by many surgeons as an absolute contra- indication to the completed operation, may be removed after resection of the clavicle, or through an incision in the neck, but so extensive an operation, though justifiable, is not demanded except in extreme cases. Though perhaps unnecessary, these extensive dissections are an error on the safe side. Doubtless in the immediate future the completed operation will require a dissection not only of the axilla, but of the supra-clavicular triangle as well. Drainage may be dispensed with if the operation has been completely aseptic, and if the wound is perfectly dry. When the breast is ulcer- ated, inflamed, or otherwise septic, or when for any reason there is abundant oozing, dependent drainage should be established through the posterior flap. The only objection to drainage in suitable cases is the frequent distention of the flaps by an effusion of blood, which may take place even in perfectly dry wounds. Wounds distended by blood require more time for convalescence, and are more liable to become septic. The wound may be united by continuous or by interrupted sutures of silk or of silkworm gut. When the wound cannot be closed, immediate skin grafting may be practised, or spontaneous closure by granulations may be awaited. The whole operation should be strictly aseptic rather than antiseptic. Nothing should come in contact with the wound that is not sterile and innocuous. Antiseptics retard immediate agglutination of surfaces; they make drainage necessary, and not infrequently produce symptoms of constitutional absorption. The low mortality of the modern com- pleted operation is due to the strict observance of aseptic details. Treatment of Malignant Tumors of the Breast by Local Applications. Paget,1 after calling attention to the likeness existing between can- cers and innocent tumors on the one hand, and specific and micro-para- sitic diseases on the other, expresses a belief that we shall eventually find 1 Lancet, November 19, 1888. 846 DISEASES OF THE BREAST. that there is some micro-parasite which is essential to the production of cancer. Furthermore, he considers cancer as allied to syphilis, tuber- culosis, glanders, leprosy, and actinomycosis. He believes that we may reasonably anticipate as effective a remedy for cancer as mercury and quinine have proved for syphilis and malaria. Injections of Methyl Violet in the Treatment of Cancer.—Prof, von Mosetig-Moorhof 1 uses solutions of methyl violet or pyoktanin (1-1000, 1-500, 1-3000) injected into the growth until the pathological tissue is thoroughly impregnated with the coloring fluid. The diseased tissue is alone affected. Enclosed tumors do not disintegrate, but undergo a retrograde metamorphosis and contract. Open tumors secrete profusely and diminish in size more rapidly. There have been no cures from this practice, but marked diminution in size has been observed. Idelson, of Berne, in a review of the literature on this subject2 says that the value or efficacy of pyoktanin in the cure of epithelioma is not yet established, and that the successes are outnumbered by the failures. The evidence is not conclusive that this method exerts a retarding influence upon the development of cellular growth. In one instance a case of very rapidly growing myxo-sarcoma was treated for a long time by daily injections of pyoktanin. The solution permeated the structure in all directions. A microscopic examination of the scrapings after the use of the remedy was made by Dr. Whitney, who reported that the cells were distinctly invaded by the solution. Repeated ob- servations convinced me that this method had no effect whatever in re- tarding the development of the disease. Though having apparently so little effect upon the luxurious growths sometimes seen in sarcomata, there is considerable evidence that in the slower development seen in some phases of cancer this method is worth trying. In no event, how- ever, should dependence be placed upon injections unless free extirpa- tion is impracticable. Escharotics.—Of all escharctics, chloride-of-zinc solution is the most satisfactory. In the case just alluded to, in which pyoktanin failed, the daily application for a short time of a fifty-per-cent, solution of chloride of zinc was attended by very favorable results. In this case the tissues of the thorax had become exposed to a diameter of about eight inches. From the base of this expanse luxuriant masses of dis- ease sprang. A daily application, for a few moments, of gauze wrung out in a fifty-per-cent, solution of chloride of zkic was followed by a local destruction of the growth, though a permanent cure was not ac- complished in this manner. The use of escharotics, however, is very unsatisfactory and never should be resorted to except when excision is impracticable. Treatment by the Injection of the Streptococcus of Erysipelas or Its Products.—The germ theory of cancer has suggested the inoculation of micro-organisms, or their products, for the purpose of combating the original disease. It was observed many years ago that the frequent occurrence of erysipelas was followed by beneficial results in the con- valescence from cancer. Feilchenfeld 3 reports a case of inoculation with erysipelas, fatal in 1 Wien. med. Presse, 1891, No. 32, S. 6. 2 Annals of Surgery, 1892, vol. xvi., p. 88. 3 Arch. f. klin. Chir., 1888, Bd. xxxviii., S. 834. TREATMENT OF MALIGNANT TUMORS OF THE BREAST. 847 four days. In Holst’s case there was temporary Improvement, but the growth began again in a few months.' Coley2 has recently treated cancer of the breast in this manner, but with less promising results than in sarcoma. Thus far he has had no complete cures, but in five out of six cases there has been a marked improvement. This method should be applied only in cases which can- not be treated by excision. On account of the great dangers incident to the injection of the living germs, the sterile products of their growth should alone be used. 1 Centralbl. f. Bakteriol., 1888, Bd. iii., S. 893. 2 Annals of Surgery, vol. xiv., No. 3. INJURIES AND DISEASES OF THE ABDOMEN. BY ALBERT VAKDER VEER, A.M., M.D., Ph.D., PROFESSOR OF DIDACTIC, ABDOMINAL, AND CLINICAL SURGERY IN THE ALBANY MEDICAL COLLEGE; SURGEON TO THE ALBANY HOSPITAL, ETC., ETC. A revision of the admirable and exhaustive chapter on abdominal diseases and injuries, written for the International Encyclopedia of Surgery by Mr. Henry Morris, can be nothing more than a digest of the advances made in the last decade. The original article is a model of intelligent research, completeness in detail, and rare surgical acumen. Few additions will be made to the subjects discussed, and they are such as have been developed in more recent years. A comparison between the management of the surgical affections found within the abdomen, a decade ago and at the present time, will show a material advancement. This condition can be attributed to no single factor. The increased knowledge of pathological conditions, the more accurate diagnosis resulting from greater experience, and the improvements in the technique are each sources of material advantage. For example: In appendicitis, the anatomical relations of the appendix, the precise pathological condition, and the diagnosis, were all in- volved in more or less uncertainty until very recently. What is true of appendicitis is equally true of pelvic abscess, extra-uterine preg- nancy, and diseases of the. liver and biliary ducts. The studies of the endo-enteric organisms and their relations to peritoneal inflammation have led to important discoveries, which promise much in the way of making clear many things that gave the surgeon great concern in the early days of abdominal surgery. The technique in abdominal section, taken in its broadest sense, has undergone many changes. Processes have become less involved and mysterious. The speculative has largely gone out from abdominal surgery. The involved processes in the preparation of the operating room, of the patient, of the sponges, sutures, ligatures, and dressings, prescribed by antiseptic surgery, have given way to the more simple and rational methods of aseptic surgery. Simplicity is aimed at in every possible direction. Experimental surgery has been of great as- sistance in establishing surgical procedures in abdominal surgery. The use of inflation of hydrogen-gas for diagnostic purposes in penetrating wounds of the intestine, and in establishing the relations of tumors to other viscera, has been of great assistance. Intestinal anastomosis by plates of decalcified bone, rawhide, or potato, as well as by the Murphy 849 850 INJURIES AND DISEASES OF THE ABDOMEN. button, is