P A': ■■*■; «.r" ..« t^j.JMr'W,. "7. :-■*■ i** \ ':■■■<■.!''*(£■ ■■-■ >$k ;'v-.'-- ^'.V ~§ ■■ v.-'.'•■*•"■■ ' "'&$ .'tS^ w wzm* m *>■• ■Tl* *J. &$ ,*%&' NATIONAL LIBRARY OF MEDICINE /■ Bethesda, Maryland Gift of Christine Miller Leahy and John Michael Miller In memory of James A. Miller, M.D. and Casper O. Miller, M.D. % Syogenesis). Pus is a creamy, whitish-yellow fluid, sometimes having a greenish tinge, thick, opaque, smooth, and slightly glutinous to the touch, with a faint odor and slightly sweetish taste. It is of variable specific gravity, ranging from 1.021 to 1.042, and is neutral or slightly alkaline in its reaction. °This de- scription is to be understood as applying to what is called healthy or laudable pus, derived from an ordinary suppurating wound in a person of good con- stitution. Beside this form, surgeons speak of sanious pus (mixedor tinged with blood), ichorous pus (when it is thin and acrid), and curdy pus (when 1 Virchow also refers to this liquefaction (as he calls it) of the intercellular substance of connective tissue, as accompanying proliferation. FORMATIVE CHANGES. 39 Fig. 3. it contains cheesy-looking flakes). Muro-pus and sero-pus are of course pus mixed respectively with mucus and serum. Chemically, pus contains water, albumen, pyine (which appears to be almost identical with fibrin), fatty matters, and salts. When formed in connection with diseased bone, pus has been found to contain 2^ per cent, of the granular phosphate of lime, and Air. Coote, in Holmes's System of Surgery, quotes from a paper by Dr. Gibb, of Canada, ten cases in which pus presented a blue1 color from containing the cyanuret of iron. Lender the microscope, pus is found to con- sist of corpuscles floating in a homogeneous liquid (liquor pun's). These corpuscles, which are variably termed pus corpuscles, pus glo- bules, or pus cells, have a diameter ranging from o oVotft *° 3 tto o^ °f an inch. They usu- ally contain several nuclei, which become ap- parent upon the addition of acetic acid. With these pus corpuscles there are commonly found granular matter, shreds of fibrin, and disintegrated lymph corpuscles. The above description applies to what must be called dead pus cells,2 the living cells possessing the power of active amoeboid movement, and corresponding in every respect with the wandering cells already referred to. It is even more difficult to speak positively of the origin of the pus cell than of that of the lymph corpuscle. In many cases (as in abscesses) the former seems to originate directly from the latter by a simple liquefaction of the gelatinous intercellular substance of lymph (p. 38) ; but in other in- stances the pus cell appears to have a different source. Virchow and other observers believe that pus corpuscles originate from rapid proliferation (luxuriation) of connective tissue and other nucleated cells, while Cohnheim,3 on the other hand, maintains that the sole origin of the pus corpuscle is the migration by amceboid movement of the white blood corpuscle through the vascular walls.4 Again, Dr. Strieker, and his able co- laborers, while acknowledging the origin of pus cells from both these sources, Pus-corpuscles, a. From a healthily granulating wound, b.' From an ab- scess in the areolar tissue, e. The same treated with dilute acetic acid. d. From a sinus in boue (necrosis). e. Migratory pus-corpuscles. (Rind- fleisch.) 1 Billroth and others speak of blue suppuration, resulting from the development of small vegetable organisms in the pus of a wound, but the coloring matter (which, according to Sedillot, pertains not to the pus cells but to the liquor puris, and may also be found in the serum of the blood) has been isolated in a crystalline form by Fados, who calls it pyocyanine; it is believed by Roucher and Jacquin to be of vege- table origin. Longuet recognizes three varieties of blue suppuration, viz., (1) that due to a change in the fluids of the part {true blue suppuration) ; (2) that due to the development of vegetable organisms ; and (3) a third variety, which he calls cyano- chrosis, which he believes to be due to the presence of an unknown substance, and which occurs epidemically, and particularly when the atmosphere is charged with ozone. 2 The absence of glycogen may, according to Hoppe-Seyler, serve to distinguish, the pus cell from the lymph corpuscle. (See note to p. 37.) 3 Mr. William Addison, more than a quarter of a century ago, maintained "that pus corpuscles of all kinds are altered colorless blood corpuscles ; and that . . no new elementary particles are formed by any inflammatory or diseased action." (See his "Experimental Researches," etc., in Trans. 1'ror. Me$. and Surg. Assoc, vol. xi. pp. 247-2f)3.) Dr. Augustus Waller, also, in 184(j, described the passage of white blood corpuscles through the walls of the capillaries. 4 A recent writer, however, Dr. Richard Caton, concludes from observations on the frog, fish, and tadpole, that (1) the migration of white corpuscles is due not to amce- baform movements, but to congestion, as in the case of the escape of red corpuscles, 40 INFLAMMATION. have shown that the pus corpuscles themselves divide and multiply, and that in profuse suppurations this is probably the chief mode of pus formation, while Scliiff maintains that pus cells arise by proliferation of the endothelial cells of the vessels of the inflamed part, a catarrhal condition of the lining coats of the vessels thus causing a true suppuration in the blood before its occurrence in the parenchymatous tissues. Destructive Changes due to Inflammation—We have now traced inflammation through its nutritive and formative changes, considering in succession the temporary hypertrophy from cellular enlargement, and the development of lymph and of pus, both forms of new material derived from pre-existing elements in the part inflamed. We have next to consider the inflammatory process as affecting already formed tissue in another way, namely, by degeneration or liquefaction. The application of an irritant, such as a blister, excites the inflammatory process, causing the formative changes which have been described, to occur beneath the cuticle. But the cuticle itself undergoes a change, and is thrown off as effete material, leaving a raw surface or abrasion. If the irritant act with greater intensity (as in the case of a burn), the destructive effect will be greater, the superficial tissues being thrown off in larger or smaller masses, and an ulcer being left. AVhen the process is accomplished by the death of visible particles, it is called slough- ing or gangrene, and the separated parts are called sloughs; when the parti- cles thrown off by the destructive action are indistinguishable to the eye, the process is called ulceration. Ulceration and gangrene cannot be looked upon as essential parts of the inflammatory process ; they are indeed often regarded as terminations or effects of inflammation rather than as themselves parts of the process in question. Pathological Summary__Let us now, before entering upon the clinical study of inflammation, briefly recapitulate what has been said as to its pathological phenomena. The inflammatory process, according to the degree of irritation present, modifies the phenomena of natural textural life as regards function, nutrition, and formation : in each case the modification is primarily in the direction of excess. As regards function, there is first increased activity, followed by perversion, and eventually, perhaps, by dimi- nution or even total abolition. The nutritive changes are shown in an al- tered state of the vascular system of the part (hyperaemia, determination) ; in an altered state of the blood itself; in an altered condition of the paren- chyma (temporary hypertrophy) ; and in a change as regards the neurotic condition, which doubtless reacts upon both vessels and parenchyma. The formative changes consist in the production of lymph and of pus. There may be also a destruction of existing tissues, resulting in its being thrown off as effete material by the processes of ulceration or gangrene. Clinical A7iew of Inflammation. In the clinical study of inflammation, there are to be considered successively its causes, its symptoms, its course, its terminations, and its treatment in its various stages and conditions. Causes—The causes of inflammation may be divided into the predis- posing, and the exciting or determining causes. The predisposing causes may be said, in general terms, to be any circumstances which impair the and that (2) suppuration may exist without migration ("ausu•a»derung,,), and, on the other hand, migration may exist without suppuration (Journ. of Zinut. and Physiol, Nov. 1870). SYMPTOMS. 41 general health of an individual, or which render his tissues less capable of resisting the injurious influences to which they may be subjected. Thus the various conditions of a person's life, the nature and amount of food which he consumes, the thermometric and other meteoric conditions to which he is 4 subjected, the nature of his occupation, his having been affected with various ^ diseases at previous periods of life, even his age, temperament, etc., may all ^ be considered at times as causes predisposing to the development of the in- flammatory process. The exciting or determining causes are usually said to ' be either local or constitutional, arising either from ivithout or from within. * I think, however, that it is more correct to look upon the determining causes of inflammation as always local or external, those which are commonly con-,/' sidered as acting constitutionally, being really either predisposing causes, or l else properly to be termed local, though acting from within the body, and therefore, in that sense of the word, internal. The determining causes of inflammation are either mechanical or chemical. - Among the mechanical causes are to be enumerated the results of external violence, blows, cuts, wounds of all kinds, fractures and dislocations (in these cases acting from within the body), the presence of foreign bodies, whether introduced from without or originating internally (as a renal calculus), dis- tention of parts, as in the cutaneous inflammation which often accompanies dropsy of the lower extremities, and compression, whether from without or from within. Among the chemical causes may be classed heat and cold, the application of acids or alkalies, poisoning of the blood by septic matters, various forms of contagion, as of gonorrhoea or chancre, etc. Certain forms of nerve lesion may probably be considered determining causes of inflamma- tion. It has longheen known that injuries or diseases of nerves may act as predisposing causes, by diminishing the natural power of the tissues to resist the external influences to which they are constantly and unavoidably sub- jected ; thus after spinal injuries, sloughing of the paralyzed parts may be produced by circumstances which would have no perceptible influence in a state of health, and carbuncle, a disease in the progress of which inflammation plavs a prominent part, appears to be often associated with diabetes, which there are strong reasons for believing to be, in some cases, an affection of the nervous system. Some experiments, made by Dr. Aleissner, would appear to show further that certain nerve fibres exercise a peculiar "trophic" func- tion, and that a lesion of such fibres may be the immediate and determining cause of an inflammatory condition of the parts supplied.1 It is sometimes said that certain abnormal properties of the circulating blood are to be considered as determining causes of inflammation; but from what has gone before, I think it will appear that this is incorrect. Either a plethoric or an anamiic condition of the blood may indeed act as a predis- posing cause, by impairing the general health; or the blood may carry in its course through the system septic or other morbid elements derived either from within or without, but in this case its function is ministerial merely, apd those morbid elements themselves are to be looked upon as the determining causes of the inflammatory process, not the blood which is simply their vehicle of transmission. Symptoms.—We have next to consider the symptoms'1 of inflammation. These may be distinguished into the local, and the constitutional or general 1 See upon this point, Holmes's .S^. of Surgery, 2d edit., vol. i. pp. 40-41, and Paget's Surgical Pathology, 3d edit., p. 36. A clinical observation of Dr. Geo. C. Har- lan's, is confirmatory of the same view (Phila. Med. Times, Dec. 13, 1873). 2 Inflammation limited to its first stage (temporary hypertrophy), as is seen in the repair of trivial injuries by immediate union, may be attended with such slight dis- 42 INFLAMMATION. symptoms. The latter will be treated of on a subsequent page, under the heading of symptomatic or inflammatory fever. The local symptoms of in- flammation maybe classified under six heads, viz.: (1) alteration of color, (2) alteration of size, (3) alteration of temperature, (4) modification of sen- sation, (5) modification of functioning (6) modification of nutrition. One or more of these symptoms may exist in a part without that part being in- flamed, and it is only when they are present in combination, that the diag- nosis of the inflammatory process can properly be made. The phenomena of the erectile tissues furnish a familiar example. Again, certain nervous lesions give rise to a combination of these symptoms so striking as to have been considered by many excellent observers to indicate a true inflammatory con- dition (the so-called neuro-paralytical inflammation), and, indeed, this state is one that can be converted into true inflammation by the action of very slight external causes. The degree in which any one of these symptoms is manifested, depends, in a great measure, upon the nature of the tissue in which the inflammatory process is going on. Thus in the case of the skin or of mucous membranes, a change of color is the most prominent symptom. Inflammation of the connective or areolar tissue is particularly distinguished by the swelling by which it is attended. In the fibrous tissue, pain is the best marked symptom. Conjunctivitis or a superficial burn, inflammation of the subcutaneous fascia, and periostitis, may be taken as illustrations of these propositions. Again, modification of function is more prominent in an in- flammation involving the eye, than in one affecting a much larger area of the skin or of the alimentary canal, while in some tissues, cartilage for instance, almost the only change that can be recognized after a long duration of the inflammatory process, is an alteration in the nutrition of the part involved. Redness, the first of the symptoms made classical by the description of Celsus,1 is perhaps the most noteworthy of all the signs of inflammation. It varies from a bright scarlet, as in the skin, to a deep crimson, or even a dusky, almost purple hue, as in some mucous membranes. In some tissues, other forms of discoloration take the place of redness ; thus the inflamed iris becames gray or brown. The redness of an inflamed part is undoubtedly due to its being in a hyperremic condition, the capillaries being dilated so as to contain more blood than in the natural state, and the red corpuscles of the blood entering into vessels which, in their normal condition, were too narrow to admit them. In some depressed states of the system, there is an absolute oozing of the coloring matter of the blood through the walls of the capillaries, thus adding a new source of discoloration, while when the inflammatory pro- cess has gone on to the formative stage, the new tissue developed from the inflammatory lymph, being very vascular, causes a more or less permanent redness, which, as is well known, may persist in a scar or in a part that has been inflamed for a considerable period. The next symptom that demands our attention is swelling. This is of course due in some measure to the hyperemia of the part, the increased amount of blood in the vessels naturally adding to the common bulk. It is, however, probable that the principal cause of inflammatory swelling, in the first stage, is the increased absorption of nutritive material, this stage of in- flammation being indeed, as remarked by Alrchow, almost indistinguishable turbance as to present no recognizable symptoms. Hence immediate union of wounds is said by Paget to be accomplished without inflammation. Clinically speaking, this may be accepted as correct, but if the pathological views given above be true, the inflammatory process must exist though unattended by definite symptoms. 1 "Nota vero inflammation)s sunt quatuor, rubor, & tumor, cum calore, & dolore" (Celsus, de re medicd, Lib. III., c. 10. Opera, ed. L. Targse, Lugd.-Bat., 1785, p. SYMPTOMS. 43 from a true hypertrophy. The swelling may be further increased, if the in- flammation continue, by the presence of what are ordinarily called the pro- ducts of inflammation, viz., by the formation of lymph or pus, or by the exudation of the watery constituents of the blood, or even, in certain cases, of the blood itself. The amount of swelling varies greatly, according to the looseness or closeness of texture of the part affected. Thus the eyelid, when inflamed, swells so rapidly as often to completely close the eye, while inflam- mation involving the cancellous structure of bone may give rise to the most excruciating suffering, and even run on to suppuration, with almost no swelling in the whole course of the affection. The increase of size of an inflamed part may be evanescent or may remain as a kind of hypertrophy, as is often seen after the healing of old ulcers of the leg, or still more markedly in the case of bone after long duration of osteitis. On the other hand, from certain nutritive changes to which we shall have occasion to refer again, a part which has been inflamed may become permanently smaller than it was in the natural condition. The third symptom to be considered is alteration of temperature, increased heat. The illustrious John Hunter entertained the view that the increased temperature of an inflamed part was directly and solely due to the fact of its receiving an additional quantity of blood, and hence it is frequently said that the temperature of an inflamed part cannot possibly exceed that of the left ventricle of the heart. The experiments upon this point of Air. Simon and of Dr. Edmund Alontgomery seem to me to establish incontrovertibly the incorrectness of Hunter's view. Their observations, which were made with the aid of a very delicate thermo-electric apparatus, are detailed in Air. Simon's able article on inflammation in Holmes's System of Surgery (2d edit., vol. i. p. 18), and their conclusions seem to me so well established and so important that I do not hesitate to quote them in full. These conclusions are :— " First, that the arterial blood supplied to an inflamed limb is found less warm than the focus of inflammation itself; " Secondly, that the venous blood returning from an inflamed limb, though found less warm than the focus of inflammation, is found warmer than the arterial blood supplied to the limb ; and " Thirdly, that the venous blood returning from an inflamed limb is found warmer than the corresponding current on the opposite side of the body. " Unquestionably, therefore, the inflammatory process involves a local pro- duction of heat." That there is thus a relative increase of heat due to the inflammatory pro- cess may be considered as proved, and that there is an absolute increase over the temperature of the central organs, is, I think, most probable. The sen- sations of the patient are of course unreliable in determining the amount of increased heat, and, it must be confessed, the impression conveyed to the hand of the surgeon cannot be implicitly trusted. Professor Gross has, how- ever, by actual observation, repeatedly found the temperature of inflamed parts to be above 100° Fahr., and has, in some instances, seen the mercury in the thermometer rise to 10o°, 106°, and even 107°. The cause of the change of temperature in an inflamed part is involved in some obscurity, and as this question is rather physiological than surgical, I shall not enter upon it further than to say that the chemical processes in- volved in nutrition may be supposed to cause the normal heat, and therefore when nutrition is disturbed in inflammation, the abnormal heat which accom- panies that process ; besides which, I see nothing unreasonable in the notion that nervous action may be more or less directly converted into heat—both 44 INFLAMMATION. being now recognized, in the language of the day, as correlative " modes of motion." The degree of elevation of temperature varies in different instances : it generally becomes less as the inflammation progresses, the thermometer fall- ing to or near the natural standard when suppuration is established. It is scarcely necessary to add that in cases of gangrene the temperature of the dead part falls below the normal standard. The fourth symptom of the inflammatory process which demands attention is modification of sensation, generally manifested as pain. The pain of in- flammation varies with the nature of the part affected ; thus in the mucous membranes it is of a scalding or itching character (as in conjunctivitis or in hemorrhoids), in the serous and synovial tissues it is sharp and lancinating (as in pleurisy or in inflamed joints), in the fibrous tissues it is dull, aching, or boring, and often worse at night (as in inflammation of bone or perios- teum). A most distressing burning pain accompanies certain inflammatory lesions of the nervous system. The form of pain varies also with the stage of inflammation ; thus, on the approach of suppuration, it assumes a marked throbbing or pulsatile character, while a peculiar burning pain sometimes heralds the approach of mortification. The pain is usually most severe when the inflammatory process is at its stage of greatest intensity ; but a sudden cessation of the pain of inflammation is always to be dreaded, as often indi- cating the occurrence of gangrene, as in the case of a strangulated hernia. The pain is usually greatest at the part where inflammation is highest, but this rule has notable exceptions. A whitlow may cause great pain in the axillary glands, while the pain of hepatitis is frequently referred to the right shoulder, and that of hip disease to the knee. The nervous connections of the parts are usually concerned in this misplaced pain, though in some cases (as in whitlow) it is directly referable to irritation transmitted by the lymphatics. If there is not mucli pain in any case of inflammation, there is often great tenderness on pressure ; as instances may be mentioned cases of inflamed joints, of mammitis, and of swelled testicle. The cause of inflammatory pain is doubtless due, in some measure, to pres- sure on the nerves of the part due to the inflammatory swelling ; but this can- not be admitted to be the sole or even the chief agent in producing the pain of inflammation, for there may be quite as much swelling and nervous com- pression from congestion or other causes, with comparatively little suffering ; at the same time, compression has its effect, for it is found that the pain is usually greatest in those tissues and organs that admit of least external swell- ing. The principal cause, however, I cannot doubt, of the pain which attends inflammation, is to be found in a direct alteration of the condition of the nerve fibres themselves. The pain of inflammation sometimes serves a good purpose in warning the patient to guard the affected part from external violence ; it is increased or diminished by position and other circumstances which will be referred to again under the head of treatment. The fifth local symptom of inflammation is modification of function. This has been already mentioned in discussing the pathological division of the sub- ject, and I trust that it was then made clear that altered function is an essen- tial part of the inflammatory process. The functional disturbances due to inflammation are perhaps most evident in the case of the organs of special sense ; thus deep-seated inflammation of the eyeball is commonly attended by frequent scintillations and flashes of light, at the same time that the power of vision may be impaired or entirely abolished. Again, in the case of an inflamed gland, the function of the organ is invariably affected, not only the COURSE. 45 amount secreted, but the properties of the secretion itself, being materially different from what they are in the normal condition. A slight degree of irritation, as has been already said, stimulates the function of secretion. In absolute inflammation it is temporarily suspended, and when restored, the nature of the secreted material is usually markedly altered. The power of using an inflamed organ is much impaired or altogether lost. It is well that this is the case, as, were it possible to read with a seriously inflamed eye, or to walk with a knee affected with acute arthritis, it is evi- dent that the prospects of recovery of the diseased part would often be mate- rially lessened. Lastly, a prominent symptom of inflammation, and one which is always present, is modification of nutrition. In the first place, as has been already seen, there is a positive hypertrophy of the affected part. This may persist after recovery, or the part may resume its natural size, or may even contract and become as it were atrophied. Inflammation may be attended with indu- ration (as in the so-called phlegmonotis inflammation of the subcutaneous tis- sues), or it may be attended with softening, as in the case of bone ; or there may be a slow wasting from a kind of interstitial absorption, without any softening or production of new material. Course___Inflammation is often spoken of as acute, subacute, and chronic. This classification may be and doubtless is convenient for certain purposes, but must, I think, be deemed incorrect. The inflammatory process is the same, no matter what duration of time it occupies, and no matter with what intensity its phenomena are displayed. It may, however, be properly re- garded as having three principal stages, through all of which it frequently passes, though it may be arrested at any period of its course. The first stage of inflammation embraces all the phenomena of the process from determina- tion, or simple active hypersemia, to the temporary hypertrophy which has been so often referred to, the second stage is characterized by the appearance of lymph, and the third by the occurrence of suppuration. Besides these we may recognize certain subordinate stages, as that of serous effusion, that of ulceration, and that of gangrene. The effusive may be considered a modifi- cation of the ordinary second stage of inflammation, and is most marked in certain tissues, particularly the serous and synovial membranes. The ulcera- tive and gangrenous stages are very closely connected together, the former being met with on the surface of organs merely, while the latter may involve the entire thickness of the part in which it occurs. Many authors describe these, which I have called stages of inflammation, as separate forms of in- flammation ; it seems to me, however, that the inflammatory process must be considered as essentially the same under all circumstances ; and hence that it is more correct, and equally convenient, to look upon effusion, suppuration, ulceration, etc., as various stages of one process, their occurrence being de- pendent on extraneous circumstances, such as the nature of the part affected, the intensity of the original irritating cause, or the general state of health of the patient in whom the process is going on, rather than on any essential diversity in the process itself. First stage___The symptoms of the first stage are those which have already been considered, viz. : changes of color, size, temperature, sensibility, func- tion, and nutrition. Second stage___The development of lymph is attended with certain modi- fications of these symptoms. Thus, the swelling may become harder, or there may be an ©edematous condition of the subcutaneous tissue from tie concomi- tant effusion of serum. The period at which the development of lymph (or as Prof. Gross terms it, lymphizatioii) occurs, varies with the tissue affected. 46 INFLAMMATION. In inflammation of the serous membranes, as the pleura, arachnoid, or peri- toneum, it occurs early ; in those of the mucous membranes seldom at all, and when it does occur, at a comparatively late period of the disease. Third stage___The approach of the third or suppurative stage of inflamma- tion is usually attended with marked changes. The redness becomes more dusky, and the swelling softens in a certain part of its area, the surrounding tissue being hard and infiltrated from the presence of lymph. The pain be- becomes pulsatile and throbbing. The cuticle over the softened portion may desquamate. If the part which is about to suppurate be of sufficient size, the presence of fluid beneath the skin may be detected by the touch recognizing fluctuation or undulation. Under other circumstances, pus may form in large quantities with very little warning, and without the occurrence of the symp- toms which have been described. In suppuration of mucous membranes, pus makes its appearance in the natural mucous coating of the part at an early period. The process of pointing of pus in the deeper seated tissues will be considered when we come to speak of abscess. Ulceration___The ulcerative stage of inflammation is that in which, in addition to the nutritive and formative changes that have been considered, there is a destruction of previously existing tissue, which is thrown off by the process of ulceration. Ulceration may be defined as that part of the inflammatory process in which portions of inflamed tissue, degenerate or liquefied, are thrown off in solution or as very minute particles from the sur- face of the inflamed part. Some writers speak of ulceration with absorption of the degenerated material, and thus consider that the process may occur in the deep-seated tissues of the body. I think, however, with Sir James Paget, that it is better to give this the name of interstitial absorption, which has been already referred to as one of the nutritive changes of inflammation, and to restrict the term ulceration to the process as met with on free surfaces, where there is an absolute casting off of the degenerate and effete material. During the process of ulceration, or while an ulcer is spreading, the affected tissue is surrounded by a circle which is inflamed, and which presents the ordinary symptoms of the inflammatory process. The edges of the ulcer are more or less sharply cut, and often have a jagged or eroded appearance. The destructive action may affect the subcutaneous tissue more than the skin itself, so that the latter may be undermined for a considerable space around the ulcer. The surface of the ulcer itself, during its period of spreading, is covered with a gray or yellowish layer of dead material (a slough, in fact), which may be very thin, consisting of mere shreds and patches, or may be thick, soft, pultaceous, and elevated. The discharge is very slight, and more serous or sanious than purulent, though I doubt if there can be any true ulceration without the existence of pus. When an ulcer ceases to spread, the symptoms of surrounding inflammation subside, and the appearance of the ulcer itself undergoes corresponding changes. Its edges become firm, from the infiltration of lymph, and are fre- quently hard and elevated. The face of the ulcer becomes clean, and the superincumbent slough comes away in flakes or is apparently dissolved in the discharge, which, though still in very limited amount, approaches more closely to the characters of normal pus. Granulation and Cicatrization.