an important time-saving appliance developed through ex- perimentation on the lower animals. Abdominal surgery, for the most part, has passed the transitional and speculative epoch in the last decade. It is now in position to assume its relation to the general system of surgery, as have amputa- tions, ligations, and excisions. The natural effect of these propitious influences has been to increase the confidence of the surgeon, and con- ditions are now attacked with boldness and success which but a few years ago were only palliated for a short time until the patient died. Peritonitis. When facts in any department of knowledge become clearly estab- lished and adequate, simplicity in classification is a natural sequence. The application of the foregoing statement to later conceptions of peri- tonitis is a striking illustration of its truth. Idiopathic peritonitis has practically been abolished from medical nomenclature, and for a good reason: it is indefinite and inaccurate. We are asked, indirectly to be sure, to accept the truthfulness of the antiquated notion that a specific inflammation may arise of itself. Clinical experience and experi- mental investigation both establish, almost if not quite beyond contro- versy, that peritonitis can only arise through bacteriological infection. That exposure to cold, strains, and contusions of the abdominal walls and viscera may be associated with a succeeding peritonitis cannot be disputed, hut only in a contributing way. Irritation results in decreas- ing the resisting power to bacteriological invasion. An injured intes- tine may let out through its coats pathogenic bacteria, which could not pass through a normal intestinal wall. A serious skepticism may be maintained regarding peritonitis in- duced by the injection of irritants like trypsin and croton oil into the peritoneum. While the results may show pathological conditions, in many cases similar to the conditions found in a bacteriologically induced peritonitis, yet they are not identical. The results of experimentation are often untrustworthy because the experiments have not been carried to a final conclusion. It is difficult to understand why a special etiology is required for peritoneal inflammation. It being granted that peri- tonitis is necessarily an inflammation induced by bacteriological infec- tion, its varieties must be determined from another standpoint than that of etiology. Pathological conditions constitute the proper basis for the differentiation of the varieties of a disease. From conditions found in operations, and at the post-mortem table, peritonitis is either septic, suppurative, plastic, or tubercular, the character of the exudate determining the variety in each case. A great variety of pathogenic bacteria have been found in the exu- dation of peritonitis—Streptococcus pyogenes and erysipelatis, Staphy- lococcus pyogenes, aureus, and albus, Diplococcus pneumoniae, Bacillus tuberculosis, Bacillus pyocyaneus, Bacillus communis coli—and a definite but variable number of each variety are required to induce inflam- matory reaction. For example: experimentation has shown that one minim of a pure culture of a given form of bacterium produces no re- action when introduced into the peritoneum of a rabbit. Five minims PERITONITIS. 851 of the same culture introduced at the same point, under identical con- ditions, produce a localized plastic peritonitis followed by recovery. Ten minims introduced into the abdomen of another rabbit, under proper control, are followed by death in thirty7- hours from septic peri- tonitis. Again, different varieties of bacteria exhibit widely varying degrees of virulence. The organisms found in ordinary suppurative processes are by far less virulent than the Diplococcus pneumoniae or the Bacillus communis coli. Pathology of Peritonitis.—The conditions exhibit decided differ- ences in each variety. If an examination be made within a few hours from the onset of a septic peritonitis, the division of the parietal peri- toneum will be followed by an outpouring of the exudation. A careful examination of this fluid, usually brownish, opaque, and foul-smell- ing, will demonstrate the presence of both red and white blood-corpus- cles, granular detritus, flocculent lymph, and innumerable bacteria. No, matting together by plastic lymph of adjacent peritoneal surfaces will be found. The peritoneum, both parietal and visceral, in every portion of the abdominal cavity, is deeply injected, and may show numerous points where hemorrhages have occurred between the serous membrane and underlying tissues. The peritoneum soon loses its glistening appearance. The vessels (lymphatics) of the mesentery are engorged. Following very closely, the lymphatic glands are swollen, the liver, spleen, and kidneys are seriously congested. If the patient can withstand the continued auto-administration of ptomaines for a few hours longer, there may appear in the spleen or liver patches of necrosis. In the last stages the exudation may be more nearly purulent. The plastic variety of peritonitis is always a localized condition, at least in the beginning. The exudate is fibrinous or fibro-plastic, never serous. The best examples of plastic peritonitis are found associated with gonorrhoeal infection of the uterine appendages, or in a portion of the cases of appendicitis. The process of matting of adjacent struc- tures may remain circumscribed or spread by continuity. In cases of chronic peritonitis, it may be impossible to isolate a single organ with- out greatly endangering the integrity of adjacent structures. Bands oc- cluding the intestines may occur, and may induce intestinal obstruction. Pure suppurative peritonitis as a primary condition does not occur. It is always secondary to either one or the other variety, usually the plastic. When in the course of a plastic peritonitis the intensity of the inflammation is such that the exudate becomes necrotic, abscesses de- velop about these centres of necrosis, and increase in size from an exten- sion of the primary process. Abscess may develop, on the other hand, from perforations in viscera—the intestine, appendix, gall-bladder, or Fallopian tube. Suppurative peritonitis is consequently found as a sequence of inflammatory changes in the uterine appendages, vermi- form appendix, or gall bladder, and in peritonitis following delivery. That the exudation associated with a purely septic peritonitis is ever distinctly purulent, in the common acceptance of that term, is open to very grave doubt. If a fluid, which may be properly termed pus, is ever found in septic peritonitis, it is only at a very late stage of the disease. The two conditions, plastic and septic peritonitis, occur to- gether under certain conditions. A localized plastic peritonitis has as- 852 INJURIES AND DISEASES OF THE ABDOMEN. sociated with it abscess, which, gradually distending, finally ruptures its wall of lymph, and the contents enter the general peritoneum. A septic peritonitis, naturally from the character of the infection, is in- duced, and proceeds rapidly to a fatal termination. In this way many neglected cases of pyosalpingitis, ovarian abscess, and appendicitis ter- minate fatally. Tubercular peritonitis is usually a low grade of inflammation in- duced by the deposit of tubercle on the peritoneum. It is observed in two varieties: one is associated with a serous, and the other with a plastic exudation—the exudate in either case resulting from the presence of tubercle on the membrane. Symptoms of Peritonitis.—In general, the symptoms of peritonitis are characteristic and do not often lead to a mistaken diagnosis. Many evidences of the onset of the disease are so commingled with those of the etiological condition that isolation and analysis are quite impos- sible, or are capable of serious misconceptions. This is especially true of appendicitis. Pain is generally, and correctly, regarded as an important symptom of peritonitis, yet pain is not necessarily present in the most virulent attacks of the septic variety. This fact is confirmed by many careful observers. Again, there is no characteristic pain either in kind or po- sition. Patients describe it as sharp or dull, steady or lancinating, and of all degrees of severity. They often describe it as a pain such as they have never felt before, and as one which gives them an idea that some- thing very serious or fatal will result from it. The pain of peritonitis may be simulated by that of appendicitis, perihepatitis, enteritis, pan- creatitis, biliary or renal colic, obstruction of the bowels, intestinal colic, gastralgia, and influenza, and can only be differentiated by a most care- ful estimate of the value of the accompanying symptoms. The pain of peritonitis is never relieved by pressure, and is accompanied by a tender- ness more or less exquisite. Nausea and vomiting are often early and very serious symptoms. First the contents of the stomach and duodenum are evacuated, and then, particularly in septic cases, large quantities of a spinach-green or blackish, flocculent fluid. Where there is in- testinal obstruction, either organic or paralytic, the vomited material becomes stercoraceous in character. Vomiting of either of the last va- rieties must always be looked upon as of very serious importance. Ab- dominal distention is a third important symptom. In septic peritonitis it comes on early and very rapidly. In plastic peritonitis, on the other hand, it is a late symptom and an indication of beginning organic intes- tinal obstruction. There are no more important symptoms of peritonitis than those found in the circulation. While there is nothing in the pulse which may be described as pathognomonic of peritoneal inflammation, yet there are few experienced observers who will not be able to establish a presumptive diagnosis from the pulse alone. The pulse is rapid—from 100 to 160—small, compressible, and very seldom dicrotic. It falls away from the finger, and may intermit. If there is much abdominal disten- tion the right heart and veins are distended and the skin cyanotic. The temperature curve of peritonitis shows nothing characteristic in septic peritonitis; it may continue below normal until death occurs, and 853 rarely rises above 102° F., though occasionally, after reaction has followed perforation, a distinct rise is observed to 104° F. or higher. In plastic peritonitis the temperature remains between normal and 101°, unless suppuration occurs, when a rigor and subsequent elevation of temperature are seen in many cases. As an element in diagnosis temperature assumes a negative position. Much has been written of the physiognomy of patients with peritonitis. The facial expression gives at once the impression of a serious illness. It is pinched, drawn, and anxious. The nose is more pointed, and the lines are lengthened, particularly at the sides of the face. The extremities are cold and cy- anotic, and are often covered by a clammy perspiration; the legs are often, although not invariably, flexed. The tongue shows, as a rule, no especial changes in peritonitis. Physical examination reveals, in addition to the symptoms already mentioned, several others of importance. In plastic peritonitis there is usually localized tenderness, associated with dullness over the affected area. Palpation shows a definable tumor. Auscultation—a valuable adjunct—gives evidences of gurgling and of peristaltic action in the intestine. In septic peritonitis there is often no part of the abdomen dull, unless the exudation is abundant. There is no peristaltic action. The intestinal coats are paralyzed. The most important physical sign of peritonitis is, beyond doubt, the peculiar resistance given to the palpating hand by the contracting abdominal muscles. It has been variously described—like a deal board under the skin expresses it most closely. To my mind, when this peculiar resistance is not present the diagnosis of peritonitis may be regarded with suspicion. Consti- pation is the common condition in peritonitis, though diarrhoea may rarely be present in the suppurative variety. PERITONITIS. Diagnosis of Peritonitis.—There are many conditions which must he excluded before a diagnosis of peritonitis can be established. Sev- eral have already been mentioned. Typhoid fever, intestinal intoxica- tion, and ptomaine poisoning are to be added. A critical study and proper estimation of the value of the different symptoms will usually prevent error in diagnosis. Tubercular peritonitis is properly considered in connection with dropsies and can receive no extended notice here. Prognosis of Peritonitis.—The prognosis of septic peritonitis is ex- ceedingly grave. Many writers are firmly of the conviction that all who suffer from it die under all forms of treatment, surgical or med- ical, but I myself believe that in many instances, with an early lap- arotomy, proper irrigation, and drainage, recovery may confidently he expected, although it is extremely difficult or impossible to say that any particular case is likely to terminate favorably. In plastic peri- tonitis, however, the prognosis is much more promising. If the in- flammation runs a mild course, the prognosis, under purely expectant treatment, is good. When it assumes a graver type, becoming suppura- tive, surgical intervention has been able to save a very large percent- age of cases. Organic intestinal obstruction is often a dangerous complication. Treatment of Peritonitis.—In theory, the treatment of peritonitis 854 INJURIES AND DISEASES OF THE ABDOMEN. is established, but at the bedside there arise many conditions of which the management is debatable. There is yet widely disseminated in the mind of the profession a confidence in the so-called opium treat- ment of peritonitis. This condition of affairs does not admit of expla- nation. After many years’ experience in both hospital and private practice I have yet to see the utility of the so-called opium treatment. I have seen it mask symptoms, and establish in the minds of the phy- sicians and of the patient’s friends a feeling of hopefulness, quickly dashed to the ground by the patient’s sudden death. It is very diffi- cult to define the proper position of opium or its alkaloids in the treat- ment of peritonitis. The indications for its exhibition, as they appear in the light of recent practice, will be given in detail at the proper place. The treatment by hydragogue cathartics, chiefly saline, is sub- ject to certain limitations. There can be no doubt, however, that this plan, so earnestly advocated by Mr. Lawson Tait, is preferable to the indiscriminate use of opium.1 The matter of the prophylactic treatment can only enter into the management of peritonitis following operations. Surgeons fully ap- preciate the importance of the condition of the intestinal canal in abdo- minal surgery. Where it is not imperative to operate immediately, the complete evacuation of the bowels forms a distinct indication for pre- liminary treatment. Tendencies to intestinal distention from indiges- tion should always be corrected, as far as possible, by suitable diet and medication. The broad subject of the aseptic technique in abdominal surgery cannot be entered upon in detail, but it can only be said that great experience and care are required in the organization of such opera- tions. However careful the surgeon may be, now and then, from defects or omissions in technique, from environment, or from serious inherent difficulties of the operation, peritonitis will follow. It should not occur often, it will occur occasionally. Post-operative peritonitis is, as a rule, septic and virulent, and its treatment must be active and immediate. Given a case of peritonitis, diffuse and septic in character, what shall be done? There is but one course that offers to the patient any hope of recovery, and that is abdominal section performed at once. Unless there are special indications, the median incision will serve the operator best. If due to perforation of the stomach, intestine, or ap- pendix, these conditions must first receive proper treatment by suture or excision. The abdomen should be flushed with sterile, normal salt solution, 6-1000, at a temperature of 105° to 110° F.2 The addition of two per cent, of alcohol to the irrigating fluid is advantageous in reliev- ing shock. Several gallons may often be used with advantage. The fluid should return clear before the flushing is discontinued. A full- 1 [The Editor feels compelled to express his dissent from this sweeping condemnation of the use of opium in peritoneal inflammation. For his own part he looks upon this drug as the most valuable single remedy for peritonitis, and is confident that by its systematic use, in connection with local depletion by leeches, he has saved the lives of many patients suffering from inflammation of the peritoneum who without it would have perished. By its syste- matic use is meant not the exhibition of an occasional dose as an anodyne, but continuous ad- ministration in the way recommended by the late Dr. Alonzo Clark—one grain of solid opium, or its equivalent, every hour, day and night, until the patient’s respirations are brought down to twelve in the minute. As for the “masking of symptoms, ” the only symptom thus af- fected is pain, and even if the absence of pain were an evil, which it is not, it would be more than compensated for by the increased facility given for physical examination by per- cussion and palpation.] 