—The repair of an ulcer is a very interesting process. The ulcer contracts, while its surface becomes elevated above the edges, and presents a vascular appearance, seeming as if studded with numerous papillae ; the discharge becomes more profuse, and presents the characters of healthy or laudable pus, while a faint blue line alon<>- the GRANULATION AND CICATRIZATION. 47 edge of the ulcer marks the gradual advance of the healing process. The papilla?, which have been spoken of above are called granulations, and an ulcer is said to heal by granulation and cicatrization. Granulations appear to consist of lymph which has become organized into new tissue, and their peculiar conical shape corresponds with the loops or arches of new vessels which give them their great vascularity. Healthy or normal granulations Vertical section through the edge of a granulating surface in process of repair, a- Secretion of pus. b. Granulation-tissue (embryonic tissue) with capillary loops, whose walls consist of a layer of cells longitudinally disposed ; their thickness decreases as we approach the surface, e. Cicatrization beginning at the base (spindle-cell tissue), d. Cicatricial tissue, e. Fully formed cuticle, its middle layer consisting of grooved cells. /. Young epithelial cells, y. Zone of differentiation. (Rindfleisch.) are small, closely set, of a bright red color, and covered with healthy pus ; they may under various circumstances be irritable, and bleed on the slightest touch, or they may be indolent and flabby, cedematous as it were from serous effusion, and may become detached in large masses as if they had not enough vitality to preserve their nutrition. The process of cicatrization does not begin until that of granulation is so far advanced that the edges of the ulcer appear depressed as regards its surface, the granulations themselves being healthy and covered with a layer of laudable pus. In the process of cicatrization the granulations become smooth and flat, and become covered with a thin bluish-white pellicle, which is the new skin. Cicatrization almost always proceeds from the surface to the centre, though occasionally islets of new skin are apparently formed in the middle of an ulcerated surface. Within the faint-blue line of new-formed skin, may be traced a line of deeper red than the ordinary color of the ulcer, 48 INFLAMMATION. consisting of granulation tissue in the transition stage to epithelium. The closure of the ulcer is promoted also by the contraction of the newly-formed tissue, probably owing to the transformation of the lymph or granulation cells into fibrils, which occupy less space, and therefore occasion the shrinking which is characteristic of all cicatricial tissues. In some instances contraction of the ulcer appears to precede the development of granulations. The healing of an ulcer leaves a permanent scar, which undergoes various changes subse- quent to its formation. Thus the scar of a burn may continue to contract for many months after the process of healing is complete, giving rise in this way to marked and sometimes very distressing deformity; there would appear indeed in some cases to be an actual development of elastic tissue in a scar, so persistent and irresistible is its contractile tendency. A scar when first formed is usually redder than the surrounding skin, or it may be bluish as if deeply congested ; in the course of time its color fades, so that an old scar is commonly of a dead-white color. Cicatrices gradually assume the appear- ances of the surrounding textures, and at the same time their deep attach- ments become stretched and loose, so that the mobility of the part is after a time measurably restored. A scar, however, never entirely gains the characters of the tissues around it, and is always more susceptible to injury, and more likely to give way and again become the seat of the ulcerative process, than the tissue in its immediate neighborhood which has never been affected. It has been pointed out by Air. W. Adams that cicatrices formed in childhood grow with the part in which they are placed. Gangrene—As abrasion (see page 40) is like but less than ulceration, so may gangrene or sloughing be considered ulceration on a larger scale, and the gangrenous as closely allied to, and, indeed, but a modification of the ulcerative stage of inflammation. Where an irritant has acted with great intensity, so large an amount of tissue may be deprived of vitality that mor- tification, gangrene, or sphacelus is said to have occurred. The term sphacelus is sometimes limited to gangrene of the soft tissues ; that of the bones is called necrosis. A mortified, gangrenous, or sphacelated part of the body can only be removed by the process of granulation, and when isolated by that process is said to be a slough, while the part affected is spoken of as sloughing. Gangrene may occur at a late stage of the in- flammatory process, or it may be primary, from the intensity with which the original irritant has acted. The onset of gangrene is marked by a peculiar dusky redness of the inflamed tissues, by the formation of bullae, filled with a dark fluid, and by the part, from being hard and tense, be- coming doughy to the touch ; the pain becomes burning, and the temperature of the part falls. When mortification has actually occurred, the part becomes mottled, purple, greenish, or even black ; sensibility and motion are lost; the part may seem shrunken ; it becomes colder than the surrounding tissue, and a peculiar odor is emit- ted, due to gaseous exhalations from the gangre- Complete sphacelus of foot and „„,, . „,„„., ,, „,, , . ,. , nou.s mass. ankle. 1 he sloping line of separa- rp, ..... tion well shown; studded with . ihis description is to be understood as apply- granuiations. (Miller.) ing to what is known as moist gangrene; there Fig. 5. INFLAMMATORY FEVER. 49 is another form of mortification, resulting principally from arterial obstruction, and to which the name of mummification or dry gangrene is applied, which presents somewhat different characters, and which will be considered in its proper place.1 When the spread of gangrene has been arrested, whether from the irritant which caused it having, as it were, spent its power, or from having reached tissues which have more vitality, and are therefore more capable of resisting the gangrenous process, what is called the line of demarcation is formed. This appears as a line of more or less vivid redness (sometimes preceded by a circle of minute vesicles), which immediately surrounds the mortified part. This line of demarcation is soon replaced by a line of granulations called the line of separation, and the slough is gradually pushed off, as it were, by the formation of new tissue beneath it, a healthy ulcer remaining when the dead part is finally removed. ^ It is usually said that the separation of a slough is „ effected by ulceration, but, as justly remarked by Air. Coote, it is rather by the process of granulation); there is no destruction of living tissues beyond the slough, but the spread of the gangrene is immediately succeeded by the reparative process of granulation. Inflammatory Fever__We have now considered the local manifes- tations of the inflammatory process in its ordinary stages, those of determina- tion, lymph development, and suppuration, as well as in its subordinate stages or varieties, those of effusion, ulceration, and mortification. The next sub- ject for discussion is the effect of the inflammatory process on the general condition of the patient, or, in other words, the constitutional symptoms of inflammation, which may be grouped together under the name of inflamma- tory, sympathetic, or symptomatic fever. Traumatic fever is another name which has been used, but which is objectionable, because the condition signi- fied may accompany inflammation which is entirely independent of traumatic causes. Surgical fever would be a good name, but for the confusion which might arise from the term having been applied (by Sir J. Y. Simpson) to an entirely different affection, viz., pyaemia. It is probable that no inflammation, however slight, is altogether unattended with symptomatic fever, though the course of the latter may be so mild as not to excite attention. An ordinary attack of inflammatory fever comes on usually within twenty-four hours of the first development of the inflammatory process. Air. Pick, of St. George's Hospital, found that in seventy-three cases of inflammatory fever following wounds, the first symptoms were usually manifested about the second or third day, sometimes later, but never after the fifth day, and occasionally within the first twenty-four hours (St. George's Hosp. Reports, vol. iii. p. 74). As the inflammatory process itself usually does not commence until about twenty- four hours after the reception of a wound, it will be observed that this state- ment corresponds pretty closely with that above given as to the commence- ment of the symptomatic fever. The onset of the fever may be heralded by various abnormal sensations; there may be an absolute rigor, or merely chilli- ness, alternating with flushes of heat. The pulse rises in frequency, varying from seventy or eighty to even one hundred or one hundred and twenty beats in the minute. It may be full but compressible, or hard and tense though small, as in cases of peritonitis. The respiration is usually hurried and some- what oppressed, and there may be evidences of positive congestion of the pul- 1 If a part dies quickly, while full of blood and other fluid matters, the gangrene which ensues is of the moist variety ; when the death is slower, the gangrene is dry. The occurrence of moist gangrene is chiefly determined by the existence of venous congestion. 4 50 INFLAMMATION. monary structures. The tongue may be red, dry, and clean, or coated with a white fur ; the mouth feels clammy, and the patient suffers from thirst. The bowels are usually confined, and the secretions vitiated. The urine is scanty and high-colored. There may be frequent micturition, or, on the other hand, retention of urine, requiring the use of the catheter. The skin is hot and dry, the temperature having been found to rise as high as 102.5°—103° Fahr. by Dr. Alontgomery, 104° by Air. Croft, 104.6° by Air. Pick, and 104.5°-105.5° by Prof. Billroth. The face is flushed, the eyes injected, and there may be distressing headache, together with muscular pains and general uneasiness. The patient is apt to be delirious at night. In favorable cases, as the local phenomena of inflammation decline, the violence of the symp- tomatic fever likewise passes away. The beginning of convalescence may be marked by profuse acid sweating, by diarrhoea, profuse diuresis, or even hemorrhage from the mucous membranes, constituting what the older writers called critical discharges. This is the course of an ordinary attack of inflam- matory fever, as met with in healthy persons in connection with traumatic or other inflammations, unattended with special causes of depression. Under other circumstances, there may be fever of an asthenic or typhoid type, re- sembling a good deal the ordinary forms of enteric fever. In these cases the tongue is covered with a dark brown fur, and is apt to be dry; sordes accu- mulate about the lips and teeth; the countenance presents a dusky hue ; the pulse is unusually feeble; the patient seems dull and soporose, and the deli- rium assumes a muttering character. This form of inflammatory fever is often attended with pneumonia of a low type. Convalescence from it is slow and interrupted, and in fatal cases death may be preceded by hiccough, sub- sultus tendinum, and coma. In what is called the irritative form of inflam- matory fever, the nervous system is especially implicated. The ordinary, sthenic, inflammatory fever may pass into the asthenic, or the latter may be present from the first. It is somewhat remarkable that the violence of an attack of inflammatory fever seems to bear no relation to the severity of the wound to which it may be due; a compound fracture may cause less constitu- tional disturbance than a slight flesh wound. There appears, however, to be a general correspondence between the intensity of the local symptoms of in- flammation and the severity of the symptomatic fever. An attack of inflam- matory fever usually reaches its height in about two days from the time of its commencement. Its whole course occupies from two to six days. If the inflammation be arrested in its first or second stage, the symptomatic fever subsides gradually; the occurrence of suppuration is usually.marked by a rapid diminution of constitutional disturbance. Thus a case is given by Air. Pick, in which, on the evening of the third day after a primary amputation for injury, the temperature was 104.6° Fahr., the pulse 110 and throbbing, the tongue furred, the face flushed, and the wound dry and glazed ; the next day the temperature had gone down to 100°, the pulse was 84, soft and com- pressible, and the wound was discharging healthy pus. Professor Billroth has described a " secondary fever," which begins on or after the eighth day, and he believes that this may occur without any primary fever having existed. It would appear, however, from the observations of Air. Pick, that there has in these cases always been a primary attack, though it may have been so slight as easily to elude observation. The primary may run into the secondary fever, the temperature not sinking to the normal standard during the interval; and in any case, if the fever last beyond the eighth day, it is to be considered as secondary. The occurrence of secondary fever, which appears to be due to the absorption of septic material, is always to be looked upon with apprehension, as indicating a grave change in the local or constitutional condition. It may be followed by deep-seated or wide- TERMINATIONS OF INFLAMMATION. 51 spread inflammation of the connective tissues, or may herald the approach of serious surgical diseases, such as erysipelas, hospital gangrene, or pya>mia. Gentz and Volkmann describe an " aseptic" form of traumatic fever, met with in cases of subcutaneous injury, etc., in which the increase of tempera- ture is the only symptom which can be recognized. Inflammatory fever, as has been said, usually subsides with the occurrence of suppuration. The formation of pus is, however, often attended with marked perturbations of the nervous system, consisting in repeated and some- times prolonged rigors, alternating with flushes of heat. In cases where suppuration is unduly prolonged, and the patient in consequence weakened, an irritative type of fever is developed which is called Hectic. In this form of fever the pulse is more rapid than in health, small and compressible ; the eyes are abnormally brilliant, and the cheeks flushed. The patient emaciates and becomes very feeble. The symptoms are usually most marked in the evening, when the skin is hot and dry, a condition which is often succeeded in the course of the night by colliquative sweating. The " cold sweat" of hectic often alternates or coexists with profuse diarrhcea, both tending to exhaust the patient. I believe that hectic is never established in cases of suppuration until the pus finds a vent externally: as long as an abscess is unopened, hectic will not occur. Extension of Inflammation__Inflammation may extend from one part of the body to another by continuity or by contiguity of structure. An instance of the former mode of extension may be found in the spread of tracheitis to the larynx or to the bronchi; an instance of the latter, in the extension of inflammation from the pleura to the lung, or from the bones of the skull to the membranes of the brain. Extension by metastasis is pro- bably rarer than is commonly supposed; the example usually given, viz., the occurrence of epididymitis in the course of gonorrhoea, is, I believe, no meta- stasis at all, but a simple extension by continuity of structure. Inflammation may spread by means of the lymphatics, as in adenitis of the axillary glands following upon a whitlow. The blood may indirectly be concerned in the spread of inflammation; as in cases of embolism, where the detached fragment or clot is carried along in the circulation, and acts as a foreign body. With regard to the agency of the nervous system in the spread of inflammation, it is proved that, by a form of reflex action, a part may be rendered more sus- ceptible to the influence of external irritants, and thus predisposed to the occurrence of the inflammatory process ; but any more direct agency of the nervous system is still a matter of doubt (see p. 41). Terminations of Inflammation__What I have called the stages of inflammation are often spoken of as terminations of the inflammatory pro- cess ; thus it is said to end in the formation of lymph, in suppuration, in ulceration, in gangrene, etc. But I think it will appear from what has been already said, that these cannot strictly be looked upon as terminations, for the reason that in each case the inflammation must go on in the surrounding parts until the Avhole process of ulceration, of mortification, etc., has been completed. Strictly speaking, inflammation can only end in resolution (a gradual return to the healthy state), or in the death of the patient, when of course inflammation must cease with the termination of other vital processes. Even metastasis, which is often called a termination of inflammation, is, as far as the part originally inflamed is concerned, really an instance of resolu- tion. The other so-called terminations do not end the process, but are merely events in its course. 52 TREATMENT OF INFLAMMATION. In resolution the symptoms of inflammation more or less quickly disappear. The pain and heat diminish, the swelling subsides, and the redness slowly fades away. The function of the part is gradually restored, and its nutrition slowly returns to the normal state. The dilated bloodvessels contract, the stagnant blood corpuscles are pushed on, and absorption, which had been to a great extent suspended, begins again with renewed activity, helping to remove the adventitious, newly formed material. Resolution may be complete, or only- partial ; in the latter case the part that has been inflamed remains perma- nently altered in structure. Thus inflammation of the eye may cause perma- nent opacity of the cornea, and gonorrhoea a troublesome form of urethral stricture. CHAPTEK II. TREATMENT OF INFLAMMATION. Before entering upon the subject of the treatment of inflammation, it may be well to reiterate what was said in the opening of the first chapter, that this process is not to be looked upon as a disease, to be met with lancet and calomel on the one hand, or with brandy and opium on the other, but is to be viewed as a modification of natural processes, which may often be con- ducted to a favorable termination by judicious management on the part of the surgeon, or by bad treatment may easily be made to end in destruction of the part affected, if not in the death of the patient. In dealing with any individual case of inflammation, the surgeon should bear in mind the nature of the pathological changes which are in progress, and administer or withhold his remedies with due regard to both the local and the general condition of his patient. Prophylactic Treatment__The first object of the surgeon, in every case, should be, if possible, to remove the cause of inflammation; and in many instances, if this, which constitutes the prophylactic treatment, can be accomplished, nothing more will be requisite. Thus the extraction of a speck of dust from the eye, or of a splinter of wood from the hand, will often prevent the development of inflammation, or at least allow its subsi- dence if already present. In any case the removal of the cause (if this can be ascertained) must be first effected, even if the inflammation continue and require further attention ; the first step in the cure of cystitis dependent on vesical calculus, is to remove the stone ; a strangulated hernia cannot pos- sibly be relieved while the constriction remains. Curative Treatment—When the cause of inflammation cannot be detected, or after its removal when that can be effected, what may be called the curative treatment comes into play. This may be divided into__I. The Hygienic treatment; II. The Local Remedial treatment; and III. The General or Constitutional Remedial treatment. I. The Hygienic treatment of inflammation is first to be considered. It is, I think, often more important than either of the others. Rest is frequently all that is necessary in the management of even severe injuries (as in many cases of fracture), and by itself will often suffice to prevent the unavoidable and needful inflammation from passing beyond the stage which is required CURATIVE TREATMENT. 53 for the repair of the lesion. No severe inflammation, whether from injury or from disease, can be successfully treated without the enforcement of rest, and even in slight cases it will be of great use in promoting and hastening a satisfactory issue. If an important organ (as the brain or lung) be inflamed, the patient should invariably be confined to bed; the same rule should be adopted for severe inflammations of less vital parts. In many cases local rest will be sufficient; thus a patient with an inflamed hand or elbow may walk about with the part supported by a sling, when a similar affection of the foot or knee would necessitate confinement to bed. Functional rest of the inflamed part is very important. No one should attempt to read with an inflamed eye, to talk with an inflamed larynx, or to write with an inflamed hand. Subsidiary to rest is position: this is a point which should be carefully at- tended to in the treatment of inflammation. All the symptoms of inflam- mation, and especially pain, are aggravated by a dependent position ; hence an inflamed leg or arm should be supported on, or even elevated above, the level of the rest of the body. Even in cases which do not require confine- ment to bed, great comparative ease and comfort may be afforded by support- ing the affected part with a suitable splint or sling. An apparent exception is to be noted in cases of inflammation about the head. Every one who has had a headache may know from his own experience that it is relieved by lying down, and it is a mistake to suppose that the impulse of blood to the head is diminished (as in the case of the foot for instance) by elevating the organ ; the reason is obvious—the brain must have a certain supply of blood, and if the force of gravity be brought into play by elevating the head, the heart compensates for it by increased rapidity of action ; hence in inflammation about the head, the recumbent should be adopted in preference to any other posture. The diet of a patient suffering from inflammation is a matter of great im- portance. Until within a comparatively recent period, surgeons united in recommending Avhat was called " absolute diet" in cases of inflammation, and this was usually pretty much equivalent to no diet at all. As regards this matter, I cannot but think that medicine is more advanced than surgery ; very few physicians at the present day, I imagine, try to starve out pneu- monias, and I cannot see why the principles which are now almost univer- sally adopted in the management of internal inflammations should not be equally applicable in the case of the external, or of the internal when pro- duced by traumatic causes. Up to a certain point, the inclinations of the patient may be looked upon as a pretty safe guide ; no man suffering from a violent inflammation, whether external or internal, has an appetite for heavy meat meals or for stimulating sauces, and it may reasonably be concluded that this is a prompting of nature to avoid such condiments. But we must be cautious not to run into the other extreme. It has been, I think, clearly shown by the researches of modern investigators, that in addition to the waste of tissue which accompanies the inflammatory process, there is a large expenditure of force (as evidenced by the great elevation of temperature),1 and it is but rational to suppose that this waste and expenditure ought to be compensated for by a supply of easily assimilable food. As to the results met with in practice, it of course becomes any one sur- geon to speak with great modesty and hesitation; I can, however, honestly aver that I have met with better success in the treatment of inflammation upon this plan, than I did Avhen I habitually directed low diet, according to 1 See in relation to this point, Rev. Dr. Haughton's "Address on the Relation of Food to Work done by the Body," etc. {Brit. Med. Journ., Aug. 1868.) 54 TREATMENT OF INFLAMMATION. the rules still laid down in many surgical works. I do not doubt but that a patient suddenly attacked with inflammation may subsist for a short time— perhaps a day or two—upon barley-water or water-arrowroot, and probably this meagre diet may be more suitable than the heavy meals which he has been in the habit of consuming ; but I believe that he will do better still by taking in small quantities and at frequent intervals some light and easily di- gestible but nutritious article of food. The diet which I myself am in the habit of ordering for patients suffering from severe inflammation, is milk in quantities varying according to the age of the individual, and at longer or shorter intervals according to the facility with which the process of digestion is accomplished. I have supported adult men for weeks at a time upon milk given by the teacupful (f'^iv) every hour, and I know of no single article of food which is adapted to so great a variety of cases as is this. In the more advanced stages of inflammation, beef-essence and different forms of strong broth may be appropriately made to alternate with milk in the patient's diet. As a general rule, once in two or three hours is often enough to give food in cases of inflammation, though when only small quantities can be taken at a time, the interval of course must be shorter. With regard to the adminis- tration of alcoholic stimulants no positive rule can be given. In the early stages of inflammation they are usually not required, and should not be given unless the state of the pulse or other circumstances indicate that they are needed. The onset of delirium (unless the brain itself be involved in the inflammation) is almost always an indication for stimulation. The quantity to be given should not commonly exceed four to six fluidounces of brandy or whiskey, or half a pint of wine, in the course of twenty-four hours ; I have, however, in the later stages of inflammation (as in some cases of severe burn), occasionally increased the amount to as much as a pint and a half of brandy in twenty-four hours, and am sure that I have saved life by doing so. In many of the milder cases of inflammation, or what clinically might be called chronic inflammation, malt liquors may be advantageously substituted for the stronger forms of stimulant. Other hygienic measures, which will suggest themselves to the intelligent practitioner, should likewise be adopted. Thus, the room which the patient inhabits should be well ventilated, and well warmed in winter. The patient's skin should be kept in a good condition by bathing, or, when this is not prac- ticable from the severity of the attack, by frequent sponging. The body- linen and bedclothes should be kept clean, and all excreta and other sources of pollution removed as quickly as possible. The patient should not be ex- posed to a glare of light, nor, on the other hand, should the room be kept so dark as to be gloomy. All sources of annoyance, as from noise, etc., should be removed, and while no fatigue, either mental or bodily, should be per- mitted, the patient, if the nature of his case allow it, should be entertained by light literature (being read to, in preference to reading himself), or by cheerful conversation. I have dwelt at some length on these topics, from a conviction that they are too often neglected. The duty of the surgeon is not ended when he has dressed a wound, and prescribed a dose of medicine. The hygienic manage- ment of a patient is of equal and in many cases of even greater importance than the mere surgical and medical treatment, which yet, too often, exclu- sively engrosses the practitioner's care and attention. II. The Local Remedial treatment of inflammation is next to be de- scribed. The applications to be considered under this heading may be classi- fied as cold, heat, moisture, local narcotics, stimulants, astringents, antiseptics, counter-irritants, cauterization, local bleeding, incisions, operations, com- pression, and friction. LOCAL TREATMENT. 55 1. Cold.