2 Thorough sponging with gauze will sometimes answer without flushing. PERITONITIS. 855 sized Keith's drainage tube should be passed into the pelvis, and this may be supplemented by strips of iodoform gauze leading from the ab- dominal wound into each flank. The wound should be only partly closed with silkworm-gut sutures, although others may be introduced, to be tied after the removal of the drainage. Where there is a paralytic condition of the intestinal walls due to hyperdistention, the question of enterotomy and evacuation through a large trocar, or of the establishment of a fcecal fistula, may arise. Where the general condition of the patient will admit of it, this pro- cedure will, in many cases, be of much assistance. No definite indica- tions can be laid down for the employment of either method. In gen- eral, they may be said to be most useful in cases where both cathartics by the mouth and enemata have failed to bring about movements of the bowels before operations have been undertaken. During operations for septic peritonitis every effort must be made to prevent shock. The patient should receive before the operation a stim- ulating enema of beef juice and whiskey, and should be warmly wrapped in flannels, with hot-water bottles so placed that the tempera- ture may be maintained. The operation must be completed with all the dispatch possible to good surgery. It is best to remove the patient to a hospital, whenever possible. The fatigue of removal in an ambu- lance is more than compensated by the advantage of trained assistants and conveniences for the operation. After-treatment of Septic Peritonitis.—Every effort must be made to establish reaction as soon as possible. External warmth and free stimu- lation are indicated. The hypodermic exhibition of morphine and atropine may be demanded, to relieve pain, but great caution is re- quired in their employment. If the reaction is satisfactory, the Leiter cold coil or ice bags may be applied to the abdomen over light, aseptic dressings. Vomiting, when persistent, is relieved by the discontinu- ance of all fluids by the mouth for a few hours. A very happy effect has been induced by the administration of the following:—• Cocain. hydrochlorat gr. ij. Hydrarg. chlorid. mitis gr. ij. Cerii oxalat gr. xvi. M. Ft. chart, no. viii. Sig. A powder every hour or two. Occasionally champagne can be retained when the stomach rejects all else. If found agreeable it may be given freely. Koumyss, Matzoon, or a reliable preparation of liquid peptonoids, may be given after twenty- four hours. When the powders above mentioned are not sufficient to produce a movement, stimulating enemata containing glycerin or tur- pentine should be given. It may be necessary to introduce the enema high in the colon by means of a long rectal tube, and a saturated solu- tion of Epsom salt may occasionally be used in this way with great advantage. The care of the drainage tube is of great importance; for the first twelve hours, the wick of iodoform gauze within the glass drainage tube need not be disturbed. Afterwards it should be changed at fre- quent intervals. The strips of gauze extending laterally into the flanks may be removed after two days, and the remaining sutures tied. The glass drainage tube will remain somewhat longer. It may be said that if the patient is in a favorable general condition, 856 INJURIES AND DISEASES OF THE ABDOMEN. and has had satisfactory motions on the third day after the operation, the chances of ultimate recovery are good. Treatment of Plastic Peritonitis.—In plastic peritonitis, where the inflammatory reaction is not severe, medical treatment by laxatives and enemata, together with the administration of phenacetin and codeine for pain, are often sufficient. Rest in bed, with ice to the abdomen, is a necessary adjunct to the outlined treatment. Resolution during the stage of decadence is often hastened by blisters and hot fomentations. When suppuration occurs and either single or multiple abscess is formed, early surgical interference is necessary, but must be under- taken with great care. Every effort must be made to enter the abscess without bringing about an infection of the general peritoneum. This can be readily enough accomplished in many cases of pelvic peritonitis and appendicitis. Conditions occur, however, in which it is impossible to reach and evacuate intraperitoneal abscesses without subjecting the patient to the dangers of a general septic infection. Here the method of opening the abscess in two stages, after the method employed by Sonnenburg, is useful. First, an exploratory incision is made, estab- lishing all the anatomical relations of the abscess, and then the wound is plugged with iodoform gauze. After firm adhesions have been established, the abscess cavity is opened and drained. The after- treatment calls for no especial description. Obstruction of the bowels is not an unusual complication of plastic peritonitis. Bands of lymph cause either direct occlusion or acute flexure. When the process is not too extensive these adhesions can be broken up by abdominal section. On the other hand, when the plastic exudation is widely distributed, or is associated with large pus cavities, enterostomy, with the making of a faecal fistula, is at once more conservative and offers better chances for ultimate recovery. The recent statistics of Konig and others have placed incision and drainage in tubercular peritonitis upon undisputed ground. In my own experience this plan of treatment is followed by cure in most cases. Lately there has accumulated much evidence in favor of the simple introduction into the peritoneal cavity of iodoform in some form or other, such as the dry powder, or the iodoform-glycerin mixture. Appendicitis. The subject of inflammation in the right inguinal region, its pathol- ogy and treatment, has undergone a very radical change, and from the maze of unmeaning terms by which it was formerly designated, such as typhlitis, perityphlitis and paratyphlitis, intraperitoneal and extra- peritoneal abscess, etc., we are at last relieved through the very thor- ough investigations that have been made by Fitz and others, and we now have the true term, appendicitis, indicating the pathological con- dition that really exists. It is possible that there may be a condition of typhlitis owing to the impaction of faeces within the caecum, and that it may perhaps lead to ulceration of this portion of the large intestine; but though it has been observed in a few cases, it is an exceedingly rare affection. Appendicitis, or inflammation of the appendix vermiformis, presents APPENDICITIS. 857 a variety of conditions as regards etiology. It is by far most prevalent between the ages of six and twenty, and in many cases is undoubtedly due to slight injuries, errors in diet, especially over-indulgence in im- proper articles of food, or exposure to cold, and not, as has heretofore been frequently supposed, to the fact of foreign bodies lodging in the appendix. With few exceptions the vermiform appendix is intraperitoneal, and hence appendicitis is almost always an intraperitoneal inflammation. Unless in these very exceptional cases, it is impossible to touch or reach the vermiform appendix without introducing a finger into the peritoneal cavity. Symptoms and Morbid Anatomy.