—There can be no question as to the efficiency of cold as a local remedy for inflammation. It is indeed spoken of, by Air. Erichsen, as a means of preventing inflamma- tion. Its utility is, perhaps, Fig. g, most obvious in cases of wounds or sprains, though it is likewise of great service in many cases of inflamed joints, and other in- flammatory affections not de- pendent on traumatic causes. It may be applied in the form of dry cold, or in connection with moisture. The use of dry cold has been especially recommended by Esmarch, and is particularly useful where the skin is un- broken, and where it is desirable to avoid the maceration and other discomforts unavoidable with wet applications. Ice may be applied in India-rubber bags of variable shape, or in thin metallic boxes, which Esmarch nr^i.,* ■ • *• . -i j <■ ,„^ ' . Mediate irrigation; coil prepared for use. (After considers preferable for hospital Petitgand.) use. The intensity of the cold may be modified by interposing a folded towel or handkerchief between the bag or box and the skin. This is an admirable way of applying dry cold, Fig. 7. Coil applied to head. (After Petitgand.) but it must be carefully watched, lest it produce gangrene (as I have seen in one case, through the neglect of the attendant), or, on the other hand, lest the ice melt, and the application be no longer a cold one. A safer and an equally efficient method of applying dry cold, is that described by M. 56 TREATMENT OF INFLAMMATION. Petitgand, under the name of Mediate Irrigation. This surgeon makes use of a flexible tube of vulcanized India-rubber, sixteen or twenty feet long, and about half an inch Fig. 8. thick, the tube-wall being only about a line in thick- ness. This tube he ap- plies to a limb like a simple spiral bandage, holding it in place by a few turns of a roller, or he makes a coil cf the tube, adapting it to the head, to a joint, to the female breast, or to any other part as required, keeping it in position by a few strips of bandage passing alternately above and below the contiguous spiral coils. Through this tube, water is made to flow from a reservoir above the patient's level, of any tem- perature that may be de- sired, and by testing the temperature of the water as it leaves the tube, the surgeon can easily ascertain to what degree he has suc- ceeded in reducing the temperature of the inflamed part itself. The applica- tion of cold to the head, by this method, is recommended by Spencer Wells in all cases of traumatic fever, as a means of reducing the temperature of the whole body. Fig. 9. Mediate irrigation : a. Supply-tube acting as a siphon ; 6. Coil applied to lower extremity ; c. Waste-pipe with stopcock. (After Petitgand.) Irrigating apparatus. (Erichsen.) In cases where there is an open wound, the relaxing properties of moisture are often advantageously combined with cold, and here the ordinary form of irrigation by means of a funnel-shaped reservoir with a stopcock, or even a skein of thread or a piece of lamp-wick acting as a siphon, may be conve- LOCAL TREATMENT. 57 niently employed. In other cases, simply covering the part with a cloth, which is wetted from time to time with cold water or an evaporating lotion, will be sufficient. Cold is useful in the early stages of inflammation, when it will greatly assist in promoting resolution, or in the latter stages, when the parts are flabby and relaxed, and when cold, especially in the form of a cold douche, is often extremely useful. Cold is not generally desirable when suppuration is impending, though I have in at least two instances succeeded in causing the absorption of an abscess by the use of dry cold. Cold is rarely useful when suppuration has actually occurred, and should always be avoided in cases of impending or present gangrene. 2. Heat is seldom employed in cases of inflammation, except in conjunction with moisture. If dry heat should be desired, it may conveniently be applied by AI. Petitgand's method of " mediate irrigation," by merely substituting warm water for cold. 3. Moisture in connection with warmth, is a very valuable remedy in inflammation. Heat and moisture may be applied in a variety of ways. Warm water dressing is very useful in cases of suppurating wounds ; the water may be applied unmixed, or it may be medicated by the addition of laudanum, lead-water, muriate of ammonium, alcohol, etc. An excellent dressing may be made by diluting alcohol with an equal quantity of water. In applying any form of warm water-dressing, the lint or other material which is saturated with the water should be covered with oiled silk, or with waxed paper, so as to prevent evaporation. Hot fomentations are often very useful in the early stages of inflammation: they are commonly directed to be made by dipping flannel in hot water, and applying it to the affected part, renewing it from time to time. This is very apt to cause maceration and desquamation of the cuticle, and hence the application, when repeated several times, becomes extremely painful; to obviate this, I am in the habit of using warm olive oil instead of hot water, a substitution which does not impair the efficiency of the remedy, while it renders it much more agreeable to the patient. Aloisture may, in some cases, be advantageously employed by the process of steaming; this may be done by means of an ordinary funnel, inverted over the hot liquid and directed towards the affected part, or by means of the atomizer, now so much used in affections of the throat and air-passages ; in employing the latter apparatus, the temperature of the vapor can readily be regulated, by varying the distance of the instrument from the part to which the current is directed. One of the most common, and certainly one of the most efficient, modes of applying heat and moisture, is by means of a poultice. I cannot unite in the crusade against this most useful remedy in which some surgeons have engaged during .the last few years: there can be no doubt that poultices have been often abused, and that in certain stages of inflammation they are capable of effecting much harm, but the same objection might be made to lie against any other remedy, and cannot justly detract from their real merit under suitable circumstances. The best materials for making poultices are flaxseed.-meal, and powdered bark of the Ulmus fulva, or slippery elm; in an emergency, however, a very good substitute may be found in corn-meal, or bread crumbs.1 The poultice should be mixed with hot water, and should be of an even consistence, so as to admit of being spread smoothly. Flaxseed or elm poultices should not be more than two or three lines in thickness, and should receive a thin coating of olive oil before being applied ; this is to pre- 1 Thin sheets of cotton wadding, saturated with a decoction of carrageen, or Irish moss, have been recently recommended as a substitute for poultices by M. Lelievre, a French pharmaceutist, and have been employed with satisfaction by several surgeons. 58 TREATMENT OF INFLAMMATION. vent their adhering to the surface of the body, and breaking in removal. Corn-meal or bread poultices must be made about half an inch thick, and may be kept from the surface by the interposition of a piece of thin and soft mus- lin. Poultices should be made freshly, immediately before application, and should invariably be covered with oiled silk or waxed paper, to prevent evapo- ration. It is well for the surgeon to give his personal attention to the making and application of poultices, as the patient's comfort greatly depends on the care and neatness with which this is done, and very few nurses will be found to do it properly, unless constantly watched by the medical attendant. The fermenting poultice, which is an excellent application to sloughing sores, may be made by mixing wheat or corn flour with half its weight of yeast, and gently warming it until it begins to swell. A convenient substitute is the porter poultice, made by incorporating common porter with the ordinary flax- seed poultice. Warmth and moisture, in whatever form used, are especially to be recommended in the second stage of inflammation, and when suppura- tion is impending. When the discharge of pus is fully established, poultices are as a rule not desirable, while in the gangrenous stage, as already said, a fermenting or porter poultice is often the best application that can be made. 4. The local use of narcotics is often advisable in cases of inflammation ; thus laudanum may be applied with advantage to inflamed wounds and irri- table ulcers, while a belladonna plaster is often of great service as an applica- tion to inflamed lymphatic glands. Anodynes may be used in connection with cold (as in the common mixture of Goulard's extract and laudanum), or with heat, as in the form of a hop poultice, often employed in cases of peritonitis. 5. Stimulants and astringents may be used with advantage in the local treatment of inflammation ; as instances I need only refer to the constant employment of nitrate of silver in inflammations of mucous membrane, con- junctivitis, gonorrh'jea, etc. 6. Antiseptics have lately attracted a great deal of notice in the treatment of inflammation, especially when resulting from wounds. I have myself, for a considerable period, made use of the antiseptic properties of alcohol and of the permanganate of potassium in the local treatment of surgical affections, but the article which is most in vogue at the present time is the carbolic or phenic acid, the merit of introducing which into common use is undoubtedly due to Prof. Lister, of London, though its properties were previously familiar to chemists, and though it had occasionally been employed in surgery, before he directed general attention to the subject. Prof. Lister's mode of applying this antiseptic agent will be described when speaking of the treatment of wounds. 7. Counter-irritants are sometimes advantageously employed in the local treatment of inflammation. This is denied by some modern writers of high authority, but, for my own part, I cannot doubt but that great benefit is occa- sionally derived from the practice. I have seen a bubo disappear without suppuration, under the application of blisters, and even if this desirable con- summation be not attained, the use of vesicants may serve to hasten the formation of pus, and thus shorten the time required for treatment. The advantages derived from the use of sinapisms and turpentine stupes, employed as derivatives, likewise seem to me unquestionable. The principal counter- irritants employed by surgeons are blisters, issues, setons, and moxa. 8. Cauterization is a remedy which may prove serviceable in certain cases of inflammation. The actual cautery may be advantageously applied to serpiginous chancroids, while caustic in some form is frequently employed by the surgeon in the treatment of ordinary ulceration. 9. Local bleeding, by cupping or leeching, is now much less often resorted to than formerly. The general question of the abstraction of blood in inflam- CONSTITUTIONAL TREATMENT. 59 mation will be considered under the head of constitutional treatment, but I may say here that I cannot doubt that local bleeding is sometimes of use, and may prevent fatal disorganization in an important organ ; I firmly be- lieve that 1 have seen it do good in cases of traumatic peritonitis. 10. Incisions, to relieve tension, are often of great use in cases of inflamma- tion ; after incising the tunica albuginea in cases of swelled testicle, I have observed the pain to disappear almost instantly, and the duration of the af- fection to be very materially shortened. In diffuse inflammation of the sub- cutaneous areolar tissue, and in phlegmonous erysipelas, numerous incisions are often absolutely essential to check the spread of the morbid process, or even to save life. 11. Surgical operations of more or less gravity are frequently required in the treatment of inflammation. Sequestra must be extracted, and gangre- nous parts cut away before the attending inflammation can be expected to sub- side. In this place I may refer to an old suggestion which has been recently revived, to treat or to attempt to prevent inflammation of joints by ligating the main artery of the limb above the part affected. If inflammation were solely dependent upon the condition of the blood and bloodvessels, this might seem reasonable enough ; but when we consider that the function of the ves- sels in inflammation is merely ministerial, and that the increased quantity of blood in an inflamed part is not the cause of, but is itself caused by the in- flammation (see page 35), it will appear, I think, that this plan of treatment is as incorrect in theory as it is in fact dangerous in practice. 12. Contpression is often of great use in the treatment of inflammation. It is especially in the later stages, when the parts are left flabby and relaxed (as in indolent ulcers), that pressure is of service, though it is occasionally useful at a much earlier period. I know of no better treatment for carbuncle than methodical pressure by the concentric application of strips of adhesive plaster. 13. Finally, friction is frequently a valuable remedy in cases of inflamma- tion. The French have systematized the use of friction, under the name of massage, to a much greater extent than has been done in England or in this country. Slow and gentle rubbing with warm olive oil, or even with the hand alone, is often very soothing in the early stage of inflammation, and may be of positive benefit in assisting to promote resolution : I have found it of great use in the treatment of mammitis, and it may also be employed in cases of sprains; in the later stages of inflammation, again, friction may prove a valuable adjunct to the employment of the cold douche. III. Constitutional Treatment__We have next to consider the General or Constitutional Remedial treatment, which, except in very slight cases, is not less important than the local measures adopted. Depletion.—Until within a comparatively recent period, any surgeon being asked what was the most important remedy in the treatment of inflammation, would have answered unhesitatingly that it was bleeding; and the expression was constantly used that venesection was the surgeon's " sheet-anchor" in dealing with inflammatory affections. Now I suppose that there is no fact better established in the whole circle of therapeutic observation, than that certain of the symptoms of inflammation (especially pain) can be relieved by the abstraction of blood ; and hence, when the prevailing doctrines of pathol- ogy taught that the essence of inflammation was an altered action of the ves- sels, accompanied by a morbid richness or " inflammatory" state of the blood itself, we cannot wonder that our predecessors thought that reason and expe- rience united in showing that loss of blood was the surest way of curing inflammation. Alore careful observation, and more just views of pathology, have, however, now shown that, in the words of Air. Simon, already quoted, 60 TREATMENT OF INFLAMMATION. " A part does not inflame because it receives more blood. It receives more blood because it is inflamed." Hence, bleeding does not remove a cause of inflammation; it merely obviates one effect of the inflammatory process. Here, as in the matter of diet, the practice of physicians has, it must be con- fessed, been more enlightened than that of surgeons. Few would indeed, at the present day, bleed for the inflammation attending a compound fracture, but it is still taught in many of our surgical text-books that venesection is absolutely required in the treatment of injuries of the head, and of wounds of the chest. Now it seems to me but reasonable that we should adopt the same principles in the management of traumatic inflammations that we do in dealing with those of idiopathic origin, and hence, that venesection should not be resorted to in the treatment of surgical affections, except for its imme- diate mechanical effect in relieving a vital part, the functional or structural integrity of which is in imminent danger. For example, bleeding may be necessary in a case of traumatic as in a case of ordinary apoplexy, when the darkly congested face, turgid lips, distended veins, and laboring pulse give warning that the brain is oppressed, and, unless speedily relieved, will cease to act; or when a wound of the lung is followed by great dyspncea, pain, and oppression, the loss of a little blood may be of benefit, just as it would at the outset of an ordinary pneumonia presenting similar conditions. Even under these circumstances, I believe local bleeding, by cupping or leeching, will be usually better than venesection ; and it should always be considered that the loss of blood is an evil, which may indeed be preferable to a greater evil, but is never a positive good. The experience of any individual surgeon should of course be referred to with great modesty, but I may say that, in the fifteen years during which I have been one of the surgeons to the Episcopal Hos- pital, I have never had occasion to employ venesection, and have directed local bleeding in but very few cases. If general bleeding be ever resorted to, it should be done in such a way as to produce the greatest effect with the least loss of blood ; hence the patient should be in a sitting posture, and the blood drawn in a full stream from a free opening in a large vein, generally the median-cephalic. Arterial sedatives are often useful in the treatment of inflammation, either after the abstraction of blood or as a substitute for it. I am sure that I have derived advantage from the Veratrum viride in cases of traumatic peritonitis, given in the form of the tincture in doses of three or four drops every three hours. It is a powerful remedy, and its use should be stopped, or at least suspended, when a decided impression is made in reducing the frequency of the pulse. Aconite has been similarly used with advantage. The prepara- tions of antimony are often of use in the management of inflammation. They are best adapted to the first stage, and seem to have a decided effect in preventing the further progress of the inflammatory process. This property of antimony has been called the "anticipatory antiplastic" effect of the remedy. Tartar emetic, which is perhaps the best form in which the drug can be given, may be employed in doses of one-sixteenth to one-twelfth of a grain, repeated every two or three hours. It may be conveniently combined with opium and diaphoretics. In any form, antimony is a remedy which should be used with great caution and watchfulness. It should never be given for a trivial inflammation, and should be avoided in cases of children or old persons, or in patients of feeble constitution. Purgatives have been much employed in the treatment of inflammationj As there is very often a loaded state of the bowels at the beginning of the inflammatory process, a brisk cathartic may be of service, and will often act in some degree as a derivative, thus being additionally beneficial. I usually, however, prefer those purgatives which are milder in their action, such as CONSTITUTIONAL TREATMENT. 61 rhubarb, colocynth, etc. If the tongue be much furred, as is often the case, a blue pill, followed in twelve hours by a dose of castor oil, will often answer as well as any other prescription. The bowels should not be allowed to be- come constipated during the progress of an inflammation, but should be re- lieved from time to time by the aid of enemata, or of small doses of magnesia, rhubarb, or other laxative. There can be no necessity, however, for violent purgation, especially as the articles of food usually given in inflammation produce comparatively little fecal matter. Diaphoretics and Diuretics are of undoubted utility in cases of inflamma- tion. They promote secretion, diminish the violence of the attending in- flammatory fever, and perhaps act in some degree as derivatives as well. The spirit of nitrous ether may be used as a diuretic, in combination with the neutral mixture or the solution of acetate of ammonia. Digitalis also may be used in the same way. Opium is an invaluable remedy in the treatment of inflammation. It is a direct promoter of what we have seen to be an important condition of re- covery, viz., physiological and functional rest.1 Of all single remedies it is probably the most useful. It may be given in the form of Dover's powder, or in a diaphoretic mixture. Some such combination as the following will be found well adapted to a great many cases :— R. Morphias acetatis gr. j ; Spirit, aatheris nitrosi f^ij ; Sacchari albi ^ij ; Aquae camphorae f^iijss; Liq. ammonii acetatis fjjiv. M. R. Morphias acetatis gr. j ; Spirit astheris nitrosi fgij ; Syrupi acacias fsjyj ; Aquae aurantii florum f^iij ; Mist, potassii citratis fjiv. M. A tablespoonful of either of these mixtures may be given every two or three hours, during the height of the inflammatory fever, and either will be found to unite very satisfactorily the properties of an anodyne, febrifuge, and antispasmodic. Alteratives___Certain substances which are usually classed together as al- teratives have an undoubted efficacy in many cases of inflammation. Mer- cury is much less often prescribed now than formerly, and there can, I think, be no question that our ancestors used it too frequently, and in too large doses. Still I cannot but believe that it does exercise an influence, particu- larly over the second stage of inflammation, or that attended with the pro- duction of lymph. It is, however, like blood-letting and antimony, a dangerous remedy, and a positive evil, though it may on occasion do good. It should, I think, be reserved for cases in which an important organ is en- dangered, and should even then be used with great caution and reserve. It is especially adapted for inflammations of fibrous and serous membranes, such as the meninges and peritoneum. It should be given in small doses, as one- sixth to one-quarter of a grain of calomel, or half a grain of blue mass, and may be conveniently combined with opium and ipecacuanha. Iodide of potassium is a valuable remedy in certain forms of inflamma- tion, especially of the fibrous tissues, such as bone or periosteum. The usual dose is from five to ten grains, three times a day. Sarsaparilla was formerly much used as a remedy for inflammation, and even now is highly recommended by so eminent an authority as Mr. Erich- sen. I cannot say that I have ever seen any effect, good or bad, from the use of this drug, and look upon it as almost, if not quite, inert. In the form of the compound syrup, it may, however, be used as an elegant menstruum for the exhibition of the iodide of potassium. Tonics are of great use, particularly in the later stages of inflammation. 1 The action of opium in inflammation is physiologically explained by its property of arresting osmosis and cell-hypertrophy 62 OPERATIONS IN GENERAL. Among the best are cod-liver oil, iron,1 quinia, and the various preparations of Peruvian bark. They are almost always required to support the system under the exhausting influences of profuse suppuration or the occurrence of gangrene. The mode of treatment which I have endeavored to indicate as suitable in cases of surgical inflammation, is essentially similar to that which has been called the " restorative" in cases of pneumonia, etc. It may be necessary in any case to bleed, to give antimony or mercury, to make free incisions (en- tailing additional loss of blood), and to resort to other depressing modes of treatment; but, hand in hand with these measures, which, though for the time needful, are all in themselves evils, the surgeon must bring his restora- tives as well; he must supply abundance of food, easily assimilable but nutri- tious, and must in many cases pour in alcoholic stimulus besides, even at the very time when he is applying leeches and administering purges. Finally, in many chronic inflammatory conditions, the surgeon must give up treating the disease, and devote himself to improving the state of the patient's general health; when it will often be found that, the constitutional condition having been amended, the inflammation itself will have spontaneously disappeared. CHAPTER III. OPERATIONS IN GENERAL; ANAESTHETICS. In its widest sense, a surgical operation may be considered as embracing every manipulation which forms part of the surgeon's practice, from the ap- plication of a poultice or the introduction of a catheter, to the extraction of cataract or amputation at the hip-joint; and as the surgeon will have occasion to do many slight and trivial operations in proportion to the number of those which are more important, it is well for him to cultivate a habit of neatness and accuracy in matters which though apparently trifling in themselves, are yet very influential in determining the comfort or discomfort of his patient. Qualifications of the Surgeon__Every surgeon should aim to be. if not a brilliant, at least a neat and successful operator; and yet the mere use of the knife and other instruments constitutes but a small part of the operative surgeon's duty. It is of much greater importance for him to be a careful and accurate diagnostician, and to have that knowledge of pathology and thera- peutics which will enable him to decide whether an operation should or should not be performed, and, when the operation is over, to conduct the after-treatment of the patient in a judicious manner, than merely to be able to do the operation in a given number of seconds, or to shape his incisions in peculiarly graceful curves; in other words, what is technically called judg- ment, is more essential to a surgeon than mere operative skill. The day is happily past when it was thought right for a surgeon to be a mere hand- worker under the direction of another, and it is becoming more and more established as a rule, that no one is justified in operating in any case, unless his own practical knowledge and judgment tell him that in that case the 1 The muriated tincture of iron may be conveniently combined with the solution of acetate of ammonium, and in this form may sometimes be given with advantage even in the earliest stages of inflammation. RESULTS OF OPERATIONS. 63 operation should indeed be performed. No one can hope to be a successful operator who is not thoroughly grounded in anatomy; it is rather mortifying, after amputating a thigh, to be unable to find the femoral artery without loosening the tourniquet, or to dissect around the neck of the scapula in an attempt to cut into the shoulder-joint; yet the surgeon must not, in his zeal for the cultivation of anatomy, neglect the other branches of medical science. The importance, and even necessity, of a thorough knowledge of practical anatomy, can, indeed, scarcely be overrated ; yet it is more essential for the surgeon to be well versed in pathology and therapeutics (or, in other words, to be an accomplished physician), than it is for him to know the attachments of every muscle in the body, or all the possible variations of arterial distri- bution. Circumstances Affecting Results of Operations__The success of an operation does not, however, by any means, depend altogether upon the skill of the surgeon. Every one must know, from his own experience, that during certain periods, or in certain classes of patients, the gravest operations have been followed by favorable results, while among a different set of pa- tients, or at other times, death has seemed almost inevitably to follow even the slightest use of the knife. Ararious circumstances influence the results of operations. Age—The age of a patient is a very important point for consideration ; children, beyond the earliest period of infancy, as a rule, bear operations well. This is doubtless owing, in some degree, to their freedom from con- stitutional diseases and from those depressing habits of life which are often acquired with approaching maturity, but is probably also due, in great mea- sure, to the happy carelessness and freedom from anxiety which is character- istic of childhood. A child neither looks forward to an operation with dread, nor is oppressed with care for the future, when the operation is over. While an operation may and often must be performed without regard to the age of the patient, the surgeon should, as- much as possible, avoid either extreme of life. The new-born infant has less power of recuperation than the older child, while, on the other hand, an operation might be perfectly proper and suitable if performed on a strong and vigorous man in the prime of life, which would be little better than butchery if practised on one tottering on the verge of the grave. Especially as regards what are sometimes called operations of election or of complaisance, is the age of the patient to be considered ; in a young and healthy woman whose beauty is marred by the contracted cicatrix of a burn, it might be not only permissible, but even imperative, for the sur- geon to resort to a plastic operation for her relief, though perhaps that opera- tion might entail long confinement, and might even seriously endanger life; but to practise such an operation on a withered crone, who could at best hope for but a few months or years of existence, would be supremely ridiculous, were it not absolutely improper. The general state of a patient's health exercises an important influence upon the success of an operation. Hence it is observed that those whose occupation has been of an exhausting or otherwise unhealthy character, bear operations worse than those whose lives have been spent under more favorable circum- stances. This is one reason why serious operations, such as amputations, are less successful among the inmates of our large city hospitals (for their patients are usually derived from the least healthy class of inhabitants), than among hearty agriculturists who bring to the operating table a constitution unim- paired by either the diseases or the vices of city life. Hence too, if, before a battle, soldiers have been worn down by long marches and insufficient food, they will bear the operations which may be rendered needful by the conflict of 64 OPERATIONS IN GENERAL. the day worse than if their general condition had been unimpaired by ante- cedent suffering. The condition of particular organs should be carefully inquired into in estimating the chances of success after any operation. No one would think of operating, unless for absolute necessity, upon a patient whose lung con- tained a large tuberculous cavity, or who suffered from serious organic dis- ease of the heart. Our army medical officers can testify to the unfavorable influence upon the' results of operations exercised by the chronic diarrhoea and attendant ulceration of the bowels, from which so many of our soldiers per- ished during the late war, and every practical surgeon knows how slight are the chances of success, after even a comparatively slight operation, in a pa- tient suffering from affections of the urinary organs, and especially from the r chronic forms of Bright's disease. The condition of pregnancy may be con- sidered a contraindication to any operation which can be properly postponed until after confinement. The temperament and idiosyncrasy of a patient exercise an influence upon the success of operations. Some races, as the Chinese, the individuals of which appear to be of a lymphatic temperament, seem to tolerate operations which among other nations would be extremely fatal. An individual of a cheerful, light, and buoyant disposition, has, I think, a better chance of re- covery from a given operation than either one who is gloomy and who fears the approach of death, or one who calmly and philosophically makes up his mind to either alternative. The hygienic conditions to which a patient is subjected before, at the time of, and after an operation, exercise a marked influence, upon the success or failure of the operation. A man who is half starved is in no condition to undergo a serious operation, nor, on the other hand, is one who habitually overtaxes his digestive powers by too much indulgence in rich and stimulat- ing food, or who exhausts his nervous system by intoxication. Those who have long been exposed to a close and impure atmosphere, or who have con- stantly inhaled noxious exhalations, whether of animal or vegetable origin, are less able to undergo an operation than those who have lived in large and well-ventilated apartments and in a healthy locality. The hygienic sur- roundings of the patient at the time of operation are also of great importance. Except in case of necessity, no operation should be done in very hot weather or during the prevalence of an epidemic, especially of such diseases as ery- sipelas or hospital gangrene. The room in which an operation is done should be large, well ventilated, and in cold weather well warmed ; it should bekept scrupulously clean. The army surgeon must indeed practise his art in cold and rain, or under the full rays of the summer sun ; his operations are emi- nently those of necessity, and must be done under circumstances which he cannot control. But in civil hospitals, and in most instances in private practice, the operator can secure such surroundings as are needful for his pa- tient's welfare. In certain operations, as in those which involve extensive exposure of the abdominal cavity, these external conditions are of extreme importance ; I should not consider any man justified in performing ovariotomy in a cold, a damp, or a foul room. After an operation, a patient should be placed in the best possible hygienic conditions. As every operation (except perhaps the very slightest) is fol- lowed necessarily by inflammation, what has already been described as the hygienic treatment of the inflammatory process should be immediately adopted. While the digestive powers should not be burdened by the admin- istration of heavy or irritating food, the patient must not be starved, under the impression that such a course can prevent the development of inflamma- tion. I know of no food better adapted to the condition of a patient imme- RESULTS OF OPERATIONS. 65 diately after an operation than milk, and hence I commonly direct milk diet under such circumstances. If it seem to oppress the stomach, or if there be any tendency to vomiting, the milk may be diluted with one-fourth or one- third its bulk of lime-water. The after-treatment of a patient who has sub- mitted to an operation should be conducted in a clean and well-ventilated room, sufficiently large to allow from 1500 to 2000 cubic feet of space for each bed which it may contain. In estimating the cubic capacity of a room, it is unfair to consider great height as compensating for limited dimensions in other respects ; and the surgeon should not allow beds to be crowded close together, because a very lofty ceiling brings the cubic capacity of the apart- ment up to the standard. Too much stress cannot be laid upon the impor- tance of free ventilation for a surgical ward ; one of the greatest merits of the pavilion system of hospital construction which was so largely adopted during the late war, was the almost impossibility of making pavilions, espe- cially with ridge ventilation, close, as they would invariably have been, had the patients and hospital attendants found it practicable to make them so. There is room for scepticism as to the practical utility of many of the plans for artificial ventilation which have been proposed of late years ; it may be doubted whether anything can compensate for the absence of large windows upon both sides of a ward. While the surgeon would of course not wish to expose his patient to a draught, and would therefore take care not to place a bed immediately beneath an open window, yet it is always better to run the risk of having too much than by any chance to have too little fresh air. Not only should over-crowding be avoided in a hospital ward, but the sur- geon should adopt means to avoid all sources of zymotic poisoning from con- tagious emanations, whether gaseous or otherwise. For this purpose, the ward should be kept scrupulously clean ; all excreta should be removed as soon as possible, and if this cannot be at once done, disinfectants, and espe- cially those containing chlorine or carbolic acid, should be freely used. The ward should contain no unnecessary furniture; there should be no pictures or engravings hung about the walls, and bed-curtains should be strictly forbid- den ; these all serve as nests to col- lect any noxious exhalations which may permeate the atmosphere. If any case of erysipelas, pyaemia, or hospital gangrene occur in a ward, the affected person should be at once removed to an isolated apartment, or at least separated as widely as possible from other wounded pa- tients; these diseases, if not directly contagious, at least do harm by im- pairing the quality of the surround- ing air. Great care should be exercised in dressing wounds, to avoid all possible sources of infection. For this purpose the " ward carriage," introduced into hospital practice in this country by Dr. Thomas G. Alorton, is an admirable contriv- ance. The most important feature of this apparatus is an arrangement by which water is drawn from a portable reservoir, so that every wound can be washed with a stream of fresh running water. If sponges be employed,. every patient should have his own, and they should be frequently renewed -r a Ward carriau 66 OPERATIONS IN GENERAL. a pledget of tow forms a good substitute for a sponge, and has the advantage that its cheapness permits it to be thrown away after once using. The lint, or other material employed in dressing wounds, should never be used twice ; hence the great importance of finding inexpensive substitutes, as has been ingeniously done by Dr. Addinell Hewson and Dr. D. H. Agnew, in intro- ducing paper lint (the best form of which is that made by Parker, of New Haven) as a cheap surgical dressing. It is well for the surgeon to wash his own hands frequently in going from case to case, and he should enforce scrupulous cleanliness on the part of his dressers and nurses ; these may seem trivial matters, but it is upon the atten- tion paid to just such things as these that the well-doing of a surgical ward often depends. Causes of Death after Operation__A patient may be in a good condition for an operation, the operation itself may be most skilfully executed, the hygienic conditions by which the patient is surrounded may be excellent, and yet the apparently best grounded hopes of success may be disappointed by death following the operation, sometimes with great rapidity. There is no subject which has greater claims for the surgeon's consideration than that of the causes of death after operation. These causes may, of course, be very various ; but there are some which seem to be so immediately connected with the circumstance of an operation having been performed, as to merit special mention in this place. Shock___A patient may die from the direct shock of the operation. As will be explained more fully when speaking of shock as one of the constitu- tional effects of external violence, there is a positive physical affection known as shock, to be distinguished from the mental emotion and perturbation which sometimes receives the same name. Hence it is erroneous to say, as is often done, that the occurrence of shock is prevented by the use of anaesthetics ; the sensation of pain is indeed done away with, and much of the mental anxiety which was formerly the cause of intense agony before and during an operation1 is no doubt avoided; but there is a powerful cause of positive phy- sical depression which, in some degree, attends every operation, and to obviate which, no certain means, as far as I know, have yet been found. A patient may come to the operating table in a perfectly composed and even cheerful frame of mind, remain in a state of complete anaesthesia during the whole operation, and yet, without any great loss of blood or other obvious cause, die within a few hours after its termination, from a purely physical condition of shock. The shock of some operations is much greater than that of others ; thus a large amputation, as through the thigh or at the hip-joint, is attended with more shock than one through the leg or arm ; the removal of a tumor in the immediate proximity of the base of the skull, is attended with more shock than the taking away of a much larger mass from another part of the body ; and there is sometimes observed in the comparatively slight operation of cas- tration a marked failure of the pulse at the instant of dividing the spermatic cord. The treatment of shock, after an operation, is to be conducted by keeping the patient as quiet as possible, in a recumbent position, and endeav- oring to promote reaction by internal and external stimulation. Sinapisms may be applied to the chest, abdomen, and inside of the thighs, and hot bricks, or bottles filled with hot water, should be placed under the bedclothes, 1 A most vivid and painful description of the suffering under amputation before the days of anaesthesia, may be found in a letter from Prof. Wilson to Sir J. Y. Simpson (Obstet. Mem. and Contrib., vol. ii., and Acupressure, p. 566). CAUSES OF DEATH AFTER OPERATION. 67 so as to produce an equable warmth of temperature. In hospitals, metallic foot warmers are usually provided, and should always be kept in readiness. While the body is to be kept warm, free access of air to the lungs must be secured by opening the windows, if necessary, and even by fanning. Fric- tions are often directed, but are of somewhat doubtful utility, as rather tend- ing, in themselves, to exhaust the patient. Brandy and ammonia may be given by the mouth, if the patient is able to swallow, and if not, may be ad- ministered by the rectum, or ether may be given by subcutaneous injection. A stimulating enema of oil of turpentine, beaten with yelk of egg, is often very serviceable. The internal administration of belladonna is advised by Dr. Reinhard Weber, and that of digitalis, in large doses, by Dr. Brunton. As soon as partial reaction has taken place, a full dose of morphia should be given, and this, I think, is preferably done hypodermically. A sixth or a quarter of a grain of morphia, injected under the skin, is more quickly ab- sorbed, and therefore more prompt in its effects, than a much larger dose exhibited in the ordinary way. It is surprising how much benefit a patient suffering from shock will derive from even a quarter or half an hour's natural sleep ; a cup of strong beef-tea, well seasoned with pepper, should be in readi- ness to be administered as soon as the patient awakes. As there is always risk of reaction running into violent traumatic or in- flammatory fever, it is well for the surgeon, as far as possible, to use external stimulation, and those internal remedies which are more evanescent in their effects, such as ammonia, rather than brandy or other preparations of alcohol. It is sometimes necessary to delay the dressing of an operation wound on account of the occurrence of shock ; under such circumstances, when reac- tion has occurred, the dressing should be effected as simply and with as little pain as possible. I have seen grave injury accrue from the introduc- tion of sutures, in the case of patients just recovering from the shock of an operation. The older writers described what they called " secondary or insidious shock," which might come on subsequently to or independently of the occur- rence of the primary form. This, which is the most fatal variety of shock, is developed at an interval of from several hours to one, two, or more days after an operation ; it is, I believe, in most if not in all cases, dependent on the formation of heart clots,1 which may cause death by directly embarrassing the action of that organ, or more remotely by fragments becoming detached and plugging the arteries of the brain or lungs, a fatal result being thus caused by the process known as embolism. Either primary shock or great loss of blood would, by diminishing the force of the circulation, tend to increase the risk of this formation of heart clots. The most promising mode of treatment con- sists in the free administration of ammonia, either by the mouth—five grains of the carbonate being given every half hour—or by the intravenous injection of diluted aqua ammoniae, as recommended by Cotton, of Edinburgh. Hemorrhage at the time of or subsequent to an operation is very often the cause of death ; nothing can be more erroneous than to assert, as is sometimes done, that a moderate loss of blood during an operation is beneficial to the patient. Every drop of blood is valuable, and though we may not go so far as to say, with some of our predecessors, that blood is the liquid life of the body, there can be no question that there is no surer way of making an opera- tion unsuccessful, than to neglect even apparently slight hemorrhage. The absolute amount of blood lost during an operation is not so immediately the 1 Fayrer has particularly insisted upon the frequency of death after operations from the formation of fibrinous coagula in the right side of the heart, and believes that a malarious state of the blood acts as a predisposing cause of such coagulation. 68 OPERATIONS IN GENERAL. cause of danger as the rapidity with which the bleeding occurs. I have seen an amputation at the hip-joint, in which one or at most two or three jets from the femoral artery, together with the shock of the operation, produced a state of collapse from which the patient never rallied ; while I have seen a much larger quantity of blood lost in other operations, where the flow was more gradual, and in Avhich the resulting depression was scarcely perceptible. Inter- mediate or intermediary hemorrhage, as it is sometimes called, is apt to occur when the patient begins to react from the state of anaesthesia and after he has become warm in bed, from vessels having escaped the surgeon's notice when the force of the circulation was depressed ; hence, if there has been much shock, or if the operator has been unable to detect the mouths of ves- sels which yet he knows must have been divided, it is well to postpone the final closure of the wound until after complete reaction. Secondary hemor- rhage may come on at any period between the occurrence of reaction and the ultimate healing of the wound ; it may result from the premature detachment of ligatures, either from their having been in the first place insecurely applied or from subsequent inflammatory changes in the coats of the vessels, or it may be due to the occurrence of sloughing, opening vessels which had not been divided, or at a part higher than the point of ligation. The treatment of surgical hemorrhage will be described when considering wounds of arteries. A patient may die after an operation, from the violence of the inflammation or of the accompanying traumatic fever which, except in slight cases, neces- sarily ensue. The symptoms and treatment of these conditions have been sufficiently discussed in Chapters I. and II., and need not be again referred to here. A patient may die after an operation from causes previously in existence which the operation has not been able to remove, or which it has unavoidably aggravated ; as an instance of the former contingency, I may refer to the deaths from hectic and suppurative exhaustion which follow excisions of joints ; of the latter, death from pre-existing peritonitis after the operation of herniotomy. The unfavorable influence of renal disease; upon the results of operations was pointed out many years since by Dr. Chevers, and A'erneuil has recently shown that a similarly unfavorable influence is exercised by dis- eases of the liver. Finally, patients after operation are frequently carried off by various affec- tions, which, while not necessarily dependent on the performance of an opera- tion, yet follow the use of the knife with sufficient frequency to entitle us to consider the operation as their exciting cause. These are chiefly erysipelas, pyaemia, hospital gangrene, diffuse inflammation of the areolar tissue, and, more rarely, tetanus; these will all be referred to in their proper place, and are mentioned now merely to complete this view of the subject. Scarlet fever is regarded by English surgeons as a serious and not uncommon sequel of operations, but I have seen nothing in my own experience to lead me to con- sider its occurrence other than a coincidence. I have, however, several times seen erythema follow operations, and have known it to be mistaken, on the one hand for scarlet fever, and on the other for erysipelas. An operation wound, as any other wound, may become the seat of diphtheritic deposit, ac- companied by low constitutional symptoms which must be treated on the same principles which guide the practitioner in treating a case of diphtheria occur- ring under other circumstances. Preparation of Patients for Operation__In view of the great dangers which are thus seen to accompany every operation, it certainly be- hooves the surgeon, whenever it is practicable to do so, to take measures as PREPARATION OF PATIENTS FOR OPERATION. 69 far as possible to avoid those dangers; and hence the importance of attending to the preparation of a patient for operation. In many cases, unfortunately, there is but little time offered for prepara- tion ; a patient with a severe compound fracture requiring immediate ampu- tation, or one who is suffocating with pseudo-membranous croup, cannot wait for any course of preparatory treatment, but must take the chance, if an ope- ration be deemed proper, without regard to the state of his general health ; yet even under the most unfavorable circumstances, the morale of the patient may often be improved by a few soothing and encouraging words, while, if there be much physical depression, a warming and stimulating draught may suffice to render him better able to submit to the ordeal of the knife than he would be otherwise. Consent of Patient__A very important question, and one which admits of grave doubt, is as to how far a surgeon may be justified in assuming the re- sponsibility of operating, when a patient is unwilling to give his assent. Of course no one would think of performing any operation of complaisance with- out the full consent of the patient, but where an operation is immediately necessary to save life, as in a case of strangulated hernia or of injury requiring primary amputation, the surgeon's position is one of great perplexity. If the patient be a child, the consent of the parents is quite sufficient; if an adult, but unable from intoxication or other cause to judge for himself, the consent of a near relation or friend who is competent to decide the matter should be obtained; in the absence of the parents or other relatives, the sur- geon must place himself as it were in loco parentis, and do fearlessly what he thinks best for his patient. If, however, an adult in full possession of his faculties refuse an operation, or if, in the case of a child, the parents refuse for him, I cannot think it the duty of the surgeon to persist in operating under such circumstances ; he should remember that spontaneous recoveries do oc- casionally occur in the most unpromising cases, and that, on the other hand, death may very likely follow the most eligible and best executed operation ; and when the true state of the case and the imperative necessity (humanly speaking) of the operation have been clearly and fully explained, I cannot think that the surgeon should be held responsible for the consequences of obstinate refusal on the part of the patient or his friends. Preparatory Treatment.—The requisite consent having been obtained, in any case that admits of a short delay, it will be desirable to occupy a few days in preparatory treatment. I do not consider it ever necessary to deplete a patient, whether by bleeding or violent purging, before an operation. The diet should be regulated, such articles as are known to be irritating and diffi- cult of digestion being avoided, while the intestinal and other secretions are brought into a healthy condition by the use of mild laxatives, etc. In the case of hospital patients, who are often brought from a considerable distance to undergo an operation, it is proper to wait until they have rested from the fatigues of travelling, and have become somewhat accustomed to their new quarters and the new faces that surround them ; as they are frequently in a state of debility, it is often essential to put them upon a course of tonics, with nutritious food, and even free stimulation, before they can be brought into a condition for operation. In the case of diabetic patients, Fischer advises the preliminary administration of carbolic acid in small but frequently repeated doses. It is always proper, the night before an operation, to administer a mild cathartic, such as a dose of castor oil, and the next morning to empty the lower bowels by an enema; this is especially important in case the rectum or adjoining parts are to be involved in the operation, but is desirable under all circumstances, as it obviates the need of a fecal evacuation for some days 70 OPERATIONS IN GENERAL. afterwards, and thus saves a good deal of fatigue and exposure which is always undesirable and occasionally very prejudicial. In the case of a woman, the operation should not be done during a menstrual period or during pregnancy, if the exigencies of the case admit of postponement. The patient should be loosely clad, and, if much bleeding be anticipated, should wear an additional garment which can be removed after the operation. No solid food should be given, if an anaesthetic is to be used, for several hours previous to its adminis- tration. All preliminary arrangements should, if possible, be completed be- before the anaesthetic is given, as there can be no doubt that prolonged anaes- thesia exercises an unfavorable influence upon the success of an operation. The rule upon this point must, however, vary with the individual case ; thus if an operation on a woman will necessitate exposure of the person, it is obvi- ously better that the anaesthetic should be administered before the patient is removed from her bed, and that the final arrangements should be postponed until she has become unconscious. Preliminary Arrangements___The surgeon should himself see that the patient is in good condition for the operation, and that all necessary prepara- tions have been made ; the operating table should be firm and solid, of a height sufficient to prevent the necessity of the surgeon's being fatigued by stooping, and surmounted by a thin mattress covered with oil-cloth and a clean sheet, or by folded blankets ; it should be placed in a good light (a northern exposure is usually considered the best), and should be provided with pillows, and additional coverings to throw over the patient. The best time for an operation, in this region of country, is in the forenoon ; if it be a dull day, or if the operation be unavoidably performed in the afternoon or evening, the surgeon must see that proper arrangements have been made for providing artificial light. The necessary instruments should be carefully arranged in the order in which they are to be employed, placed in a suitable tray, and covered with a clean towel until the time has come to use them; it is a good rule to think over beforehand all the steps of the operation and the possible contingencies that may arise, and provide the proper instruments accordingly. The surgeon must instruct each of his assistants as to the duties he is expected to perform, and each assistant should, as far as possible, confine himself to his own duties and not interfere with those of the rest. For most operations two or three assistants are sufficient, and few can require more than five or at most six. One should take charge of the anaesthetic ; another hand the instruments ; a third support the part to be operated on ; a fourth be ready to suppress hemorrhage, etc. All the needful dressings, sponges, basins, bandages, etc., should be arranged where they can be readily reached. Having seen to all these preliminaries (the patient being in posi- tion, anaesthetized, and the part to be operated on divested of superfluous hair and clothing), the surgeon is ready to begin the operation. It may seem almost superfluous to say that on such an occasion the surgeon's personal de- meanor should be quiet and dignified ; eccentricities of costume and conduct should be avoided, the perfection of an operation consisting greatly in the simplicity of its concomitant circumstances. Though the operator and his assistants may, from natural disposition or from long habit, have come to look upon an operation as an every-day affair, it must be remembered that to the patient and his friends it is an occasion fraught with the deepest interest and the most anxious solicitude ; hence, both for his own reputation and out of regard to the feelings of others, the surgeon should repress manifestations of excitement, and still more of levity. It may seem needless to dwell so long upon this matter, and I do it only because I have frequently seen these reasonable rules neglected, simply through thoughtlessness. I know of one instance in which, after the first incision was made, an assistant was obliged ANAESTHETICS. 71 to remove the operator's hat, lest it should fall into the blood, and in which almost all the bystanders continued to solace themselves throughout the ope- ration with pipes or cigars. Operation.