—The symptoms in acute perfor- ative appendicitis are very rapid in their development; sharp pain is felt, accompanied by nausea and immediate prostration, and the pulse is rapid, reaching 120 within a few hours. When a patient becomes suddenly and dangerously ill, with symptoms of general peritonitis, the diagnosis of acute perforating appendicitis may be ventured with al- most absolute correctness, even though many of the local symptoms are absent. The conditions of collapse are present, and the patient some- times dies within twenty-four or thirty-six hours from the onset of the disease, seldom living longer than the third or fifth day, except there be surgical interference. When we consider the anatomical structure of the appendix, the method of invasion of the mucous membrane, and the subsequent lym- phatic and circulatory phenomena, they are found to be identical with similar processes occurring elsewhere in the body. Acute, perforating, fulminating appendicitis presents the most serious type of the disease, and one attended by the gravest dangers to life. The conditions found at operation, however early undertaken, are usually as follows: The appendix itself is either uniformly dark in color, or mottled; its peritoneal surface has lost its glistening appear- ance ; it is thickened and often distended; the mesentery is swollen from circulatory stasis; and perforation, if it has not already occurred, is impending. The perforations may be either single and large, or multiple and small. I have removed appendices at operations that in this respect resembled a sieve. The general peritoneum is injected, and there is a reddish-brown, foul-smelling, ichorous exudate in the abdom- inal cavity. Paralysis of the intestinal walls occurs at the onset of the disease. Abdominal distention comes on early and is very great. A most important feature of this form of the disease is that at no time is there any disposition to its localization; there is no exudation of plastic lymph, or at least not sufficient to prevent general infection. The experimental introduction of large quantities of pathological organisms gives, pathologically, precisely similar conditions, and there is no great difference in the manner of infection. In other cases the process is much slower, and the degree of bacterio- logical invasion is materially less. Time has been allowed for walls of lymph to be thrown out, affording a barrier and preventing general peritoneal infection, even though the inflammation reaches a point where perforation occurs. The small intestines, the mesentery, and the omentum are all attached 858 INJURIES AND DISEASES OF THE ABDOMEN. together by the exudate, thus forming a posterior wall to the abscess cavity, and giving rise to the percussion dullness and the tumor. Appendiceal abscesses will sometimes open into the rectum or the vagina, or may burrow backward into the lumbar region, particularly if the appendix is attached in that direction; and in neglected cases of suppurative appendicitis the abscess has been known to find its way behind the liver into the pleural sac, or into distant parts of the abdom- inal cavity. While the classification is rather arbitrary, yet most cases can be studied under three divisions, viz., catarrhal, simple catarrhal, oblit- erating, or relapsing appendicitis; suppurative appendicitis; and per- forative, acute, or gangrenous appendicitis. Catarrhal appendicitis is the form most frequently met with; the inflammation begins in the mucous membrane, is associated with catarrhal exudate or ulceration, and under favorable conditions is fol- lowed by subsequent cicatrization, with constriction and obliteration, or on the other hand distention, according to the seat and character of the pathological changes. It is in the catarrhal form of appendicitis, espe- cially when the inflammation is subacute, that there is very little dis- position to spontaneous recovery; and these cases should always be looked upon as menacing the life of the patient, a possible exception being in those instances in which the appendix becomes obliterated and is shut off by smooth adhesions from the peritoneal cavity. In these cases of catarrhal appendicitis, with localized peritonitis, the induration resulting from the exudate may remain for months after the primary condition has become quiescent. Cases of catarrhal appendicitis pre- sent largely a condition of continued constipation before the onset of the disease; and the overdistended caecum, with consequent irritation and catarrhal inflammation, provides unusual facilities for the spread of inflammation by continuity. The exciting cause of that spread of inflammation is undoubtedly the Bacillus coli communis, which quickly infects the peritoneum. This organism, under favorable conditions, is capable of penetrating the walls of the appendix, causing the most virulent inflammatory reac- tion. In gangrene of the appendix, removed early, pure cultures of this organism have been found, while examinations made in other cases, both of the fulminating and of the suppurative type, have uni- formly shown the presence of the colon bacillus. It is not always found alone. Other organisms, such as the Staphylococcus pyogenes aureus and the Streptococcus pyogenes, have also been found in cases of mixed infection, but it is a question of considerable doubt whether the ordinary organisms of suppuration are capable of causing appen- dicitis. Where the Bacillus coli communis becomes virulent, its energies are not alone directed against the peritoneum, but also against the intes- tinal contents. Decomposition fermentation occurs, with the deve- lopment of poisonous ptomaines and other deleterious animal pro- ducts, which when absorbed produce profound systemic intoxication. Hence a careful examination of the exudate in appendicitis is likely, under many circumstances, to furnish a clew to more accurate prog- nosis. Catarrhal appendicitis is ushered in sometimes by a slight chill, with APPENDICITIS. 859 nausea, and with slight intestinal obstruction which generally yields to a mild laxative, the acute symptoms subsiding in one, two, or three days, and the patient returning to apparent health; but another attack, more or less severe, follows in a period varying from a month to six months, as the case may be, and the condition then becomes one of relapsing or recurring appendicitis. Catarrhal appendicitis may be more severe in some one of its attacks, perforation occurring, or the case going on to the development of an abscess which becomes extraperitoneal from Nature being able to shut off the abdominal cavity by adhesive peritonitis; a tumor then presents itself,, suppuration takes place, and the condition becomes one of true suppurative appendicitis. These cases do well after operation if too great search is not made for the sloughing appendix, the abscess cavity being washed out and properly drained. But by far the most serious and fatal cases are those of fulminating, acute, gangrenous, or perforating appendicitis. These are the cases in which the symptoms are very rapid in their development. The pain is localized, and generally in the right inguinal region, the point of great- est tenderness on pressure corresponding to what is known as McBur- ney’s point, about two inches from the anterior superior spinous process of the ilium, in a line from that process to the umbilicus. The location of the appendix is however variable, it being sometimes found under the caecum, sometimes with a long mesentery in the left inguinal region, sometimes above the umbilicus, reaching as far up as the under surface of the liver, or, when abnormally long, deep in the pelvis; and the point of greatest tenderness is wherever the appendix happens to be, but as its usual position is in the right inguinal region, the detec- tion of tenderness there is a sign of considerable value. Diagnosis.—The diagnosis of appendicitis is certainly becoming bet- ter understood by the profession, yet errors are not infrequently made. It has been mistaken for renal, biliary, or intestinal colic, intestinal obstruction, salpingitis, psoas abscess, general or pelvic peritonitis, typhoid fever, impaction of faeces in the caecum, cancer, tuberculosis, and dilatation of the ureter. The study of appendicitis for the past ten years has had much to do with eliminating that very uncertain term “idiopathic peritonitis,” and it has been well said that ninety per cent, of so-called cases of inflammation of the bowels can be traced directly to the appendix vermiformis. In the clinical study of this disease the pulse has been much neglected. It is not only its rate that is important, but its character; the fright- ened action of the heart apparently presents doubt and uncertainty in the condition of the pulse, a condition that tells that although the beat is but 90 now, in a few hours it will be 120 or more. A too brief ex- amination of the condition of the circulation will not always reveal its true state. Perforation of the appendix, however, is not always fol- lowed by an immediate increase in the pulse-rate, though this comes very soon. The temperature cannot be relied upon to any great extent in the classification of cases of appendicitis. A very dangerous perforation may be present, and yet the temperature may remain nearly normal for several hours. 860 INJURIES AND DISEASES OF THE ABDOMEN. Treatment.—Unquestionably very many eases of catarrhal appendi- citis recover under medical treatment, and without operative interfe- rence. The administration of laxatives and of rectal enemata, so as to obtain a free movement of the bowels, is often the only treatment required; but when the patient has suffered a number of attacks, and the disease is of the relapsing variety, the operation for removal of the appendix, intermediate or between the attacks, is a very successful procedure. It is a source of misfortune that there is still a belief among many physicians that the presence of a tumor is necessary for the diagnosis of appendicitis, or as an indication for immediate operation. The very contrary is true. A tumor is practically no part of fulminating appen- dicitis. With another class of physicians the presence of a tumor is looked upon as a favorable sign, an indication that the case will re- cover without an operation. While this belief is not so dangerous as the preceding one, it yet leads to disastrous results by allowing the formation of widely dissecting abscesses, and a resulting condition of saprsemia, not very rare in cases of delayed operation. It is certain, however, that in these cases of the suppurative form of appendicitis, immediate surgical interference does not become as imperative as in the fulminating variety, and it may be said that when once the tumor has been recognized, the patient’s pulse remaining below 90 and the temperature about normal, it is safe to wait, relieving the bowels by rectal enemata. until the end of the tenth or twelfth day, when the abscess which has formed may readily be opened and drained. On the other hand, an error is often made in delaying too long an operation where there is a localized abscess. Too great manipulation of the parts is at times indulged in by the attending or consulting physician, and the abscess may thus be ruptured, leading to a rapidly fatal peritonitis. When an operation is done for suppurative appendicitis, in a case in which there is present a well-defined abscess cavity, the object of the operator should be to drain that cavity without infecting the general peritoneum. It is far better to do this and resort to a second operation at a later period, should there be a return of symptoms, than to attempt too much in searching for the appendix, risking the opening of the peritoneal cavity. In all operations of this kind careful attention should be paid to the subject of complete, thorough drainage, by the use either of gauze or of a glass drainage tube, the technique being carried out with great completeness. In conditions of septic peritonitis due to perforation, associated with any variety of appendicitis, there are times when the free flushing of the peritoneal cavity with saline solutions becomes absolutely necessary. As to this form of appendicitis, very prompt operative interference is required on the part of the medical attendant, or the patient will pass beyond the skill of the surgeon within a few hours. Cases that result from perforation and the escape of the contents of the appendix, with or without the secretion from the caecum, but having the Bacillus coli communis as the infective micro-organism, develop septic perito- nitis rapidly, and prove fatal in a very large majority of instances. In cases that have been reached early, however, though there has been present a gangrenous condition of the appendix, yet its complete re- PYLORECTOMY AND GASTRO-ENTEROSTOMY. 861 moval has resulted in a fair percentage of recoveries, when the patients would certainly have died had only medical treatment been contin- ued. As to the mode of removing the appendix, there is perhaps no better method than that of placing a temporary ligature around it near its attachment to the csecum, after having tied off its mesentery and thus controlled the vessels; then making a flap of the peritoneal coat, in- vaginating it with three or four fine sutures, loosening the temporary ligature, and inserting the stump within the csecum, the peritoneal surfaces of which are finally themselves brought together. In this manner the peritoneum, if slightly roughened, very quickly takes on adhesive inflammation, and the entire appendix is obliterated. Cholecystotomy. In relation to this subject much has been added during the past ten years. Surgeons have been able to reach the bile ducts and gall blad- der with a greater degree of freedom than heretofore, owing to the little danger of peritonitis when the operation is thoroughly aseptic; the results, however, in reference to biliary fistula, have not been alto- gether satisfactory. In some cases the discharge has been a great annoyance to the patient, and has continued, notwithstanding ef- forts made toward its closure, or to relieve stenosis of the common duct. Attempts have been made by various surgeons to establish a direct communication between the common duct or gall bladder and the small intestine, and cholecystenterostomy is apparently becoming an established operation in suitable cases. The reports made thus far of the use of the Murphy button in these cases have certainly been very encouraging, and it is an appliance which should be employed under certain restrictions. When the gall bladder is distended, there is very little difficulty in making an anastomosis between it and either the large or the small intestine, and when there is a moderate dilatation of the cystic duct this may be used satisfactorily for the same purpose. This method should certainly be adopted when there is complete stenosis of the common duct. Incision of the gall bladder or ducts, with removal of the obstruction and immediate closure, is now again receiving much successful attention. Pylorectomy and Gastro-Enterostomy. Regarding the operations of pylorectomy and gastro-enterostomy, there can be no doubt that the former has made little permanent impres- sion upon the practical surgeon. There are a certain number of cases— not many—in which the operation can be done successfully, and prob- ably the use of the Murphy button would be of benefit in them. In cases where the tumor or other pathological condition can be removed, requiring extensive section of the stomach, it is best to close the open- ing in this viscus and establish a direct anastomosis independently between some other portion of the organ and the upper end of the duodenum. 862 INJURIES AND DISEASES OF THE ABDOMEN. Gastro-enterostomy is a justifiable operation in some cases, even though the tumor cannot be removed, and may be employed for the purpose of prolonging life and making the patient more comfortable. Retroperitoneal Tumors. There is no department of abdominal surgery which requires more careful investigation, and which is capable of greater improvement in operative management, than that of new growths occurring in the re- troperitoneal space. Anatomical Relations and Pathology.—A careful study of re- ported cases shows that the most frequent origin of these growths is in the connective tissue of the capsule of the kidneys. None of them can he said to be absolutely benign, not even those made up of normal tis- sues, such as the lipomata, fibromata, or myxomata, although they may not lead to the formation of metastases or to infiltration of the sur- rounding parts. From the great size to which they develop, the con- sequent discomfort which they cause, and their tendency to undergo degenerative changes, they cannot be classed as innocent growths. Those which spring from the pelvic walls encroach upon and involve the bladder, uterus, and rectum, and often present features difficult of diagnosis. Smaller growths originate from the retroperitoneal lympha- tics, the bodies of the vertebrae, and the root of the mesentery. From the change which occurs in their anatomical relations it is often quite impossible to determine the exact point of origin of many large retroperitoneal growths. They almost uniformly present themselves in the line of least resistance (that is, anteriorly), and upon reaching a sufficient size to attract attention they appear at either side of the um- bilicus, although they may appear centrally. Owing to circulatory changes within the mass, their liability to subsequent malignant infii- tration, and the development of cachectic conditions, they present, clinically, features of great gravity, and are sometimes immediately hazardous to life. The so-called cyst of the broad ligament is very often partially retroperitoneal in character. There is in these cases no inconsiderable amount of evidence to sup- port the theory of Cohnheim relative to the origin of tumors. They are sometimes active in their growth, often becoming cystic and reach- ing immense proportions. They often show a marked tendency to recur locally when removed. The microscope, besides revealing the usual elements of lipoma or myxoma, often presents a dense, round-celled infiltration in the stroma of the growth, indicating a sarcomatous element. Tumors found in the kidneys of young children are, for the most part, mixed tumors, chiefly myo-sarcomata. In sarcomatous growths circulatory changes are likely to occur— thrombosis, with subsequent softening and cystic degeneration. Lipomata are usually slow-growing, particularly the subserous, and seldom change to other varieties, though they may primarily be mixed in character (myo-lipoma). Fibromata and cystomata, for the most part, spring either from the RETROPERITONEAL tumors. 