—The steps of an operation should all be planned in advance, and the less talking that is done after the knife has been once taken in hand, the better. Time is not quite as important now as it was before the days of anaesthesia, but it is certainly not good for the patient if the surgeon be obliged to stop and hold a consultation at each stage of the operation. The incisions should be made as much as possible in the lines of the natural depressions of the part, so that they will come together without undue tension or deformity ; they should be sufficiently free, and made with a firm pressure, sufficient to carry the knife through the skin and superficial fascia at the first cut ; at the same time the operator should never be in a hurry, and should not be misled by any idea of fancied boldness into stabbing rashly into his patient's body—a course which is never requisite, and which may occasion- ally lead the surgeon much deeper than he has any wish or intention of going. Hemorrhage during an operation should be prevented by the use of a tourni- quet or Esmarch's bandage, or by the pressure of an assistant's fingers ; it is even sometimes desirable to pause and secure each artery as it is divided. When the operation is completed and all oozing of blood checked (which may be facilitated, after tying the vessels, by exposing the wound for a short time to the air, or by pouring over it a stream of <&M water or of diluted alcohol), the edges of the incisions should be brought together with sutures. This is best done while the patient is still in a state of anaesthesia, though if there have been much shock or hemorrhage, it should be deferred until reaction has taken place. The sutures may be made of ligature silk, of ordinary thread, or of metal. The lead suture is, I think, preferable for most cases, as it will not bear a very great strain, and thus acts as a kind of safety-valve against undue tension. In other cases, and especially in certain plastic ope- rations, silver or unoxidizable iron wire forms a better material than lead, and when very close approximation is required, the harelip pin may be em- ployed in preference to other forms of suture. If the wound be extensive, it may be necessary to give additional support by means of adhesive plaster. Narrow strips should be used, to be applied between the points of suture, and to extend some distance on either side of the incision. The wound should then be lightly dressed, and the patient placed in a clean bed, which should be at hand and already warmed. It is often a good plan to give a hypodermic injection of morphia, before the patient has quite recovered from the effect of the anaesthetic. The after-treatment has already been referred to (see page 64). The surgeon should not, if practicable, leave his patient, until he has seen him comfortably fixed in bed, till complete reaction has occurred, and till he is satisfied that no risk of bleeding is to be anticipated. He should also see that a competent nurse is in attendance, to whom he should give full and explicit directions as to the management of the patient in the intervals between his visits. Anesthetics. It must be acknowledged that a great change has been brought about in the practice of operative surgery by the introduction of Anaesthetics; patients will now submit to operations which formerly they would rather have died than endure, and thus many operations which without anaesthesia would have been absolutely impracticable, are now perfectly feasible and are frequently 72 OPERATIONS IN GENERAL. employed. In this way the range of operative surgery has been greatly ex- tended. The advantages derived from anaesthetics are unquestionable ; the patient is saved entirely from pain, and in a great degree from the mental anxiety and disquietude which formerly necessarily preceded an operation ; and it is probable, likewise, that the physical shock of the operation is in some degree diminished. The surgeon also is enabled to concentrate his attention upon the duty before him, undistracted by the cries and struggles of his patient. But are the benefits of anaesthesia quite unaccompanied with attendant though by no means countervailing evils? Statistics have been collected on either side of this question, Prof. Simpson maintaining that the mortality after operations has diminished since the use of anaesthetics, and Dr. Arnott that it has increased. My own impression is that, as a matter of figures, the latter statement is correct. But though there may be an increased death-rate, this increase is not, I believe, fairly to be attributed to the em- ployment of anaesthesia. Formerly, a surgeon, in consideration of the great pain which an operation would inflict, would naturally reserve the use of the knife for those cases in which it was most probable that the patient would be markedly benefited, and would decline interference in any case in which the patient was not in a good condition to undergo the inevitable suffering of the operation: now, since the pain of the operation is no longer to be dreaded, we are constantly induced to extend the benefits of our art to cases which for- merly would have been left without operative treatment, and to give a last and possibly faint chance to patients who otherwise would have been aban- doned to certain death. In the large majority of cases, the chances for each individual are, I believe, made better by the use of anaesthetics. I have myself repeatedly noted an improvement of the pulse during the inhalation of ether, and have found the patient's general condition absolutely better after an amputation than before it was begun ; and I can scarcely conceive of any case in which a serious operation would be proper at all, in which it would not be likewise proper to employ anaesthesia. Still, we must be careful not to err on the other side. It is to be feared that students and young practitioners often get a false impression upon this point, and from seeing the frequency and apparent profusion with which an- aesthetics are administered by their clinical teachers, derive a notion that these agents are perfectly harmless, and may be indiscriminately resorted to under all circumstances. The true rule upon this matter (a rule which is, indeed, applicable to all our perturbing modes of treatment) is, that when an- aesthetics are not positively beneficial, they are injurious. Hence, under ordi- nary circumstances, they should not, I think, be employed, except for really important operations, and those which without their use would be tedious and painful. It is seldom right to give anaesthetics for purposes of diagnosis merely: there are, however, parts of the body the lesions of which are so obscure, and in dealing with which a mistaken diagnosis might lead to such grave errors of treatment, that it is often not only justifiable but even impera- tive to employ anaesthesia in their examination. Injuries about the hip-joint may be taken as an illustration of this statement. The reduction of disloca- tions is rendered so much easier to both patient and surgeon by the use of anaesthetics, that these agents may almost always be properly employed in such cases ; on the other hand, it is seldom necessary to use them "in the dressing of fractures. Cases for what are called capital operations (where life is immediately involved), are almost invariably cases for anaesthesia ; for smaller operations, the practice should vary according to the time required for their performance ; thus, anaesthetics should be given before operating for piles, or for phimosis, for these are tedious procedures ; while opening an ab- ANAESTHETICS. 73 scess, cutting an anal fistula, and tapping a hydrocele, are quickly done, and do not usually require the use of these agents. History___The history of the introduction of anaesthesia into the practice of surgery is a subject which is full of interest, and well worthy of the attention of every intelligent practitioner. The limits of this work will not, however, permit more than a very brief reference to it. Alany efforts to prevent the pain of operations had been from time to time made, by the use of narcotics, either in vapor or administered internally, by pressure on the nerves of the part,1 by profuse preliminary bleeding, by elec- tricity, and by other methods ; but the first really promising experiment in the introduction of anaesthesia dates back but about a third of a century, to the year 1844,2 when Dr. Horace Wells, a dentist of Hartford, Connecticut, rendered himself unconscious by breathing nitrous oxide gas (which had pre- viously been experimented with by Sir Humphry Davy), and in that condi- tion submitted to the extraction of a tooth. Dr. Wcdls repeated his experi- ment before the medical faculty and students of Harvard College, Boston, but lamentably failed. In 1846, Dr. W. T. G. Alorton, another dentist, a pupil and partner of Wells, began to experiment with the vapor of ether, whether independently or in consequence of hints received from Dr. Wells, Dr. Charles T. Jackson, or both, has never been satisfactorily established. It is stated that Morton's first experiment was made with chloroform (under the name of chloric ether), and hence the honor of discovering both of the great anaesthetic agents of modern times has been claimed for this country. It seems proper, however, that the real credit of a discovery should be given to the man who first practically makes that discovery useful to his fellows, and hence the merit of introducing chloroform as an anaesthetic belongs, I think, as undoubtedly to Sir James Y. Simpson, as does the merit of introducing ether to Alorton himself. The first surgical operation (beyond the extraction of a tooth) done with the aid of ether, was the removal of a tumor, by Dr. John C. Warren, at the Alassachusetts General Hospital, in 1846, the anaesthetic being administered by Dr. Alorton. The first case in which ether was used in this city, was, I believe, one of dislocation, at the Pennsylvania Hospital, the operator being Dr. Edward Peace. In the fall of 1847, Prof. Simpson, of Edinburgh, began to experiment with chloroform, which soon became the favorite with British and Continental surgeons, by whom it is still almost universally pre- ferred to ether. The latter substance is, on the other hand, preferred in some parts of France, and very generally in this country. Either agent has some advantages over the other, and some corresponding disadvantages. Chloroform is more prompt in its effects than ether, the pa- tient is usually quieter while coming under its influence, it is less apt to cause vomiting, a smaller quantity than of ether is required to produce anaesthesia, and the patient reacts more quickly when the inhalation is stopped. It, how- ever, requires much greater care in its administration than ether, and its use is attended with much greater risk to life. The above statement gives my own estimate of the relative merits of these agents, and, I believe, corre- sponds pretty closely with the opinions usually entertained on the subject ; it is, however, but right to say that Dr. Lente and Dr. Squibb, of New York, 1 More recently the late Dr. Aug. Waller has shown that muscular relaxation and anaesthesia may, in some cases, be effectually induced by pressure on the cervical portions of the vagi {Practitioner, December, 1870). 2 A claim of priority has recently been made on behalf of Dr. Crawford W. Long, of Georgia, who is said to have used ether in surgical operations as early as 1842. I hope that I may be pardoned for saying that the evidence in Dr. Long's favor seems to me quite inconclusive. * 74 OPERATIONS IN GENERAL. believe that anaesthesia may be induced by means of ether as quickly as can safely be done by means of chloroform, and with a quantity costing less and weighing very little more than the requisite amount of the latter ; and that other writers have maintained that vomiting is at least as frequently caused by chloroform as by ether. Dr Kidd, on the other hand, regards ether as quite as dangerous as chloroform (Dub. Qu. Journ. Med. Set'., Aug. 1867, p. 63). For my own part, I confess that I prefer ether, in a very large majority of cases ; it is certainly, I think, safer than chloroform, and is sufficiently con- venient for almost every case that the surgeon is called upon to treat. In particular cases, however, I am in the habit of using chloroform ; thus in extraction of cataract, the greater struggling and risk of vomiting produced by ether are decided contra-indications to its use ; and as the vapor of ether is very inflammable, and that of chloroform not at all so, the latter should be preferred for operations about the face, when there is any possibility that the use of a hot iron may be required. Precautionary Measures___Whatever anaesthetic be resorted to, certain precautionary measures should be employed in its administration. It is often said that organic visceral disease, especially a fatty state of the heart, should forbid the use of anaesthetics ; but whatever may be the risk under these cir- cumstances, it would probably be still greater if the operation were performed without an anaesthetic, and hence I cannot think its use in such cases impro- per. It would, however, be right, if disease of the heart were suspected, to watch the administration with special care, and particularly to give no more of the anaesthetic than was absolutely necessary. The patient should be pre- pared by removing any constriction of the clothing upon the throat or around the waist, so as to prevent pressure on the larynx, or interference with the action of the diaphragm. No solid food should be taken for several hours before the anaesthetic is given, though, if there be much depression, it is often well for the patient to swallow half an ounce or an ounce of brandy, with a moderate dose of opium or morphia, immediately before the administration is begun ; if the operation be necessarily prolonged, further restoratives should be given from time to time, the use of the anaesthetic being suspended suffi- ciently to allow the action of deglutition to be performed. The patient is best placed in the recumbent position to inhale any anaesthetic, though this is less important in using ether than in using chloroform, when it is absolutely essential. The inhalation should be begun gradually, so as not to alarm the patient by the impending sense of suffocation, and all unnecessary noise should be avoided, as tending to produce undue excitement and delay the induction of insensibility. Effects of Anaesthetics—The first effect of an anaesthetic is upon the nervous system ; there is excitation, usually pleasurable, followed by insensi- bility to pain and complete unconsciousness, though some of the muscles may remain slightly rigid and tense, and reflex motion be not totally abolished ; this is the most favorable condition for many operations which do notrequire extreme delicacy, such as amputation, excision of tumors, etc., when absence of sensation and voluntary motion is all that is requisite. In the next stage there is complete relaxation of the muscular system, while the force of the circulation and respiration is much diminished. This condition must be in- duced for the performance of the more delicate operations, and for the reduc- tion of dislocations. The approach of this stage may be known by the test of touching the conjunctiva; if reflex motion be suspended, this action will not produce winking. When anaesthesia is pushed beyond this stage, the patient must always be looked upon as in a very critical state. The pulse, the respi- ration, and the color of the face must all be constantly watched, and the * ANAESTHETICS. (0 aiuvsthetic either removed or continued in lessened quantity and with extreme care. Stertorous breathing, as pointed out by Prof. Lister, is of two kinds: one, the palatine, which is caused by vibrations of the soft palate, may occur early (as in ordinary snoring), and is not necessarily important; the other, or laryngeal stertor, depends on the vibrations of the portions of mucous membrane which surmount the apices of the arytenoid cartilages, and is always indicative of extreme danger. Death from the administration of an ana'sthetic may come from failure of either foot of the vital tripod, the head, the lungs, or the heart; in other words, it may be due to coma, to asphyxia, or to syncope. As a matter of practical experience, it is very difficult to distinguish which of these conditions may have been the primary one, for whichever organ fails first, the others cease to act in a very short time after- wards. As shown by Prof. Lister, the appearance of respiration may con- tinue after the supervention of true laryngeal stertor sliows that the access of air to the lungs is greatly impeded, if not absolutely checked; hence deaths are sometimes attributed to paralysis of the heart, which are really due to asphyxia, or, more correctly, apneea. The following is the course to be pur- sued whenever death appeal's imminent during anaesthesia : The inhalation must be immediately stopped, and the patient supplied with fresh air by opening windows, etc. He should be turned on his side to allow fluid to escape from the mouth, but should on no account be raised from the recum- bent posture. Nelaton, Sims, and others, believing that the risk in chloro- form poisoning is from cerebral anaemia, advise that the patient should be inverted, so as to favor the flow of blood to the brain. Inhalations of nitrite of amyl are suggested by Schuller, and by Burrall, of New York, and have been successfully employed by Bader and others. The tongue should be drawn out as far as possible, with tenaculum or artery forceps ; extreme pro- trusion is necessary to insure opening of the larynx. Artificial respiration should be at once employed, and is most conveniently effected by alternately compressing and expanding the walls of the chest. Electricity may be applied over the region of the heart and diaphragm, and through to the spine, while cold water may be dashed over the face and chest, and frictions applied to the extremities. Fitzgerald, of Alelbourne, suggests intravenous injections of ammonia, while Baillie advises the introduction of ice into the rectum. As soon as the patient is able, he should swallow a little brandy. If it should be necessary to reapply the anaesthetic, it should be done with renewed caution and watchfulness. Noel, of Louvain, having constantly observed a venous pulse in the jugular and subclavian veins during the stage of awaking from chloroform ana-sthesia, considers this an evidence of profound functional dis- turbance of the heart, and urges that the patient should be carefully watched as long as this phenomenon continues. Secondary JEff'ects.—Certain secondary consequences of an unpleasant nature are occasionally due to the use of anaesthetics. These are headache, sick stomach, and bronchial irritation. In nervous women, hysterical symp- toms are sometimes developed, which may continue for some time and cause a good deal of annoyance. It is said that apoplexy or paralysis is sometimes produced in old persons by the use of anaesthetics, but I have never met with such an occurrence in my own practice. The nausea and vomiting which very frequently follow the use of these agents, and especially ether, may be usually relieved by giving small quantities of milk and lime-water, or of iced carbonic-acid water; in more severe cases, chloroform, given in doses of twenty or thirty drops in emulsion, will be found very effective. The occur- rence of these annoying symptoms may often be prevented by giving a hypo- dermic injection of morphia before the state of anaesthesia has passed off, and thus allowing the system to recover itself by a few hours' sleep. The bron 76 OPERATIONS IN GENERAL. chial irritation may be relieved by keeping the patient quiet and giving a mildly sedative expectorant, such as the wild-cherry bark with a little opium or hyoscyamus ; in some cases, however, the lung itself becomes affected, being deeply congested, and a low form of pneumonia or a kind of suffocative cartarrh may follow, and may possibly prove fatal in the course of a few days. This is a serious occurrence, and must be met by giving stimulating expectorants, such as carbonate of ammonia and senega, and by the adminis- tration of wine or brandy according to the general condition of the patient. These unfortunate consequences may follow, even when the anaesthetic has been given with the greatest care and judgment; they are, however, more likely to ensue when too large a quantity has been used, when the adminis- tration has been too long continued, or (in the case of chloroform) when it has been given without a sufficient admixture of air. Administration of Ether___The best mode of giving ether is from a thin and hollow sponge, wrung out of water, and surrounded by a pasteboard or light metallic cone, which should be perforated at the top. The hollow of the sponge should be large enough to embrace both mouth and nostrils. The ether should be chemically pure, and should be poured upon the sponge in quantities of not less than half a fluidounce at a time. The first few inhala- tions should be made while the sponge is a few inches distant from the nos- trils, but as soon as the state of an;esthesia has begun, the sponge may be closely applied, and need not usually be removed, except when necessary to add more ether, till unconsciousness is complete. Of coarse if, as will some- times happen, the patient be seized with a fit of coughing, and choke, or, from having eaten a meal immediately before the operation, should begin to vomit, the sponge must be withdrawn until tranquillity be restored. If a patient breathe freely, he cannot be too rapidly etherized, and there is no danger, as in the case of chloroform, from the vapor being too concentrated. p]nough air is drawn through the perforation of the cone and the interstices of the sponge to obviate any risk from this cause, and rapid etherization is much less apt to cause pulmonary congestion than slow inhalation of the vapor pro- longed through a considerable period ; still, as a patient may choke from various causes, as from an accumulation of saliva and mucus flowing back- wards over the glottis, or from vomited matters collecting at the back of the mouth, a constant watch should be kept upon the countenance and the respi- ration, and the approach of any dangerous symptoms promptly met. The patient can greatly assist the production of anaesthesia by taking deep inhalations; he should, therefore, be constantly urged by the surgeon, not, as is often done, to "draw in his breath," but to "blow out," to "blow the sponge away from him." This is a practical hint which I learned from that excellent surgeon and brilliant operator Prof. Joseph Pancoast, of this city, and a moment's reflection will show that, though paradoxical, it is reasonable and strictly correct: the vapor of ether is so penetrating and irritating to the throat, that it is very difficult voluntarily to draw it in by a deep inhalation; but it is perfectly easy to blow into the sponge, and, as a full expiration is inevitably followed by a deep inspiration, the surgeon's purpose is thus most readily accomplished. The plan of administering ether which has been described, is essentially that which has been employed for some years at the Episcopal Hospital of this city, and I doubt if it can be practically improved. The old method, by a sponge simply surrounded with a towel, is equally efficient, but allows more evaporation, and, therefore, wastes more ether. Dr. Lente uses a cone of newspaper, with a towel pinned inside, and so folded as to prevent any, even the slightest, admixture of air ; and Dr. A. H. Smith has devised an inge- nious portable apparatus, which consists of a large India-rubber ball (such as ANAESTHETICS, is sold for a football) lined with patent lint, and with an aperture cut for the face. Prof. Porta, of Pavia, stuffs the nostrils with cotton, and causes the patient to inhale the ethereal vapor from a pig's bladder closely fitted to the mouth. Other inhalers, more or less complicated and ingenious, have been devised for the administration of ether (including those of Drs. Lente, Squibb, Allis, and Robe, and those of Messrs. Morgan and Richardson, of Dublin), but I am not aware that they possess any practical advantages over the simple method which I have recommended. Whatever apparatus be used, great care should be taken that no compression be exercised upon the larynx. The lips and nose may be anointed with simple cerate or cold cream, to prevent any cutaneous irritation from the contact of the ether. Chloroform is, I think, best given from a folded handkerchief or piece of lint, held at first five or six inches from the nose, and afterwards brought as near perhaps as half an inch to an inch, but never allowed to touch. Not more than a fluidrachm of chloroform should be poured on at once, and eva- poration may be prevented by throwing a single towel loosely over the ope- rator's hand and patient's face. This is not as safe an agent as ether, and one of the principal dangers in its administration is the risk of too great con- centration of its vapor ; hence the surgeon should constantly bear in mind the importance of allowing a sufficient admixture of air, and should err on the side of allowing too much rather than too little. The average amount of ana'sthetic required for an ordinary operation is from half an ounce to an ounce ; though Prof. Gross states that he has given as much as twenty ounces in two hours, without any unpleasant consequences following. Aarious inhalers have been devised with a view of regulating the amount of chloro- form used, and of securing the proper admixture of air, and when the ad- ministration lias to be conducted by one unaccustomed to the em- Fig. 11. ployment of chloroform, probably one of these instruments might advantageously be resorted to; but in the hands of an experi- enced person, I believe that the greatest safety to the patient is that sense of immediate respon- sibility which should always be felt by the giver of chloroform, and that hence the best inhaler may occasionally prove injurious by inspiring a false sense of se- curity. Air. Clover's apparatus, which is probably the best, is thus described by Erichsen : It con- sists uof a bag holding 8000 cubic inches of air, which is sus- pended from the coat-collar at the back of the administrator, and connected with the face-piece by a flexible tube. The bag is charged by means of a bellows (Fig. 11, i) measuring 1000 cubic inches ; and the air is passed through a box warmed with hot water, into which is introduced at each filling of the bellows as much chloroform as is required for 1000 cubic inches of air. This is done with a graduated glass syringe (Fig. 11, 2) adjusted by a screw on the piston-rod to take up no more than the quantity determined on, which is usually from 30 to 40 minims. When the bag is full enough, the tube is removed from the evaporating vessel, and the mouth-piece (Fig. 11, 3) adapted to it. The patient cannot Clover's chloroform apparatus. (Erichsen.) 78 OPERATIONS IN GENERAL. get a stronger dose than the bag is charged with; but the proportion can be made any degree weaker, by regulating the size of an opening in the mouth- piece, which admits additional air."1 Even with this instrument at least one fatal case has occurred, and I believe that no mechanical arrangement, how- ever accurate, can take the place of the personal care and attention of the surgeon. A mixture of ether and chloroform is frequently used in this country, and many surgeons believe that by this plan they unite the advantages and avoid the evils of both agents. For my own part, I do not think that any benefit is to be derived from the employment of mixed vapors, more than is obtained from the use of ether alone ; and I have seen, at least once, such serious symptoms follow the use of this combination, that the operation had to be temporarily abandoned, when the patient was only restored by a prompt re- course to artificial respiration.2 Various other substances, principally belonging to the group of ethers, have been found to possess anesthetic properties, and have been occasionally em- ployed in surgery : none of them, however—not even the bichloride of methy- lene, which is employed by Spencer Wells—has proved so satisfactory as to take the place of the two agents, the use of which has been above described. The same may be said of the intra-venous injection of chloral, as recom- mended by AI. Ore, and other European surgeons. Nitrous oxide, or laughing gas, which, it will be remembered, was the substance employed by Dr. Wells in his early experiments, has lately been re-introduced in this country, and is quite extensively used in dental practice. I have seen an amputation done while the patient was rendered unconscious by the use of this gas, and though the symptoms presented were sufficiently alarming, it certainly seemed an effective agent as far as the prevention of pain was concerned. It appears to act by inducing an asphyxial condition, which of course could not be long continued with safety to the patient: it is now, I believe, almost universally abandoned as an anaesthetic in general sur- gery, though it is still constantly used in the extraction of teeth. Local Anesthesia is sometimes useful in preventing the pain of slight operations, where unconsciousness on the part of the patient is unnecessary or undesirable. It is usually produced by the application of cold to the part to be operated on, either by means of a mixture of ice and salt, as recommended by Dr. J. Arnott, or by the rapid evaporation of ether or other very volatile substances, as proposed by Dr. Richardson. The freezing mixture may be ap- plied in the proportion of two parts of powdered ice to one of salt, being kept from the surface to be anaesthetized by inclosure in a bag of gauze or of thin muslin. Ten to fifteen minutes' application is usually sufficient to in- sure the freezing of the skin, which becomes blanched, opaque, and tough, and may then be incised without suffering on the part of the patient. Dr. Richardson's method consists in applying a fine spray of pure ether in the line of the proposed incision, by means of a hand atomizer. The same writer recommends that where this method is employed, the incisions should be made with scissors instead of a knife. According to Dr. Letamendi, the oc- currence of anaesthesia may be hastened by making a slight incision, not deeper than the papillary layer of the cutis, as soon as the part to be frozen has become red under the application of the ether spray. Local anaesthesia has been used successfully in an operation as important and severe as ovari- otomy ; I cannot but think, however, that general anaesthesia is preferable 1 Science and Art of Surgery, vol. i. p. 44. 2 Wachsmuth advises that the vapor of turpentine should be combined with that of chloroform, by mixing one part of the former substance with five of the latter. BANDAGING. 79 for all but very slight operations, if for no other reason, on account of avoid- ing the mental shock which is entirely distinct from the sensation of pain. Moreover, the process of freezing is itself very painful in some instances, especially when mucous membrane is involved, as in the case of haemorrhoids, and the use of the ether spray is not entirely free from danger ; thus, in a case of excision of the tunica vaginalis for hydrocele, which occurred in this city, the use of the spray was followed by extensive sloughing of the scrotum, which well-nigh cost the patient his life. Another mode of producing local anaesthesia, which is highly commended by Squibb, Wilson, and Bill, is the topical application of carbolic acid. i>- Before leaving the subject of anaesthetics, I may give the student one cau- tion, which is never to give ether or chloroform to a woman, unless in the presence of witnesses. A curious but undoubted property of these agents is, that they occasionally produce most vivid erotic dreams, and this may hap- pen even with a patient whose mode of life and character are above suspicion. Several most vexatious prosecutions, and even convictions, for indecent as- sault, have occurred in this country, where yet calm after-investigation ren- dered it almost morally certain that no assault had been committed, and that the plaintiff's sensations had been quite deceptive, and due to the effect of the anaesthetic which had been administered. Hence a woman may, without any evil intention, and really believing that she is telling the truth, inflict an ir- remediable injury on a medical practitioner, if he cannot by the evidence of eye-witnesses prove the incorrectness of her assertions, and thus establish his own innocence. CHAPTER IT. MINOR SURGERY. It is not intended to embrace in this chapter a description of all the opera- tions which are usually treated of in works on Alinor Surgery; some of these procedures have already been referred to, and others may be more appropri- ately considered when discussing the various conditions which demand their employment. I purpose now merely to describe certain minor surgical man- ipulations which are applicable to a great variety of cases, and which seem therefore to find an appropriate place in this preliminary division of the work. Bandaging.