863 walls of the pelvis or from the subperitoneal connective tissue of that region. Diagnosis of Retroperitoneal Tumors.—There is no single symp- tom that is pathognomonic of these growths, and the diagnosis must be made mainly by exclusion. The patient’s sex, or the history of the case, may at once exclude the organs of generation, bimanual examina- tion rarely failing to locate the uterine appendages and to determine pathological changes occurring in them. Subperitoneal uterine fibroids are the only uterine growths likely to be confused with those under consideration, hut solid tumors of the ovary and broad ligament present greater difficulties, which at times cannot be surmounted. The his- tory of the case, however, together with a painstaking weighing of general symptoms, will assist in clearing up the diagnosis in the event of doubt. Disturbances as regards biliary excretion may occur from pressure of the growth on the common duct. Tumors of the liver always move synchronously with respiration; retroperitoneal growths, as a rule, do not. Differentiation from hypertrophy and tumors of the spleen presents less difficulty than in the case of the liver. Tumors of the omentum lack the fixed position of retroperitoneal growths. An examination of the urine may give a clew to the diagnosis, and in many cases the withdrawal of fluid by the aspirator, and its careful examination, will throw light on the nature of the tumor. Dullness on percussion is often relative rather than absolute. Rectal insufflation of hydrogen gas, with distention of the stomach, may be a valuable adjunct to diagnosis, more especially where a care- ful examination has previously been made and percussion areas have been outlined upon the abdomen; the process of inflation should be carefully watched so that the relation of the intestinal tube to the tumor may be determined. Prognosis.—'Without operative interference there is but one termi- nation to these cases, though the rapidity of the fatal result varies somewhat with the character of the growth. From the clinical his- tories found in surgical literature, the mean duration of life, after dis- covery of the tumor, appears to be not more than nine months. Much promise is offered by operative treatment, recovery having followed the removal of retroperitoneal tumors weighing as much as fifty pounds. Incomplete operations have been immediately fatal oftener than when the tumor has been completely removed. Treatment.—Considerable modification in operative detail will from necessity be made in the removal of retroperitoneal growths. Langen- beck’s incision for removal of the kidney may be made use of. By separating the peritoneum from the internal border of the tumor and attaching it by sutures to the internal border of the abdominal wound, the whole field of operation becomes extraperitoneal. Removal of the growth by enucleation must be accomplished with great care, and it is always desirable to determine the source of blood supply and the rela- tions of the tumor to the great vessels. Occasionally it is necessary to remove the kidney with the tumor, and the danger of hemorrhage is then very great. As in all abdominal work, the operator must be pre- 864 INJURIES AND DISEASES OE THE ABDOMEN. pared for any and every possible complication. The cavity must be thoroughly drained after simple enucleation of the tumor, as well as when the kidney is removed with the growth, either by full-sized drain- age tubes or by tampons of iodoform gauze. The after-treatment is the same as after other cases of abdominal section. Intestinal Sutures and Anastomosis. A trustworthy digest of the multitude of methods proposed for the union of intestines by resection and anastomosis would exceed by far the necessary limitations of this article, and I shall therefore claim a certain latitude in the selection and presentation of those which have appealed more directly to my surgical judgment and personal expe- rience. In the first place, it may be said that of all the numerous and often fantastic methods of intestinal suture devised before 1880, none deserve especial mention other except those of Lembert, Czerny, and Halstead. A fuller acquaintance with the practical application of these methods will prove a revelation to many who have been disposed to question their utility. Success in intestinal surgery depends very largely upon manual dex- terity, far more than upon the special method employed. There are no short or easy roads by means of which one can arrive at proficiency. A certain amount of experimental surgery must be done by all who enter this field of surgery. He who undertakes the union of resected intestines by simple suture for the first time after having completed an otherwise severe operation, deserves no greater success than he is likely to achieve—namely, the death of his patient. Two methods of union of intestines are employed, that by simple suture, and that by the use of foreign bodies, such as vegetable or animal plates, rings, or metal buttons. All things being equal, the first method seems at once the more attractive, but certain disad- vantages are found to exist which, to the minds of many, are contra- indications to its employment. The time required to effect union by suture alone has been urged as an objection with much persistency. Some writers assert that an hour at least is required to perform a cir- cular enterorrhaphy, time that can rarely be afforded with safety to the patient; but I am convinced through practical demonstration that such an operation can be performed in half the time indicated. Given a patient in moderately good condition and in the hands of a skilful anaesthetist, circular enterorrhaphy can be performed by a surgeon of reasonable skill without greatly increasing the shock. The danger of gangrene and ulceration, with subsequent perforation at the point of suture, is another objection which has been raised, but it may be an- swered that this misfortune occurs also when other methods are em- ployed. A defective technique is responsible for the accident in the majority of cases. Operating in tissues which through inflammatory processes have a lessened vitality, or drawing sutures too tightly, will account very often for the disastrous consequences. From an experience with all methods, I find it very difficult to rid myself of the belief that resection and anastomosis by simple suture is INTESTINAL SUTURES AND ANASTOMOSIS. 865 the ideal method, and for this the sutures devised by Lembert and Czerny will be found fully adequate. The condition of the patient being such as to warrant resection, the following precautions are to be observed: The point of section in the intestine must be selected where there can be no doubt of the vitality of the part. Having determined the length of bowel to be removed, it is cleared of intestinal contents by gentle pressure, and is held at each side by the fingers of a trust- worthy assistant. The intestine is divided in a slightly oblique man- ner, removing more at the periphery than at the mesenteric border, so that there may be no doubt as to the sufficiency of the blood supply. It is not desirable to remove a large V-shaped portion of mesentery, but as little should be taken away as is compatible with avoiding acute flexion at the point of resection; the mesenteric vessels should be con- trolled by immediate ligation with fine catgut. Czerny sutures of fine silk are next to be placed at intervals of one- fourth of an inch, and tied within the intestine—the tying being delayed until all the sutures are in place. The portion of intestine between the folds of the mesentery requires the most careful attention, and one or two sutures must be placed at this point. When the first row of sutures are tied, all of the mucous membrane will be invagi- nated. The Lembert sutures should then begin at the mesentery, one or two being placed at the point at which the intestine is not covered by peritoneum, and should be continued, six to the inch, around the entire circumference of the bowel to the point of beginning. A resection undertaken under suitable conditions, and carried out in the manner described, offers every opportunity for a favorable result. Conditions sometimes arise when a resection is contra-indicated, either from the extent of intestine which would have to be removed, or from