—Bandages are used to retain surgical dressings, to exercise compression, to assist the coaptation of wounds, or to keep injured parts at rest, as in the treatment of fractures and dislocations. The most convenient form of bandage, and one which is almost universally applicable, is made by tearing unbleached muslin or other material into strips from two to four inches wide, and from five to eight yards in length. One-inch bandages are occa- sionally used for application to the fingers or penis, but strips of adhesive plaster are generally more convenient for retaining dressings to these parts. A bandage two inches wide is suitable for the head or neck ; one three or three and a half inches wide for the arm or leg, and a four-inch bandage for the thigh. Still wider strips, five or six inches, are required for the trunk. To be ready for use, these bandages are tightly rolled, either by hand or by a 80 MINOR SURGERY. little apparatus which is figured in most works on minor surgery, and which is convenient for use in hospitals, or where a great many bandages are daily employed. When thus prepared, the bandage is called a roller, or a roller bandage. Some surgeons use bandages rolled from both ends, or double- headed rollers, but the single-headed roller is more generally applicable, and indeed is sufficiently convenient for every practical purpose. The ordinary bandages used by the surgeon are the spiral, the figure of 8, or spica, and the recurrent. Spiral Roller Bandage___As most persons use the right hand with greater facility than the left, the bandage is usually held in the right hand, and ap- plied from left to right above (or in Fig. 12. the direction in which the hands of a watch move), as regards a trans- verse section of the part to be band- aged. As a rule, also, the roller is started at the distal part of the limb to be bandaged, and made gradually to approach the trunk. The surgeon should, however, accustom himself to bandage with the left hand as well as with the right, and downwards, or in a direction receding from the trunk, as well as upwards. The plain spiral bandage, as its name implies, consists of simple turns of the roller around a limb or other part in a spiral direc- tion. It is applicable only where the part to be bandaged has a uniform diameter, as in the limbs of very thin persons. Where the limb is conical, rather than cylindrical, the reversed spiral is to be applied. In making the reverses, the surgeon fixes the previous turn of the bandage with the fingers of the left hand, and holding the roller lightly in the right hand, gives it a quick half turn, so as to cause the part which is unrolled, and which should not be too tightly drawn, to fold evenly upon itself; the roller is then carried around the limb as in the ordinary spiral bandage. It will be found advantageous, in applying the reversed spiral, to alternate the reverses with plain turns, or, if the limb be too conical to admit of this, to cover in every two or three reverses with a plain spiral turn ; the effect is indeed less agreeable to the eye, but a bandage thus put on is much more likely to retain its position than one consisting of reversed turns alone. Figure of 8 or Spica Bandage___This bandage is used for application to the various joints. It consists of simple turns of the roller which pass above and below the joint, and cross each other at any convenient point, usually at the flexure of the articulation. The term spica is applied to the figure of 8 bandage for the ankle, the hip, or the shoulder. In the case of the shoulder, one branch of the spica goes around the arm, while the other may be applied to the neck, though more usually and better to the chest. A figure of 8 band- age may likewise be used around both shoulders, to draw them together, or Reversed spiral of the lower extremity. BANDAGING. 81 Fig. 13. Fig. 14. The posterior figure of 8 of the knee. when applied so as to bring the crossing in front, may be made available in giving support to the female breast. Recurrent Bandage___The recurrent bandage is principally used in applying dressings to the head or to a stump. One or two circular turns are first made around the head or the upper part of the stump, and the bandage is then brought in recur- rent semicircles backwards and forwards from the forehead to the occiput, or over the face of the stump, as the case may be; the recurrent turns are secured by additional circular turns corresponding to those first made. Compound Roller Bandages.—Besides the bandages above described, which are all made from a single roller, various more complicated appliances may The spica of the shoulder. Fig. 15. Fig. 16. The four-tailed bandage of the chin. be occasionally useful. Those most often employed are the single and double T bandages, the four-tailed band- age, and the many-tailed bandage, or that of Scultetus. The T bandages, the forms of which are described by their names, are convenient for retaining dressings to the perineum ; the single T being applicable to the female and the double T bandage to the male. The four-tailed bandage, which is made simply by splitting both ends of a piece 6 Bandage of Scultetus, 82 MINOR SURGERY. of a broad roller, may be conveniently used for the knee-joint, or in cases of fractured jaw, while the bandage of Scultetus, wliich consists of numerous short overlapping strips of bandage (Fig. 16), may be sometimes resorted to in the treatment of compound fractures. Handkerchief Bandages___An ingenious Swiss surgeon, M. Mayor, intro- duced, some thirty or forty years since, a new system of bandaging, in wliich broad handkerchiefs, or squares of muslin or other material, took the place of the ordinary roller. The handkerchiefs were to be folded into triangles or into cravats, and it is surprising to see, from the illustrations which accom- pany Mayor's essay, to what a great variety of circumstances these simple means are applicable. Though the handkerchief can never supersede the roller, nor indeed rival it in general utility, yet is it well for the surgeon to bear in mind the possibility of resorting to this system, as an emergency might well arise in which the handkerchiefs of bystanders could be more easily obtained than any other means of bandaging. Fixed or Immovable Bandages___A'arious substances have been employed of late years to give greater firmness and solidity to the ordinary roller band- ages, and may be applied either to the common spiral and spica bandages, or to that of Scultetus. The most usual forms of immovable bandage are those made with starch, with gypsum or plaster of Paris, with gum and chalk, with dextrine, with simple flour paste, or with the silicate of potassium. Whatever material be used, there is apt to be some constriction exercised upon the limb in the process of drying, and hence it is best to protect all the bony promi- nences with a moderately thick layer of cotton wadding, the elasticity of which will prevent any injurious consequences from this cause. The starched bandage requires two rollers, the inner one of which is saturated with thick starch, the outer one being left dry or only starched on its inner surface as it is applied. The starched bandage requires from thirty to fifty hours to dry, and is on this account not so convenient as that made of plaster of Paris. For the gypsum or plaster of Paris bandage, a roller, which should be coarse and of loose texture—crinoline is a suitable material—is prepared by rubbing into it the dry powdered plaster of Paris. It is dipped in water for a few seconds to prepare it for use, and is then applied as an ordinary spiral, over an ordinary muslin bandage, or a closely-fitting stocking. When its applica- tion is completed, it is smeared over with a little dry plaster of Paris. This bandage has the advantage of becoming firm in about a quarter of an hour, and constitutes, I think, the best form of immovable apparatus. It is an excellent dressing for fractures of the lower extremity after the union of the fragments has become moderately firm. The gum and chalk bandage requires mucilage and chalk to be rubbed together in a mortar till a mixture of a creamy consistence is obtained ; this is then smeared over a dry roller, previously applied. It requires four or five hours to become dry. The dextrine band- age was particularly recommended by A'elpeau ; the dextrine, or British gum, is to be dissolved in camphorated alcohol (ten parts to six), and when of the consistence of honey, five parts of hot water to be added, when, after shaking for a few minutes, it is ready for use. A\dpeau used two rollers, the first dry, and the second soaked in the dextrine before application. The flour paste bandage is applied like those of starch or dextrine, and is considered by Prof. Hamilton to be as satisfactory as either. The silicate of potassium (liquid or soluble glass) has been used by several German, French, and American sur- geons as a substitute for starch in the application of immovable bandages, and has the advantage of drying more rapidly (in from four to twelve hours, according to the number of bandages used), and of being easily softened by the use of hot water when it is desired to effect its removal. From two to six layers of bandage may be employed, the silicate being applied in a state REVULSION AND COUNTER-IRRITATION. 83 Seutin's pliers. of syrupy consistence by means of a brush. The silicate of potassium has been lately particularly recommended by Prof. Darby, of New York, and glue, mixed with oxide of zinc, by Dr. Levis, of this city. Immovable bandages may be applied by themselves, or may be reinforced by the employment of light splints, made of thin wood or metal, leather, gutta-percha, or pasteboard. If, as often happens, the apparatus becomes loosened after a few days, from the subsidence of swelling, it may be slit up on one side with a strong-backed knife, or with a pair of Seutin's, Wathen's, or A"on Bruns's pliers, the edges being then trimmed, and held in place after readjustment with tapes or bandages; or, as suggested by Darby, holes may be bored in either edge, and the apparatus then laced up as a boot. By slitting up an immovable bandage on both sides, two light and accurately fitting splints are formed, consti- tuting what the French call a " bandage amoro-immobile." When applied to ulcers or compound fractures, a trap may be cut opposite the seat of lesion of the soft parts. Revulsion and Counter-Irritation___Counter- irritation is often employed by the surgeon, and may vary in the intensity of its effects from the slight redness pro- duced by a brief application of a mustard poultice, to the extensive sloughing caused by the actual cautery. Rubefaction.—The most convenient rubefacients are mus- tard-flour and oil of turpentine. The latter is applied warm upon flannel, while mustard should be mixed with water and applied in the form of a poul- tice, which may be rendered milder in its effects by diluting the mustard with Indian-meal. A very convenient application is what is sold under the name of " prepared sinapism," made by causing the mustard flour to adhere to paper by means of gum; it is made ready for use by simply dipping it in warm water. Vesication may be produced in a variety of ways. The most usual is by means of the ordinary blister plaster, made with the officinal cantharidal cerate of the pharmacopoeia; can- tharidal collodion may be painted Fig. 18. over the part to be blistered, and, if the skin be not too thick, will be found a very prompt and con- venient mode of producing vesi- cation ; or the solid stick of nitrate of silver may be used as a vesi- cant, Or the Strong aqua ammo- Corrigan's button cautery. niae, or iron heated by immersion in boiling water. The last method is best employed by means of Sir D. Corrigan's "thermal hammer," or "button cautery." When vesication is pro- duced by the use of cantharides, it is well, in order to guard against strangury, to withdraw the blister when it has begun to act, and to complete the " raising" of the vesicle by the application of an emollient poultice. If it be desired to produce a permanent blister, the raw surface may be dressed with cantharidal or savine ointment, or other irritating substance. The endermic method of medication, which was formerly more used than it is now, con- sisted in applying various drugs, especially morphia, to a freshly blistered surface ; this plan of treatment, though efficient, is now almost altogether superseded by the hypodermic mode, which is usually preferable. 84 MINOR SURGERY. caustic: Porte-moxa. Issues may be established by the employment of moxa. by means of various or by the knife. Moxa may be made of different materials, the simplest, and therefore the best, being cotton-wool or lint saturated with a solution of nitre, and rolled after drying into the form of a cone. This should be applied by means of an instrument called a " porte-moxa," or moxa-bearer, and should be ignited at the top of the cone, the surrounding tissue being protected by means of wet lint. The moxa is a very painful application, but is probably the best means of making an issue when a profound, impression is desired. Caustic issues may be made with Vienna paste ; this is a mixture of five parts of caustic potassa with six of quicklime. It is made into a paste with alcohol, and applied through a per- foration in a piece of adhesive plaster. Fifteen or twenty minutes' contact will usually insure the formation of a sufficient eschar. An issue may be made with the knife, by making a simple or a cru- cial incision, preferably by transfixing a fold of skin and cutting outwards. When suppuration is fairly established, the issue may be kept open by the use of irritating ointments, or by the application of glass beads or issue peas, held in place by strips of plaster. Setons___A seton is a sinus, kept from healing by the introduc- tion of a foreign body ; it is, in fact, an issue with two orifices. In the subcutaneous tissue a seton may be established by means of a long and broad needle, which carries a thread or strip of muslin (to be left in the wound), or by transfixing a fold of skin with a sharp, straight bistoury, and passing an eyed probe carrying the foreign body along the track of the knife. A seton may be kept open for a long time, when it is intended to act as a derivative, or it may be temporary merely, when the object is to excite a limited degree of irritation. Actual Cautery.—The cautery is the most powerful counter-irritant which the surgeon possesses. It is applied by means of irons of various shapes, heated to a red or white Fig- 20. heat in a convenient char- coal furnace. The gas cau- tery is used by directing a jet of burning gas upon the part to be cauterized, while the galvanic cautery, origi- nally suggested by Heider, and made practically use- ful by Marshall and Alid- deldorpff, consists of a pair of forceps with long and narrow blades, holding cop- per or platinum wires which are applied cold, and afterwards heated by means of the galvanic current. Paquelin has recently introduced a modification of the actual cautery, which acts by utilizing the property of heated platinum to become incandescent when exposed to the action of certain gases. Acupuncturation is sometimes used as a means of counter-irritation in cases of neuralgia, etc., or to allow effused fluids to drain off, as in cases of oedema. It is effected by introducing long and slender needles with a slow rotatory motion accompanied with slight pressure, taking care not to wound important structures. Electro-pnnctit'ration is effected by passing a current of electricity through the ordinary acupuncture needles which are previously introduced. Different forms of cautery iron. HYPODERMIC INJECTION — VACCINATION. 85 Hypodermic Injection__The hypodermic method of treatment is now very much used, and it is probable that its full capabilities have not even yet been developed. The physician employs a considerable variety of drugs by this method, but the only remedy which has been as yet much used Marshall's galvanic cautery. in surgery by hypodermic injection is morphia, though some experiments have lately been made with mercury thus administered in cases of syphilis, and with ergot in cases of fibroid tumor of the uterus. The most conve- nient preparation of morphia for hypodermic use is the strong solution of the sulphate, known as Alagendie's solution. Its strength is sixteen grains of the salt to the fluidounce, and eight minims therefore contain about a quarter of a grain of morphia, which is a large enough dose to begin with. The cylinder of the hypodermic syringe should be of glass, and graduated to min- ims, and the piston should fit accurately. In giving a hypodermic injection, the surgeon should pinch up a fold of skin with the fingers of the left hand, and thrust in the nozzle of the syringe with a quick motion and in a somewhat oblique direction; great care must be taken to avoid any subcutaneous vein, as from neglect of this precaution serious symptoms of narcotic poisoning may be rapidly induced, the drug being instantly thrown into the circulation, instead of being gradually introduced by absorption from the subcutaneous areolar tissue. The nozzle of the syringe should be kept sharp and scrupu- lously clean : if it be not clean, its use is apt to be followed by considerable irritation, and sometimes the formation of a small abscess ; a result wliich I have never known to follow the hypodermic injection of Alagendie's solution with a clean syringe. The hypodermic injection of ether has been successfully employed in cases of collapse from post-partum hemorrhage. Vaccination___A'accination is usually performed by the physician or accoucheur, rather than by the surgeon ; still, it may be regarded as a surgical operation, and a brief reference to it will, therefore, not be out of place. Vaccination may be effected either with the lymph of the vaccine vesicle, or with the dried scab; the latter is probably more often employed in this coun- try, and is usually quite satisfactory. The scab should be of a dark amber color, and not too thin ; a sufficient portion is to be shaved off with a lancet, and rubbed up with a few drops of water till it forms a mixture of creamy consistence. The skin is then to be slightly abraded with a dull lancet, until the slightest pink tinge is perceived, when the vaccine matter is to be applied, and slowly worked in. Some surgeons prefer to introduce the vaccine matter by two or three punctures, and others by minute incisions. The plan which I have described seems to me the best, as less likely to draw blood, which might wash away the matter, and thus defeat the operator's object. The place usually selected for vaccination is the left arm, about the point of insertion of the deltoid muscle. Some persons appear to be insusceptible to the vaccine influence, while in others the protective power of the operation appears to wear out in the course of years : hence it is well to re vaccinate from time to time, especially if the patient be in any way exposed to the epidemic influ- ence of smallpox. The surgeon should, of course, be careful, in preparing to 8<; MINOR SURGERY. Fig. 22. vaccinate, to select a good scab from a healthy child ; he should also look closely to the cleanliness of his lancet. Vaccination, like any other operation, may be followed by inflammation, or even by erysipelas, and there seems to be no doubt that on several occasions syphilis has been inoculated by careless vaccination ; hence too much caution cannot be exercised as to the source of the vaccine scab, and as to the cleanliness of the instrument employed. The best age for vaccinating infants is, I think, about the end of the third month, though it may, if necessary, be done at a much earlier period. Bloodletting___As was mentioned in the chapter on inflammation, the surgeon is now much less often called upon to draw blood than formerly; still, every practitioner should know how to bleed, apply cups, etc., and I shall, therefore, briefly notice the principal methods of surgical depletion. These are scarification, leeching, cupping, puncturation, venesection, and arteriotomy. Scarification___This is done with light touches of a very sharp lancet or other knife. It is particularly useful in cases of violent conjunctivitis, when attended with great swelling or chemosis, and is often requisite to prevent destruction of the cornea in such cases. Leeching.—There are two varieties of leech employed in practice ; the American, which draws about a fluidrachm of blood, and the Furopean, which draws at least four times as much. The part to be leeched should be well shaved and washed, and the leeches may be induced to begin their work by smearing the skin with a little warm milk or blood: according to Prof. Gross, an almost infallible plan is to dip the leech in small- beer. The leech may be applied with the fingers, or in a rolled card, or several together in a pill-box, etc. -They should not be forcibly detached, but allowed to drop off of themselves, a process which may be hastened by sprinkling them with a little salt. The bleeding from the leech-bites may be encouraged by warm fomentations, or may be repressed by exposure to the air, or by pressure with dry lint. If the bleeding be excessive, it may be necessary to touch the spot with nitrate of silver or the perchloride of iron, or even to close the edges of the little wound with a delicate twisted su- ture. Leeches may be applied to the inside of the various mucous outlets of the body through appropriate specula. Cupping is a convenient mode of employing local deple- tion. The cup is first applied so as to invite the blood from the deeper parts to the cutaneous surface ; this is done by atmospheric pressure, the air in the cup being exhausted by means of a portable air-pump, or an elastic bulb of vulcanized India-rubber ; or, in the absence of these, a sufficient rare- faction may be produced by introducing the flame of a spirit- lamp for a few seconds into the interior of the cup, which is then quickly applied. The scarificator is provided with a number of blades which are projected by means of a spring, and which can be set so as to cut more or less deeply, as may be required. The cup is first employed so as to produce superficial congestion ; it is then removed, and the scarificator instantly applied, and as quickly as possible replaced again by the cup, into which the blood will continue to flow until the vacuum is destroyed by the internal becoming equal to the external pres- sure. Dry cupping is effected by the use of the cup without the scarificator; it may be employed as a derivative in cases in which depletion is not indi- cated. M. Junod has introduced an apparatus consisting of a pump, the cylinder of which is large enough to embrace a whole limb; it is made air- Mechanical leech. BLOODLETTING. 87 tight by means of a wide India-rubber band, and serves to dry-cup, as it were, the whole limb at once. Its inventor claims that it gives the benefits of general depletion without the evils attending the loss of blood, but though the instrument is certainly ingenious, I am not aware that it has been found of much practical utility. Under the name of mechanical leeches (Fig. 22), small instruments are sold which combine in one a cup, an exhausting apparatus, and a scarificator: they may be used when it is desired to draw blood from a very limited area, and when ordinary leeches cannot be obtained. Theobald, of Baltimore, recommends that instead of using the scarificator, a superficial "nick" should be made with a delicate knife before adjusting the cup, and that a solution of carbonate of ammonia should be applied to prevent clotting and encourage the flow of blood. Puncturation occupies a position midway between cupping and scarifica- tion. It is best done with the point of a sharp scalpel or bistoury, and, in addition to its depletory effect, is often serviceable by relieving tension. It is principally used in cases of diffuse areolar inflammation or of erysipelas. The punctures may often be advantageously extended into limited incisions, but should not penetrate deeper than the subcutaneous tissue. A form of puncturation which is often employed by the general practitioner, is " lancing the gums," in cases of difficult dentition. JZnesection___A'enesection, or phlebotomy, consists, as its name implies, in the division of a vein ; it is the ordinary operation by which general bleeding is effected. It may be done with a bistoury, with an ordinary thumb-lancet, or with a spring-lancet or fleam. On the very few occasions on which I have had recourse to venesection, I have employed a simple lancet, and believe it to be as convenient and perhaps safer than any other instrument. In this country, and in England, bleeding is almost always done from one of the veins at the bend of the arm, preferably the median-cephalic, as its course is further from the line of the brachial artery than that of the median-basilic. In France, bleeding is occasionally practised from the veins of the foot. To prepare a patient for bleeding, the upper arm should be surrounded with a fillet or folded handkerchief, so as to interrupt the venous but not the arterial circulation, and thus render the superficial veins full and prominent; the sitting posture is usually the best, and the patient may grasp a stick, to steady the limb, which is held out in a semisupine position. The opening in the vein should be made with an oblique puncture, the lancet cutting its way out, as it is withdrawn. The vein should be compressed below the point of section with the thumb of the surgeon's left hand, until the cut is completed, that a premature gush of blood may not obscure the seat of operation. If the blood flow sluggishly, the patient may be directed to alternately increase and relax his grasp of the stick which he holds, the action of the muscles of the fore- arm tending to increase the rapidity of the flow of blood. The bleeding will usually cease at once upon the removal of the fillet, when the wound may be lightly dressed with a small compress and a figure of 8 bandage. AVhen bleeding is done at the foot, the saphena vein is opened above the inner malle- olus. Sometimes the external jugular vein is opened in cases of apoplexy, or in children when the arm is very fat; a compress is placed over the vein immediately above the clavicle, and the vessel is opened where it crosses the sterno-cleido-mastoid muscle: the chief risk in this operation is from the admission of air into the vein. Arteriotomy is practised on the temporal artery, or preferably on its ante- rior branch, above the outer angle of the eyebrow ; the section should be made obliquely with a sharp bistoury, and, when enough blood has been drawn, should be made complete, so as to allow the ends of the vessel to retract. A firm compress and bandage should then be applied. 88 MINOR SURGERY. Transfusion of Blood__This operation maybe sometimes required in cases of profuse hemorrhage, as in flooding during or after labor. The chief precautions necessary are to prevent the blood from coagulating before it is injected, and to avoid introducing air into the patient's vein. Blood from a healthy bystander is drawn into a tumbler, kept at the temperature of the body by being surrounded with warm water, and, having been defibrinated by "whipping" with a glass rod, table-fork, or other convenient implement, is injected, in quantities of two fluidounces at a time, by means of an ordinary syringe (or, as advised by McDonnell, of Dublin, a glass pipette), into the median-basilic vein, which has been previously laid bare ; the whole amount injected should not exceed three-quarters of a pint to a pint. By using a syringe with a sharp-pointed nozzle, the vein may be injected without having been previously exposed. Prof. Gross has devised an ingenious apparatus, by which the blood is made to flow into an exhausted receiver, and thence by a gum-elastic tube directly into the patient's vein, while AI. Alaisoneuve uses a simple flexible tube with a bulb provided with valves, so as to pump the blood directly from one vein into the other. Other forms of apparatus for the direct transfusion of undefibrinated blood have also been devised by Alonocq and by Roussel, of Geneva. Arterial transfusion, or the injection of defi- brinated blood into the radial or posterior tibial artery, is recommended by Hueter as preferable to the ordinary procedure. Saline injections into the veins have been tried with some success in cases of cholera, collapse, as has the injection of milk by Dr. E. AI. Hodder, of Canada. Alilk injections have also been employed under various circumstances, with more or less benefit, by Dr. T. G. Thomas, Dr. J. W. Howe, and Dr. Bullard, of New York, and by Dr. Pepper, Dr. Hunter, and Dr. E. Wilson, of this city. Karst and Schmeltz recommend hypodermic injection of defibrinated blood as a substitute for transfusion. According to Lombroso and Atthill, the operation of trans- fusion is in itself not free from risk, and should not be resorted to in any case in which cardiac or pulmonary disease is present. In order to prevent the shivering which usually follows the operation, Bitot advises that quinia should be administered two days previously. Fig. 23. Aspirator. Aspiration.—This is an operation which has for its object the withdrawal of fluid from a closed cavity without the admission of air. The use of a suc- tion trocar has long been familiar to American surgeons through the labors HISTORY OF AMPUTATION. 