the situation of the parts involved, as in the operation of gastro-enter- ostomy. In such cases lateral anastomosis by Abbe’s method presents distinctive advantages. The method of Abbe is as follows: After resection of the intestine and closure of the divided ends by the Lem- bert suture, the parts to be joined are brought side to side, and two rows of Lembert sutures are applied, one-fourtli of an inch apart, and an inch longer than the proposed incision. The material employed is fine silk, twenty-four inches long, and the needles are left threaded at the end of the row. An opening in the adjoining segments of intestine is now made, four inches long, by scissors. The incision is made one- fourth of an inch from the line of sutures, both rows being on the same side. Any bleeding vessels are caught by haemostatic forceps. The adjacent cut surfaces are now sutured by a through-and-through, over- hand suture, the hemorrhage being controlled in this way. The two free borders are next sutured in a similar manner, after which the open- ings are approximated, and the first described rows of continuous Lembert sutures are continued around the opening to the point of beginning. From the description, this process would seem to require too much time. Practically, however, with a little experience, it may be very quickly accomplished. This method presents the advantage of giving a very free communication between the divided intestines, the lack of which is a serious objection to the use of plates and buttons. A great many ingenious methods have been devised to lessen the 866 INJURIES AND DISEASES OF THE ABDOMEN. time required in doing intestinal anastomosis, and at the same time to avoid many of the unfortunate results which follow simple suture. All of these have been employed successfully by different operators, and merit impartial investigation. Senn has been a pioneer in this field of surgery, and undoubtedly the decalcified bone plates invented by him are much more satisfactory than any of the similar devices employed. Plates made from vegeta- ble substances, such as potato and turnip, or from rawhide or catgut, are inferior when applied for the purposes for which they were designed. It may be urged, upon substantial evidence, that the communication established when any of these methods is used is insufficient, leading to either immediate or remote obstruction; and as an evidence of the general dissatisfaction felt by surgeons in employing any of these methods, it is only necessary to call attention to the fact that each has been abandoned as soon as a more recent plan has been suggested. Recently there has been presented a device for both intestinal resec- tion and anastomosis that for ingenious construction, simplicity, and rapidity of application, excels all others, namely, the Murphy button. Already a large number of cases in which this instrument has been successfully employed have been reported; but while I am not dis- posed to undervalue the service rendered to surgery by this invention, it can hardly be said that sufficient experience has as yet been accumu- lated to warrant its general employment. To those who have not done much experimental work in intestinal surgery, however, it presents a method full of promise. Many circumstances, such as the surroundings of the patient, the lack of skilled assistance, or the patient’s enfeebled condition, may make it advisable to use the Murphy button in prefer- ence to adopting any other method. Certainly no abdominal surgeon should fail to be prepared to use this valuable, time-saving, and often life-saving device. HERNIA. BY JOHN A. WYETH, M.D., OF NEW YORK. A hernia, literally defined, is a tumor formed by the escape of the whole or a portion of any viscus from its normal cavity. By common consent, the term is now almost wholly restricted to protrusions of in- testine or omentum (or both), from the cavity of the abdomen or pel- vis, and these protrusions may occur through an opening which is con- genital or acquired. Complete inguinal hernia following the descent of a testicle, or ventral hernia due to failure of perfect union in the aponeuroses of the abdominal muscles, are instances of the former; while a protrusion of the intestine after a wound of the abdominal wall is an example of hernia through an acquired opening. The hernia may take place into an adjoining cavity, as the thorax (dia- phragmatic), or may protrude beneath the skin (femoral, umbilical, ventral, etc.). Classification of Hernia. Hernise are classified according to their place of escape: inguinal, femoral, umbilical, diaphragmatic, gluteal, obturator, lumbar, vagi- nal, pudendal, and perineal. The term ventral is applied to all herniae occurring at points on the abdominal wall other than those indi- cated in the classification just given. Of hernise in general, the in- guinal variety forms about 80 per cent, of all cases; femoral, 10; um- bilical, 5; the remaining varieties, 5. Of every five patients affected with hernia four are males. Inguinal hernia in males occurs more often in the first ten years of life than in any subsequent decade, the period from the twentieth to the fortieth year being next in order of frequency. According to Kingdon, femoral hernia in males of all ages is met with in four of every hundred cases; in the first decade in one of every three hundred; in the second two per cent. ; in the third and fourth together, four and a half per cent.; in the fifth and sixth, six per cent.; and after this, eight per cent. In females inguinal and femoral hernke are met with in about equal proportions. The latter variety is rarely met with before puberty, but occurs chiefly during the child-bearing period (Thomas Bryant). 867 868 HERNIA, Structure of Herne®. The contents of the hernia are enclosed in a sac, almost always formed by the peritoneum lining the abdominal cavity. The sac may be carried immediately in front of the escaping intestine or omentum (femoral, umbilical, etc.), or these viscera may descend into a sac already formed by the escape of some other organ (inguinal, scrotal). In the rare cases of hernia of those portions of the large intestine not covered b}T peritoneum, there is no true sac. The sac of a hernia is generally described as possessing a mouth, that part which looks directly into the abdominal cavity; a neck, the constricted portion at the opening into the abdominal cavity; a body, and a fundus, or most protruding portion. When the intestine alone enters into the forma- tion of a hernia, it is called enterocele; if omentum alone, epiplocele; if both are enclosed in the sac, entero-epiplocele. The coverings of a her- nia outside of the sac will vary with its location, and will be given in the consideration of the different varieties. As far as the sac itself is concerned, it varies in thickness, generally in proportion to the age of the hernia. In a recent hernia, it is exceed- ingly thin, while in some forms of scrotal hernia, of long duration, it may be as much as TV or £ of an inch in thickness. A hernia is said to be reducible when the contents of the sac can by any means be re- turned into the cavity of the abdomen; irreducible when adhesions exist to such an extent that this cannot be effected; strangulated when the circulation in the tumor is arrested by constriction at any portion (usually at the neck). Special Hernia. Inguinal Hernia.—An inguinal hernia may he direct or indirect, complete or incomplete, congenital or acquired. The indirect or “ oblique” variety is much the most frequently met with. In the male, the contents pass into the internal abdominal ring and follow the sper- matic cord along the inguinal canal, at times descending into the tunica vaginalis testis. In the female, the descent is into the canal of Nuck, following the round ligament in the inguinal canal, and at times as far as the labium. The epigastric vessels are internal to the neck and be- hind the body of an oblique inguinal hernia. (1, Fig. 1721.) A direct hernia does not enter the internal abdominal ring, but pushes the fascia which is to the inner side of the epigastric vessels and immediately behind the external ring directly in front of the tumor and out at the external ring. The epigastric vessels are external to the neck, and may be displaced slightly in front and to the Older side of a direct inguinal hernia. (2, Fig. 1721.) An inguinal hernia is said to be complete when the contents protrude beyond the external ring; incomplete when the tumor is within this limit. A complete inguinal hernia in the male may descend into the cavity of the tunica vaginalis testis, the contents resting in contact with the testicle (