89 of Drs. Bowditch and Wyman, of Boston, to whom its introduction is due, but the aspirator of Dieulafoy is a more perfect instrument, and that gentle- man is justly entitled to the credit of having generalized and popularized its employment. The aspirator, as improved by Potain (Fig. 23), consists of a jar or bottle connected by flexible tubes on one side with an exhausting pump, and on the other with a delicate canula carrying a fine trocar, the apparatus being provided with stopcocks to prevent the admission of air. A vacuum having been established in the jar, the trocar and canula are introduced by a quick thrust into the part affected, when, the stopcock being opened and the trocar withdrawn, any fluid that is present is forced out (if not too thick to flow through the canula) by atmospheric pressure, and is collected in the reservoir. The most useful applications of the aspirator are, I think, to cases of hydrothorax and empyema, to cases of cold abscess connected with the hip or spine, and to cases of distended bladder from stricture or prostatic enlargement. Tachard has proposed to modify the construction of the aspi- rator by the introduction of the siphon principle. CHAPTEE V. AMPUTATION. It is often said, by unreflecting persons, that amputation is the opprobrium of surgery, and indeed the proposal to cut off a limb must be considered as an acknowledgment of failure on the part of the surgeon to effect a cure in any other way. But when we consider that an amputation is never done except with a view of saving life, which is more or less endangered, or to remove what is no longer of service, but a mere useless and troublesome appendage, it must be confessed that no operation can more truly deserve the name of conservative ; "the humane operation" it was called by some of the older surgical writers, and it is probable that there is no other procedure in the whole range of operative surgery which has saved so many lives and obviated so much suffering as this. The word '-amputation," as now used, is generally understood to apply to the removal of a limb, though we still speak of amputating the penis, and some writers employ the term also for excision of the breast. A limb may be amputated through its bones or through its joints ; the former operation is an amputation in the continuity of the limb, or simply an amputation ; the latter an amputation in the contiguity, a disarticulation, or an exar- ticulation. History___The ancients generally amputated merely through parts already dead, probably from fear of hemorrhage, to control which they had very imper- fect, if any, means. It is probable, however, that Celsus, who lived about the beginning of the Christian era, was in the habit of amputating through living structures, and he also divided the bone at a higher level than the soft parts (thus anticipating in some degree the modern circular operation); he was acquainted with the use of the ligature, but whether or not he applied it to the vessels after amputation, is not quite certain. The use of a fillet to con- trol the circulation, before amputating, is due to Archigenes, who, however, 90 AMPUTATION. neglected the preliminary dissection of the soft parts, dividing the entire limb at the same level, and using a hot iron to arrest the bleeding. Until the latter part of the seventeenth century, there was little improvement upon these rude procedures ; Pare had indeed introduced the ligature, but it was not generally adopted, and amputations were still done in essentially the same way that was prescribed by Galen and his followers. Alany surgeons dreaded to cut through living parts at all, and others sought to prevent bleeding by the use of heated knives. The first tourniquet was introduced by Alorel, in 1674, and a few years later an English surgeon, named Young, devised, appa- rently independently, a similar contrivance. These early tourniquets con- sisted merely of a fillet twisted with a stick, very much, in fact, like the simple apparatus which is now known as the Spanish windlass. Alorel's tourniquet was subsequently improved by the celebrated Petit, and the instru- ment which he devised is essentially that which is used at the present day. This illustrious Frenchman, and the English Cheselden, about the same time began to operate by a double incision, in which, however, according to Velpeau, they had been anticipated by Alaggi (1552), cutting first the skin and sub- cutaneous fascia, and then the muscular tissue and bone at a higher level. Louis, on the other hand, returned to Celsus's plan, and cut down at once to the bone,1 which he then divided higher up ; he also employed digital pressure in place of the tourniquet, believing that the latter interfered with the retrac- tion of the muscles. The modern circular operation, a combination of Petit's and Cheselden's with that of Louis, was perfected by Benjamin Bell and Hey in Great Britain, and by Desault in France, towards the latter part of the last century. Another form of circular amputation was practised by Alanson, who, after dividing the skin, attempted to cut the muscles into the shape of a hollow cone, by a sweep of the knife held in an oblique position. Other ope- rators, however, did not succeed in carrying out Alanson's instructions (the almost inevitable result of his operation, according to his opponents, being a spiral incision which would terminate at a higher point than its commence- ment), and the "triple incision" of Hey soon became the common English operation, though Alanson's was still successfully practised by Dupuytren and others in France. In the meanwhile, amputation by means of a flap, cut from without inwards, was introduced, or, according to Velpeau, re-introduced, by Lowdham and Young in England, and shortly afterwards the formation of a flap by transfixion, by Verduin, of Amsterdam. The flap operation was sub- sequently improved by several other surgeons, and was finally adopted and brought into common use by the labors of Liston and Guthrie in England, of Klein and Langenbeck in Germany, and of Dupuytren, Larrey, Roux, and some others in France. All the different methods of amputating may be considered as mere varieties of these two principal modes, the flap and the circular. Conditions requiring Amputation—The circumstances which may render amputation necessary are manifold; they will be fully discussed in subsequent chapters, in considering the various injuries and diseases to which the human frame is liable, but I may here briefly enumerate the following, as the principal conditions which are considered to indicate the removal of a limb. 1 M. Velpeau states that Louis divided the soft parts by two incisions {Med Ope'ra- toire, t. ii. p. 353); a careful examination of Louis's three memoirs in the Mem. de VAcad. de Chirurgie, convinces me, however, that upon this point M. "Velpeau is wrong, and that Mr. Lister (of whose excellent paper in Holmes's Syst. of Surgery I have made much use in preparing this sketch) is correct in regarding Louis's operation as essen- tially the same as that of Celsus. CONDITIONS REQUIRING AMPUTATION. 91 1. When a limb is torn off by the action of machinery or carried away by a cannon-ball, there can be no question as to the propriety of amputation. The operation may indeed be said to have been already done by the accident which caused the injury, and all that remains for the surgeon to do is to put the wound in such a condition as to promote its healing, and insure the for- mation of a well-shaped stump. 2. Mortification, when the gangrene is more extensive than a mere super- ficial slough, is usually a cause for amputation. The ordinary rule, and a very sound one under most circumstances, is that the surgeon should not operate until the line of separation is well established : thus, in the form of gangrene resulting from the intensity of the inflammatory process (as after frost-bite), no operation should be done while the mortification is still extending, but the surgeon should wait until nature herself indicates that the limit of the destruc- tive process has been reached, and may then amputate at any convenient point above the line of separation. On the other hand, in the strictly local forms of gangrene resulting from direct injury, as in compound fractures, amputa- tion should be performed as soon as the signs of mortification are unequivocally manifested ; delay will commonly cause the loss of the patient, before time has been afforded for the formation of any line of demarcation. There is another class of cases, principally met with in military practice, which often demands immediate amputation. This is where gangrene follows upon an arterial lesion at a distant point, as in mortification of the foot from a wound of the femoral artery. The gangrene, in such cases, first shows itself by a change in the color of the affected part, which is at first pale and tallowy, and subse- quently becomes mottled and streaked; there is at first numbness, followed by insensibility of the mortified member. In such cases, I think, with Air. Guthrie, that while the gangrene remains limited to the toes or foot, it is right to wait, in hopes that it will not pass further; but if it manifest a tendency to spread above the ankle, amputation should be at once performed at the point where experience shows that the morbid action is likely to cease, that is, a short distance below the knee. In a similar condition of the arm, amputation should be performed at the shoulder-joint. With regard to the dry gangrene which attacks the extremities of old persons, it is generally advised to refrain from amputation altogether, from the fear that the morbid action would recur in the stump; and, indeed, the constitutional state of patients thus affected is usually so unfavorable for any operation, that the sur- geon would naturally hesitate about proposing to amputate. It has, however, been suggested that as this senile gangrene, often at least, depends on arterial obstruction, a better chance would be afforded by amputating high up in the thigh than by any other mode of treatment; and this plan has been actually put in practice by James, of Exeter, and some others, with favorable results. It is obvious, however, that the additional risk from the operation itself would be so great, that it could only be justifiable in exceptional cases. Amputation is sometimes required in cases of hospital gangrene, either after the cessation of the process, on account of the extensive destruction of parts, or even during its progress, on account of profuse hemorrhage which may occur from the opening of a large artery. 3. Amputation is sometimes necessary to remedy the evils produced by exposure to heat or cold. In cases of frost-bite, if merely the fingers or toes are affected, it is better to allow the dead parts to be spontaneously separated, and to trim off the stump subsequently ; if the mortification be more extensive, amputation may be done through the dead tissues (in order to remove a use- less and offensive mass), and a second amputation be performed when the line of separation has been clearly established. In cases of burn or scald, it is proper to wait until the sloughs have spontaneously come away, and until the 92 AMPUTATION. reparative power of nature has been fully tested, when, if it be found mani- festly inadequate to the task, an amputation may be performed with the best prospects of a favorable result. •4. Compound fractures and luxations frequently render amputation neces- sary. The majority of primary amputations in civil hospitals are for these accidents, and the number of such cases which require removal of the limb is constantly becoming larger, with the multiplication of railroads and the con- sequent increase of travel. 5. Lacerated and contused wounds produced by railway or machinery acci- dents, by the attacks of wild animals, etc., may require amputation even though the bones have escaped injury. 6. Amputation is very often rendered necessary by gunshot injuries. Though so much has been done of late years to save limbs in military prac- tice by the introduction of excision as a substitute for amputation, still the latter must always continue to be a frequent operation in the hands of the army surgeon ; and, indeed, in no cases is it more truly the " humane opera- tion" than in the frightful injuries wliich are produced by the missiles of warfare. 7. Various affections of the bones and joints require removal of the limb. The number of cases of this kind which are now submitted to amputation is happily gradually becoming more limited, thanks to the introduction of exci- sion and to the modern improved methods of treating these affections without operation. Still, it is probable that there will always remain a certain num- ber of cases, in which the destruction of tissue is so extensive that nothing short of amputation will avail to save life. 8. Amputation is required in certain lesions of arteries; thus, if the pop- liteal artery be ruptured, amputation is almost always indicated. Again, certain traumatic aneurisms, or spontaneous aneurisms which have become diffuse, are more safely treated by amputation than in any other way. 9. Morbid growths may render amputation imperative. Even non-malig- nant tumors may, from their size or other circumstances, call for removal of the affected limb, while malignant affections of the extremities, especially if the bones be involved, almost always demand amputation. 10. Tetanus has been considered a cause for amputation, and the operation has occasionally been followed by recovery from the disease. The experience of the profession has, however, shown that amputation cannot be regarded as a remedial measure under such circumstances, and few surgeons would now think it right to add the risks of a capital operation, when there is so little prospect of benefit accruing; if, however, amputation was in any case other- wise indicated, the occurrence of tetanus would be an additional reason for the performance of the operation. Amputation is not justifiable in eases of hydrophobia, nor in those of poisoned wound, from bites of serpents, etc. 11. Finally, amputation may be required for the relief of deformity, whether natural or acquired. These are operations of complaisance, and should there- fore only be performed with the limitations specified in the chapter on opera- tions in general. Instruments—The instruments required for amputation are a tourni- quet or other means of controlling the circulation, knives of various shapes and sizes, saws, bone-nippers, artery forceps and tenacula, ligatures, retrac- tors, sutures and suture needles, and scissors. Tourniquet—The use of the tourniquet in amputation has been reprobated by some excellent surgeons, among others by the late Air. Guthrie. The only objections to it are that it produces a certain amount of venous congestion, and that it may interfere with the muscular retraction which is desirable in INSTRUMENTS. 93 the circular operation.1 But by taking care to elevate the limb before screw- ing up the tourniquet, and not to do the latter till the moment before making the incisions, the interference with the return of venous blood is so slight as to be unimportant, while the difficulty as regards the muscles can easily be obviated by retrenching the bone if necessary after the vessels have been secured, and the tourniquet removed. In fact, the evils of this instrument are more apparent than real, while its advantages are manifest and incon- testable. Guthrie and Hennen speak of compressing the artery with one hand while the amputation is done with the other, but such a course seems to me more adapted to show the skill and fearlessness of the surgeon than to promote the good of the patient; safety should never be sacrificed to brilliancy, and there can be no question that a well-applied tourniquet renders an amputation safer than the best directed manual pressure ; for while the latter can Fig. 24. only check the flow of blood through the main vessel, a tourniquet con- trols all the arteries at once, and it is often the smaller vessels that give the most trouble. To prevent loss of venous blood, Silvestri and Esmarch suggest that the limb should be first bound with an elastic bandage from below up- wards, and then surrounded at the highest point with a band or tube of caoutchouc instead of a tourni- quet ; the lower bandage is then to be removed, when the operation may be performed in temporarily bloodless tissues. Esmarch's me- thod has been largely employed by surgeons during the last few years, and with very general satisfaction; from my own experience I am pre- pared to recommend it as a valua- ble resource in cases in which the Petit's tourniquet. anaemic state of the patient renders it more than ordinarily important to avoid the loss of blood, or in which it is necessary that the field of operation should not be obscured by bleeding. It should not, however, be employed unnecessarily, as its use has been sometimes followed by troublesome consecutive hemorrhage, by paralysis, or even gan- grene, of the limb to which it has been applied, and, it is said, by embolism of the pulmonary artery and death. To prevent the oozing which follows removal of the tube, Nicaise advises compression of the wound with a sponge dipped in a 1-50 solution of carbolic acid. Ingenious modifications of Esmarch's tour- niquet have been devised by Foulis, H. L. Browne, and others. The best tourniquet for ordinary use is that known as Petit's, from having been introduced by the celebrated French surgeon of that name. It consists of two metal plates, the distance between which is regulated by a screw, with a strong linen or silk strap provided with a buckle. It is thus applied : a few turns of a roller are passed around the limb, and a firm pad or compress thus 1 It lias been recently maintained that pyozmia is caused by the use of the tourni- quet, which is supposed to cause venous thrombosis at the point of application ; but all that is known of the circumstances under which pyaemia occurs discountenances such an idea. 94 AMPUTATION. secured immediately over the main artery. Upon this pad is placed the lower plate of the tourniquet, so that the artery is held between this plate and the bone, and the strap is buckled tightly enough to keep the instrument in place. When the surgeon is ready to make his incision, the screw is turned so as to separate the plates and thus tighten the strap till the arterial circulation is entirely checked. It is often said that, provided that the compress is placed over the artery, it makes no difference to what part of the limb the tourniquet plate is applied: this is a mistake, and a moment's reflection will show that it is so : the mechanism of the tourniquet is such that it makes direct pres- sure at two points only, viz., immediately below the plate, and at a point dia- metrically opposite ; at every other point of the circumference the pressure exerted by tightening the strap is oblique or gliding. Hence, unless the plate be immediately over the artery or diametrically opposite to it, the effect of turning the screw will be inevitably to push the vessel more or less to one side, and thus the circulation may not be controlled, though the instrument be applied as tightly as possible. Hence, as a rule, the tourniquet plate should Spanish windlass. vessel. go immediately over the artery : where this is not practicable, as in the case of the axilla or the popliteal space, it should be placed at a point diametrically opposite. A'arious other forms of tourniquet have been devised, but none of them approach in value to that of Petit. The ordinary field tourniquet, as it is called, consists merely of a strap and buckle with a pad to go over the vessel; it is no better than the common garrot, or Spanish windlass (Fig. 25), made with a stick and handkerchief. Other forms are the horseshoe or Signoroni's tourniquet (Fig. 26), Skey's tourniquet (Fig. 27), and the various artery compressors, which are designed so as not to control the smaller vessels ; however useful these may be for cases of aneurism or accidental hemorrhage, they are not, I think, as good as Petit's instrument for employment in ordi- nary amputations. In certain special operations, however, these are very valuable ; thus hip-joint amputation is shorn of half its terrors by the use of Skey's tourniquet or Lister's aorta-compressor (Fig. 28). INSTRUMENTS. 95 Amputating Knives.—Formerly surgeons used for the circular operation a knife with but one edge and a very heavy back, shaped somewhat like a sickle ; the modern amputating knives, however, which are adapted for either of an inch. Thus, a knife with a cutting edge eight or nine inches long, will answer for most amputations of the thigh, while one with an edge of six or seven inches will do for smaller Fig. 29. Amputating knife. limbs. Double-edged catlins (Fig. 30) are used principally for the leg and forearm, and are convenient in freeing the interosseous space for the applica- Fig. 30. Catlin or double-edged knife. tion of the saw ; their width should not exceed three-eighths of an inch. Beside the ordinary amputating knives, the surgeon should have at hand one or two strong scalpels or bistouries (Figs. 31 and 32), about three inches Ions, while for smaller amputations, as of the fingers, a very slender knife with a heavy back will be found convenient. The blade of such a knife should be about two inches long and an eighth of an inch wide. The mea- surements which I have given are rather smaller than those usually directed, 96 AMPUTATION. but are, I think, such as will be found satisfactory in most cases ; for my own part, I much prefer a small knife to a large one, and am, indeed, in the habit of using a three-inch blade for the largest limbs, having found it quite ample Bistoury Fig. 32. Scalpel. even tor amputation at the hip-joint. The handles of amputating knives should be of rough ebony, which is less likely to slip when bloody than either bone or ivory. Saws___The amputating saw should be about ten inches long by two and a half wide ; it should be strong, with a heavy back so as to give additional firmness, and the teeth not, too widely set, but just enough to prevent binding. For operations about the hand or foot, a small saw with a movable back (Fig. 33) will often be found useful. Fig. 33. Small amputating saw. Bone-nippers or Cutting Pliers may be used in amputating the phalanges, or for smoothing off any rough edges left by the saw in larger operations. Ten to twelve inches is a good length, of which the blades should not occupy more than two inches; the blades, which are sharp, should be set at an ob- tuse angle with the handles, which must be very strong and roughened to prevent the hand slipping. Fig. 34. Bone-nippers. Artery Forceps and Tenacula are used in taking up the vessels ; the best form of forceps is essentially that invented by Liston, and known as the " bull-dog forceps;" the blades FlS- 35> should be expanded a short distance above the points, that the ligature may easily slip over without including the in- strument itself in the knot; they may be made to fasten with a catch, or, which I think Artery forceps closing by their own spring. 1S better, be provided with a INSTRUMENTS. 97 spring which keeps them closed except when opened by pressure of the sur- geon's fingers. The tenaculum or sharp hook must be of sufficient size and but slightly curved ; it is not as good an instrument Fig. 36. as the forceps for most cases, but is sometimes useful, especially where the parts are matted to- gether by inflammation, and the artery cannot be Tenaculum, or sharp hook, with which the arterial orifice is separated by the forceps ; picked out. sometimes it is necessary to take up a little mass of muscle or areolar tissue with two tenacula, and throw a ligature around the whole. Though I have never seen any harm result from this ligature en masse, it should not be practised when it can be avoided, and, as far as possible, each vessel should he drawn from its sheath and tied separately. Dr. Hodgen, of St. Louis, has devised an ingenious artery forceps which draws the artery from its sheath by its own weight, and is provided with a cutting slide to divide the ligature, thus enabling the surgeon to dispense with the aid of an assistant. Ligatures may be made of a variety of materials, such as catgut, horsehair, iron or silver wire, or more commonly, and I think better, of fine whip-cord or strong sewing-silk. The silk should be cut into lengths of about eighteen inches, and must be well waxed to fit it for use. The ordinary skein of silk contains about six yards, and is thus sufficient for twelve ligatures. In ordinary amputations Fig. 37. the number of vessels requiring ligature is about six or seven, but if there has been inflammation, causing enlargement of the small arteries, as many as twenty or twenty-five ligatures may be necessary. The artery having been drawn out of its sheath by the forceps or tenaculum, the ligature is thrown around it and secured by what is called the reef-knot, the peculiarities of which can be better understood from the annexed The reef-knot. cut than from any description. It is usual after tightening the knot to cut off one end of the ligature, allowing the other to hang out at the wound. It is convenient to retain both ends of the ligature which surrounds the main artery, knotting them together for purposes of dis- tinction. Short-cut ligatures were very highly commended by Hennen and others at the beginning of this century, but are now, I believe, generally abandoned, except in the form of the carbolized ligature of Prof. Lister; catgut is the material usually employed, but Maunder prefers carbolized silk. I have myself successfully tied the common carotid with a short-cut, carbol- ized, catgut ligature, and have no doubt that, when a good article is employed, it is quite safe, at least for arteries ligated in their continuity. For securing wounded arteries, however, or those divided in amputation, I still prefer the ordinary silk ligature. When catgut is employed, three knots instead of two should be tied, to prevent slipping. Some surgeons apply a single knot only to small vessels. I see no advantage in this plan, wliich is certainly not as safe as the use of the common reef-knot. Acupressure may be used to secure arteries after amputation, as may various ingenious modifications of acupres- sure, in which a wire is used instead of a needle; these will be considered in the chapter on wounds of arteries. 7 98 AMPUTATION. The Retractor consists of a piece of muslin six to eight inches wide, one end of which is split into two tails for the thigh or arm, and into three for the leg or forearm. It is applied Fjo-. 38. around the bone or bones to keep the soft tissues from being injured by the saw, and to prevent bone dust from being caught among the muscles, an occurrence which would greatly interfere with the rapidity of the healing process. The Sutures may be applied with the ordinary " surgeon's nee- dle," which for use in stumps should be large, strong, and but Surgical needles. slightly curved ; or, if the flaps be very thick, a needle, mounted in a handle and with the eye near the point, such as is used in the operation of strangulating a naevus, will be found convenient. The best material for the suture is, I think, lead or malleable iron wire, though this is a matter which may be safely left to the fancy of the operator. Scissors are used to cut the ligatures and sutures, or to retrench any pro- jecting nerves, tendons, or masses of fascia. Operative Procedures__The various modes of amputating may be considered as mere modifications of the two original forms of the operation, the circular and the flap; thus the oval operation, or that of Scoutetten, is based upon the circular, while the different methods of Yermale, Sedillot, Teale, Lee, etc., are but varieties of the flap operation. Circular Method—An amputation by the circular method is thus per- formed : Anaesthesia having been induced, and the seat of operation washed and shaved, the patient is brought to the side or the foot of the operating table, so that the limb to be removed projects well over the edge. The cir- Fig. 39. Amputation by circular method. (Druitt.) culation should be controlled by means of a tourniquet, or by manual pres- sure exercised by an assistant, while another assistant holds the affected limb in such a position as is convenient for the operator. The latter should stand SO that his left hand will be towards the patient's trunk ; thus, in amputating /^\ /"■"€ OPERATIVE PROCEDURES. 99 the right leg the surgeon stands on the patient's right side, while in removing the left leg he stands between the patient's limbs. The surgeon then, steady- ing and drawing upwards the skin with his left hand, slightly stoops, and carries his right hand, which holds a knife of sufficient length, around the patient's limb, so that the back of the knife is towards his own face. Press- ing the heel of the knife well into the flesh, he makes a circular sweep around the limb, rising as he does so, and thus being enabled to complete the whole or at least the greater part of the cutaneous incision with one motion ; a few light touches of the knife will now allow considerable retraction of the skin, and, if the limb be slender, this degree of retraction may be sufficient. The first incision must completely divide all the structures down to the muscles. If the skin have not retracted sufficiently, the surgeon now, either with the same knife or with an ordinary scalpel, rapidly dissects up a cuff of skin and fascia, about half as long as the limb is thick. In doing this, care must be taken to cut always towards the muscles ; neglect of this rule will cause di- vision of the cutaneous vessels and consequent sloughing of the part. Having done this, the operator grasps the cuff of skin with his left hand, and, with the large knife, makes another circular cut at the point of the cuff's reflec- tion, through all the muscles and down to the bone. A wide gap is usually immediately produced by the retraction of the cut muscles; if it be not suffi- cient, however, the surgeon quickly separates the muscular structures from their periosteal attachments with the finger or the handle of a scalpel, press- ing them back and thus cleaning the bone for the space of about two inches. If the limb contain two bones, the interosseous tissues must be divided witli a double-edged knife or with the ordinary scalpel. The retractor being ap- plied and firmly drawn upwards, the bone is now to be sawn at the highest point exposed. It is well first to divide the periosteum with a knife, and to use the saw lightly at first, so as to avoid splintering. The saw should be held vertically, and if two bones are to be divided, they should be sawn to- gether. The assistant who holds the limb must exercise care to keep it in such a position as neither to interfere with the action of the saw nor to allow the bone to break before the section is completed. As soon as the limb is re- moved the surgeon secures the vessels, momentarily loosening the tourniquet, if necessary, that the gush of blood may indicate the position of the smaller arteries, and, when all bleeding is checked, proceeds to dress the stump. If any projecting spiculae have been left by the saw, they must be removed with strong cutting pliers, and any tendons or nerves that hang out from the stump should be cut short writh sharp scissors. The skin cuff is then brought to- gether with sutures, so as to convert the circular into a linear incision, its direction being horizontal, vertical, or oblique, according to the fancy of the operator. It is well to apply a bandage with circular turns from above down- wards, to the stump, so as to prevent spasm or subsequent muscular retrac- tion. Sometimes great difficulty is experienced in turning up the skin cuff, from the conical shape of the limb. In such cases the surgeon may slit the cuff at one or both sides, thus converting the procedure into a modified flap operation. Flap Method___Amputation by the flap method is susceptible of an almost infinite number of variations. Tims there may be only one flap, more com- monly two, or even a larger number. The flaps may be cut antero-posteriorly, laterally, or obliquely; they may be made by transfixing the limb and cutting outwards, or may be shaped from without inwards, or one may be made by transfixion and the other from without. They may include the whole thick- ness of tissue down to the bone, or merely the skin and superficial fascia, or they may embrace the superficial muscles, while the deeper layer is divided 100 AMPUTATION. Fig- 40. circularly (Sedillot). Finally, they may have a curved outline, or they may be rectangular. In practising the ordinary double-flap amputation, the sur- geon stands as for the circular amputation, and grasping and slightly lifting the tissue which is to form the flap, enters the point of the long knife at the side nearest himself; then pushing it across and around the bone with a decided but cautious motion, and slightly raising the handle when the bone is passed, he brings the point OUt diametrically Op- Amputation by antero-posterior flap operation. (Bryant.) posite its place ot entrance. Holding the blade in the axis of the limb, he then shapes his flap by cutting at first downwards, with a rapid sawing motion, and then obliquely forwards. Turning up the flap, he re- enters the knife at the same point as before, carries it on the other side of the bone, brings it out with the same precautions as at first, and cuts his second flap. He then applies the retractor, makes a circular sweep to divide any re- maining fibres, and saws the bone as in the circular operation. In many situations, as in the front of the leg where the bone is superficial, it is impos- sible to make a flap by transfixion, and in any part, if the limb be large, the flap thus made is unwieldy, the skin retracting more than the muscles, which project and interfere with the closure of the wound. Hence it is often better to make at least one flap by cutting from without inwards, dividing the skin and superficial fascia by the first incision, and the muscles by a second, at a higher point. In view of the wasting and gradual disappearance of muscular tissue, which always takes place in a stump, some surgeons think to save time and trouble by making flaps of skin only ; but, apart from the danger of sloughing, which always attends these long skin flaps, unsupported by muscle, the re- sulting stump is not so serviceable, for though the true muscular structure does indeed disappear, the fibrous sheath of the muscle remains, becoming condensed into a thick pad which forms a very necessary covering for the bone. In making antero-posterior flaps by transfixion, the anterior one should be cut first; if the flaps are shaped from without inwards, the lower should be formed first, as otherwise the blood from the first incision would obscure the line of the second. In making lateral flaps, the outer should be the first cut, and, generally, it may be stated that that flap should be first formed which does not contain the principal artery. I have advised that for the flap as well as for the circular operation the surgeon should stand with his left hand towards the patient's trunk. Many authors, however, including Mr. Liston and Mr. Erichsen, direct that exactly the opposite posture should be assumed, with the left hand on the part to be removed. I have no doubt that every one will find that position most con- venient to which he is most accustomed ; but consider that which I have recommended to be the best, as enabling the operator to have more control over hemorrhage, in case of sudden slipping of the tourniquet or relaxtion of his assistant's grasp. OPERATIVE PROCEDURES. 101 Oval Method___The oval amputation in its simplest form may be considered as a circular operation, in which the cuff of skin has been slit at one side, and the angles rounded off. In this form it is used for disarticulation at the metacarpo-phalangeal joints, and, with a slight modification, constitutes Lar- rey's well-known method of amputating at the shoulder-joint. Another form of the oval operation, which in this case should rather be called elliptical, is particularly adapted to the knee and elbow-joints, though it is applied by the French to other parts as well. The incision in this form of amputation con- stitutes a perfect ellipse, coming below the joint on the front or outside of the limb ; the resulting flap is folded upon itself, making a curved cicatrix and furnishing an excellent covering for the stump. Modified Circular Operation___This plan seems to have been indepen- dently suggested about the same time, by Mr. Liston and Mr. Syme. It may be regarded as the ordinary circular operation, with the skin cuff slit on both sides and the angles trimmed off. It is done by cutting with a suitable knife two short curved skin-flaps, and dividing the muscles with a circular sweep of the instrument: it is particularly adapted to amputations through very muscular limbs. Fig. 41. Modified circular amputation. (Skey.) Teale's Method by Rectangular Flaps___This operation, which was intro- duced and systematized by Mr. Teale, of Leeds, about twenty years ago, undoubtedly furnishes a most elegant and serviceable stump. There are two flaps of unequal length, the shorter always containing the main vessel or ves- sels of the limb. The flaps are of equal width, but while one has a length of half the circumference of the limb at the point where the saw is to be ap- plied, the other is but one-quarter as long (i. e. one-eighth of the circum- ference). The lines of the flaps should be marked with ink or crayon before beginning the operation, as otherwise, especially in dealing with a conical limb, it is almost impossible to cut the long flap of the requisite rectangular shape. Both flaps are to embrace all the tissues down to the bone, and the long flap, which is in shape a perfect square, is, after sawing the bone, folded on itself, and attached by points of suture to the short flap. The advantages of this mode of amputating are that it secures a good cushion of soft parts over the end of the stump, and that the resulting cicatrix is entirely with- drawn from the line of pressure, in adapting an artificial limb : its disadvan- 102 AMPUTATION. tage is that, if used upon a muscular limb, it requires the bone to be divided at a much higher point than would otherwise be necessary, and thus, in the case of the thigh at least, adds much to the gravity of the operation. Hence it has been suggested by Prof. Lister to alter the relative dimensions of the flaps, making the longer of just sufficient size to bring the cicatrix out of the line of pres- sure, while its diminished length is compensated for by increasing that of the short flap. I have myself employed this modified form of Teale's operation (keeping, how- ever, the rectangular shape of the flaps), and have found it to answer quite as well as the original. Relative Merits of the Different Methods___I do not purpose to enter Teale's amputation. (Bryant.) into a discussion of the supposed advantages of one method of amputating over another, believing that excellent results may be obtained by any of these plans, and that the difference in the results of amputation in the bands of various operators is not so much due to the particular procedure employed, as to the judgment displayed in selecting cases for operation, and the care mani- fested in conducting the after-treatment. When I began to operate, I prac- tised one or other form of the flap amputation almost exclusively, having a prejudice against the circular method, which is certainly less easy of execu- tion and less brilliant than the other. During late years, however, my views upon this point have undergone some modification, and I now prefer the cir- cular operation in certain localities. The surgeon should not, I think, confine himself to any one method exclusively, but should vary his mode of operating according to the exigencies of the particular case. If any general rule were to be given, I should say that the circular incision or Teale's method gives the best stumps in the forearm, the modified circular in the upper-arm and the upper part of the thigh, the common double-flap operation immediately above and below the knee, the circular or lateral-flap in the lower part of the leg, and the oval operation at the joints. The points to be considered in choosing an operation for any particular part of the body will be referred to in discussing the special amputations. Simultaneous, Synchronous, or Consecutive Amputation. —It occasionally becomes necessary, in cases of severe injury, to remove two or more limbs by primary amputation at the same time. Sometimes this has been done by two surgeons operating simultaneously, but it is better for one to do both amputations consecutively, beginning with the limb that is most severely hurt. Though the prognosis of these double amputations is always unfavorable, yet recoveries have followed with sufficient frequency to justify the surgeon in having recourse to the knife, when the condition of the patient will at all permit it. If the hemorrhage can be effectually controlled by tour- niquets, it is better to remove both limbs before stopping to take up any ves- sels ; though if the first amputation have produced much depression, it may be necessary to pause and administer restoratives before proceeding to the second. Perhaps the most remarkable case of synchronous amputation1 on 1 Quadruple amputations, or amputations of both upper and both lower extremities, have been successfully performed by Dr. Alfred Mullen, Acting Assistant Surgeon, DRESSING OF THE STUMP. 103 record is that done by Dr. Koehler, of Schuylkill Haven, Pennsylvania, who thus removed both legs and one arm from a boy of thirteen, the lad making an excellent recovery in spite of this severe mutilation. Dressing of the Stump.—After an amputation, the stump should not be dressed until all hemorrhage has ceased. Sometimes after all the recog- nizable vessels have been secured, a troublesome oozing continues from the face of the stump ; this is usually venous bleeding, and will commonly cease of itself when the tourniquet is removed. If it do not, it may probably be checked by elevating the stump, and pouring over it a stream of cold water, or of diluted alcohol.1 Bleeding from the medullary cavity of the sawn bone may be stopped by inserting a piece of dry lint, a plug of wood, or better, a pellet of previously softened white wax; the latter has the advantage of being perfectly unirritating, so that, if necessary, it may be allowed to remain when the flaps are brought together. A plug of catgut is preferred by Riedinger. If the surgeon have any reason to fear consecutive hemorrhage, the stump should not be finally closed for some hours, or until complete reaction has occurred, a piece of lint, dipped in olive oil, being meanwhile laid between the flaps (as suggested by Mr. Butcher), to prevent their adhering, and the sutures left loose until the surgeon is ready for the final dressing. The liga- tures are to be brought out at one or both angles of the wound, as may be most convenient; it has been suggested to bring each one through the face of the flap by a separate puncture, but such a plan seems to me more adapted to delay union by producing increased irritation, than to promote quick healing. The edges of the amputation wound are to be brought together, not too tightly, by the use of sutures, and the flaps, if heavy, may be additionally supported by the use of adhesive strips. It is a great mistake to hermetically seal a stump; there is always a considerable flow of serum for some hours after an amputation, and if this fluid be not allowed to escape from the stump, it in- evitably decomposes and produces irritation. Various modes of dressing a stump have been employed ; Mr. Teale directed what has been called dry- dressing, which was, in fact, no dressing at all, the stump being simply laid on a pillow (which was covered with gutta-percha cloth), and protected by throwing over it a piece of thin gauze. Sir J. Y. Simpson highly commended the exposure of both amputation and other wounds to the air, calling the scab produced by this exposure a " natural wound lute." Dr. J. R. Wood, of New York, goes still further, treating stumps by what he calls the " open method," without either sutures, plasters, or dressings. MM. Guerin and Maisonneuve have, on the other hand, devised ways of treating stumps in ex- hausted receivers, giving their respective plans the euphonious titles of '■pneumatic occlusion" and " continuous aspiration." A. Guerin has recently recommended the employment of cotton, as a means of excluding deleterious germs, which are supposed to exist in the atmosphere. The " antiseptic method" of Prof. Lister has been quite extensively used in the treatment of stumps, and, I doubt not, answers a very good purpose. The dressing which I myself prefer, consists of a piece of sheet lint soaked in pure laudanum, U.S.A., and Dr. Begg, of Dundee; but it does not appear that the operations in either case were synchronous. 1 Under the name of parenchymatous hemorrhage, Dr. Lidell has described (following Stromeyer) a general capillary oozing, due to dilatation of the capillary vessels, either by the inflammatory process, or as the result of obstruction of the principal veins from thrombosis. The treatment recommended in the former case consists in the applica- tion of the persulphate or perchloride of iron, hot water, or the actual cautery ; in the latter, ligation of the main artery, or amputation at a higher point (U. S. San. Com- mission Surgical Memoirs, vol. i. pp. 237-250). 101 AMPUTATION. covered with oiled silk or waxed paper, and secured in place with a light re- current bandage ; the local use of the narcotic is soothing to the patient, while the styptic and antiseptic properties of the alcoholic menstruum are often use- ful. In military practice cold water is the most convenient application to a recent stump, and, if not too long continued, answers very well. Whatever dressing is used, the stump should not be disturbed for forty-eight or seventy- two hours, by which time suppuration will usually have begun ; the wound may then be dressed with diluted alcohol, with lime-water, or with any other substance that the condition of the part may indicate. If organic sutures have been used, they should be removed about the third or fourth day; metallic sutures may remain longer, and need not usually be taken away until firm union has occurred, and until they are therefore of no further use. The ligatures may be expected to drop from the smaller vessels after the fifth or sixth day ; from the larger arteries after the tenth or twelfth. The ligatures should always be allowed to drop of themselves ; but when the time usually requisite for their separation has elapsed, the surgeon may at each dressing gently feel them, to ascertain if they are loose. If acupressure has been employed, the pins or needles from the smaller vessels may be re- moved on the second day; that on the main artery on the third or fourth, according to the extent of the clot formed, which may be estimated by the point at which pulsation in the flap ceases. Structure of a Stump__A stump continues to undergo changes in its structure for a long while after cicatrization is completed; the muscular sub- stance wastes, and the muscles and tendons become converted into a dense fibro-cellular mass, which surrounds the bone ; the bone itself is rounded off, and its medullary cavity filled up ; the vessels are obliterated up to the points at which the first branches are given off, firm fibrous cords marking their place below; the nerves1 become thickened and bulbous at their extremities, these bulbs being composed of fibro-cellular tissue, with numerous nerve fibrils interspersed. Upon the firmness and painlessness of a stump, depend greatly the facility and comfort with which an artificial limb can be worn. In the case of the upper extremity, there is comparatively little difficulty, and very ingenious and serviceable arms and hands are now supplied by the manufacturers. In the lower extremity, it is found that very few stumps will bear the entire pressure produced by the weight of the body in walking upon an artificial limb, and hence a portion at least of the pressure should be taken off by giving the apparatus additional bearings upon the neighboring bony prominences ; thus for an amputation of the leg, the artificial limb should bear upon the knee, while in the case of a thigh stump, the tuber ischii and hip should receive the principal pressure. Affections of Stumps—Any one of the constituents of a stump may give trouble after an amputation, and the treatment of the morbid conditions of a stump is a very important matter for the surgeon's consideration. 1. Spasm of the muscles often occurs and causes much suffering a few hours after an amputation ; it is best treated by the use of a moderately firm bandage around the part, and by the exhibition of anodynes. Dr. Mitchell has recorded cases in which persistent and intractable choreic spasms occurred at a later period. 1 Localized atrophy of that half of the spinal cord which corresponds to the side on which amputation has been performed has been observed by Dickinson and Vulpian, and is, according to the latter author, directly due to the section of the nerves of the amputated limb. Similar changes have been observed by S. Or. Webber and Genzmer, while Chuquet and Luys have observed cerebral atrophy on the opposite side. AFFECTIONS OF STUMPc 105 Fig. 43. Thigh stump, with splint for extension. (Bryant.) 2. Undue retraction of the muscles may occur and continue for days or even weeks after an amputation, interfering with cicatrization, and giving rise to a very intractable form of ulceration, or even going so far as to produce what is called a conical or sugar-loaf stump. The mechanical ulcer, as it is called, of stumps, requires the limb to be firmly bandaged with circular and reversed turns from above downwards ; the action of the muscles is thus restrained, and the soft parts coaxed down- wards, as it were, and enabled to heal while the tension is removed; or extension may be applied by means of a weight and broad strips of adhesive plaster, or a light splint as in Fig. 43. There is, however, another cause for the production of conical stumps, in cases of young persons, apart from muscular retraction or wasting by suppuration; this is a positive elongation of the bone by growth subsequent to amputation. This is chiefly seen in the leg and upper arm, and the occurrence in these situations, rather than in the thigh or forearm, is easily accounted for by remembering the physiological fact, that the upper extremity grows principally from the upper epiphysis of the humerus and the lower epiphyses of the radius and ulna, while the lower extremity grows chiefly from the lower epiphysis of the femur and the upper part of the tibia. Hence, in amputations of the thigh or forearm, the principal source of growth for that particular member is taken away ; while in the upper arm or leg, it remains, and is liable to cause subsequent protru- sion of the bone through the soft parts. To whatever cause the existence of a conical stump be traceable, if the stump will not heal over the bone, or if, though a cicatrix form, it be thin, tender, and constantly liable to re-ulcerate, there is but one remedy, which is to resect the projecting end of the bone ; this is fortunately a proceeding which is attended with but little risk, and its results are usually satisfactory. 3. Erysipelas or diffuse cellular inflammation may attack the tissues of a stump ; and either constitutes, under these circumstances, a very serious affection. All sutures should be at once removed, soothing and emollient dressings applied, and the general treatment adopted which will be described when speaking of those diseases. 4. Secondary hemorrhage may occur from the vessels of a stump, at any time before complete cicatrization has taken place. If it be not profuse, ele- Fig. 44. Aneurysmal varix in a stump. (Erichsen.) vating the part, and the application of cold, or pressure, will often be suffi- cient to check the bleeding; if it continue, or recur, more decided measures must be adopted, which will be discussed in the chapter on wounds of arteries. 5. Aneurismal enlargement of the arteries of a stump occasionally occurs ; the annexed wood-cut (Fig. 44), from Mr. Erichsen's Surgery, illustrates 106 AMPUTATION. Neuromata of stump, after amputation of the arm. A large neuromatous mass at a ; opposite 6, the tumors are more defined. (Miller.) a case of aneurismal varix occurring after amputation through the ankle- joint. 6. Neuroma, or painful enlargement of the nerves of a stump, occasionally occurs. This distressing affection is, according to Mitchell, not due to the bulbous enlargement of the nerve (which Fig. 45. is, indeed, met with in all stumps), but to the existence of neuritis, or of a sclerotic condition resulting from inflammatory changes. Should the pain evidently arise from any distinct tumor connected with a nerve, it would be proper to cut down and remove it; under other circumstances a portion of the nerve may be excised at a higher point, or a reamputation may be performed, though unfortunately these are by no means infallible remedies ; Dr. Nott gives a case in which a man submitted to three re-amputations and three nerve ex- cisions for neuralgia of a stump, deriving at last only questionable benefit from this large experience in operative surgery. As a palliative remedy, the application to the stump of the strong tincture of the root of aconite is occasionally useful, or hypoder- mic injections of morphia may be used, as in other cases of neuralgia. Girard records a case in which relief was ob- tained by the repeated employment of electro-puncture. Leeches, ice, and counterirritants may also prove serviceable in some instances. 7. The tendons in the neighborhood of a stump may become contracted and cause troublesome deformity; thus, after Chopart's amputation on the foot, the natural arch of that organ being destroyed, the tendo Achillis may be drawn up by the powerful muscles of the calf, and a painful form of club- foot result, the cicatrix being thrown against the ground in walking. The occurrence of this condition should, if possible, be prevented by the use of appropriate splints and bandages, and it may be sometimes even necessary to resort to tenotomy when milder measures will not suffice. 8. Periostitis, Osteitis, and Osteo-myelitis, one or all, may occur in a stump, and may defeat the surgeon's anticipations of a successful issue. If acute and extensive, these affections endanger life, and, especially in the femur, are apt to ter- minate fatally. The diffuse suppurative form of osteo-myelitis is especially apt to occur when the division of the bone has exposed the medullary cavity, and is almost sure to end in pyaemia and death ; the only mode of treatment is re-amputa- tion at the nearest joint, and this is of course an almost des- perate remedy. Less violent forms of bone inflammation result in the occurrence of— 9. Necrosis, which may likewise be produced by injury from the saw, at the time of operation. The treatment of this condition consists pretty much in waiting for the natural sepa- ration of the necrosed part, which will then be exfoliated as a ring of dead bone, or as a long conical sequestrum. I do not Necrosisofthe believe that anything is to be gained, under these circum- bone after ampu- stances, by interference with the slow but safe processes of tation. (Liston.) nature; in the ease, however, of the occurrence of acute ne- Fic MORTALITY AFTER AMPUTATION. 107 erosis, as it is sometimes called, or more properly diffuse subperiosteal sup- puration, it may be necessary to amputate to save life, just as it would be under the same circumstances occurring elsewere than in a stump. 10. Caries may occur in the bone of a stump. I have seen benefit result in such cases from the injection of the preparation introduced by M. Notta, under the name of Liqueur de Vitiate. (R. Zinci sulphatis, Cupri sulphatis, aa gr. xv ; Liq. plumbi subacetatis f ^ss ; Acid. acet. dilut. vel Aceti alb. f'5iijss. M.) 11. Finally, an adventitious bursa may be formed over the bone of a stump, as in any other part subjected to much pressure. If this bursa become painful, the artificial limb should be altered so as to relieve it from pressing ; if this be not sufficient, an effort may be made to obliterate the bursa by the introduction of the tincture of iodine or by establishing a small seton, or the bursa itself may be excised. Mortality after Amputation__The results of amputation depend on a variety of conditions. Some of these are common to this as to other serious operations, and have mostly been sufficiently referred to in the chapter on operations in general; the most important circumstances coming into this category are the age and the constitutional state of the patient, and the hy- gienic conditions to wliich he is subjected before, at the time of, and alter the amputation. The relation between the barometric condition of the atmo- sphere and the mortality after amputation has been particularly investigated by Dr. Addinell Hewson. He finds that, at the Pennsylvania Hospital, the mortality varied from 11 per cent, with an ascending, to 20 per cent, with a stationary, and 28 per cent, with a falling barometer. While the column of mercury was rising, the average duration of life, in fatal cases, was only seven days, but was thirteen while the column was falling; and of all the cases that died within three days, over 7;~> per cent, proved fatal while the barometer was rising. " Surely," he adds, " these figures need no commentary as to how well they sustain the idea that the results of operations are materially influenced by the weather, and that the risks from shock are increased by opposite conditions" (Penna. Hosp. Reports, vol. ii. p. 34). Recent statistics as to the influence of the age of patients upon the results of amputation have been collected by Dr. T. G. Morton, Mr. Golding-Bird, and Mr. Holmes, the latter of whom finds that " the risk of amputation is constantly rising throughout life, and at any given period after thirty years of age the risk is more than twice as great as it was at the same period after birth." Beside the circumstances which have been referred to, there are others which affect the result of amputation, and which are peculiar to this as dis- tinguished from other operations ; these are now to be considered. 1. Locality___The part of the body at which an amputation is performed exercises an important influence on the result; amputations of the lower extremity are more apt to prove fatal that those of the upper, and in the same limb the rate of mortality varies directly with the proximity to the trunk of the point of amputation. These facts will appear from the following table, which I have prepared from the published statistics of British1 and American2 hospitals, and from those of our late war,3 together with those of the war in the Crimea.4 1 St. George's Hosp. Reports, vol. viii.; Med.-Chir. Trans., vol. xlvii.; and Guy's Hosp. Reports, 3d s., vol. xxi. 2 Am. Journ. Med. Sciences, April, 1875; Boston City Hosp. Reports, 2d s., 1877; and Boston Med. and Surg. Journal, 1871. 3 Circular No. (!, S. G. (>., Washington, 1865, and Surgical History of the War. * Legouest, Chirurgie d'Arm^e, pp. 722-735. 108 AMPUTATION. Table showing Mortality of Amputations in Different Parts of the Body, for Traumatic Causes, in Civil and in Military Practice. Civil Hospitals. American and Crimean Wars. Aggregates. Locality. Cases. Deaths. Mortality, per cent. Cases. Deaths. Mortality, per cent. Cases. IDeaths Mortality, per cent. Thigh . . Leg ... Arm . . . Forearm . 367 633 332 298 197 264 86 41 53.68 41.71 25.90 13.76 3516 3278 6415 2181 2715 1089 1805 444 77.22 ?,?, oo 28.14 20.35 3911 6747 2479 2912 1353 1891 485 74.99 34.59 28.03 19.56 Totals . 1630 588 36.07 15,390 6053 48.85 17,020 6641 39.02 In amputations of the thigh, the mortality varies according as the operation is done in the upper, lower, or middle third. The following are the per- centages given respectively by Legouest and Maeleod, both referring to the British army in the Crimea, though for different periods of the war. Legouest. Maeleod. Upper third.......87.2 86.8 Middle third.......58.5 55.3 Lower third.......55.0 50.0 2. The part of the bone which is divided in an amputation influences the result, the mortality being greater when the medullary cavity is opened than when only the cancellous structure at the end of the bone is involved. This appears to be owing to the greater probability of pyaemia supervening under the former circumstances. Of 295 cases of amputation which were followed by pyemia during our late war, 155, or 52.5 per cent., were through the shaft of the femur (Circular No. 6, S. G. O., 18G5, p. 43). 3. The nature of the affection for which an amputation is done, exercises a most important influence upon the result: thus amputations for injury are much more fatal than those for disease; the removal of a limb for cancer is more likely to be followed by death than the same operation if practised for caries or a chronic joint affection ; while amputations of complaisance or expediency (as for deformity) are less successful than those for other patho- logical conditions. The relative mortality of amputations for injury and dis- ease, as exhibited by the published reports of hospital practice in various countries, is shown in the following table :__ MORTALITY AFTER AMPUTATION. 109 Amputations for Injury. For Diseask or De-formity. Totals. Place of observation. OS O P Mortality, per cent. ■5 ft Mortality. per cent. "5 ft Mortality, per cent. French Hospitals1 English Hospitals2 American Hospitals3 652 610 1252 378 250 400 57.98 40.98 31.95 947 1107 629 406 251 117 42.87 22.67 18.60 1599 1717 1881 784 501 517 49.03 29.18 27.49 Aggregates 2514 1028 40.89 2683 774 28.85 5197 1802 34.67 The mortality which attends amputations of expediency has been particu- larly investigated by Mr. Golding-Bird, of Guy's Hospital, who finds it to be (in that institution) 26.8 per cent., as compared with a death-rate of 21.1 per cent, for other pathological causes; or, if the lower extremity alone be considered, the former class of cases gives a mortality of 42.8 per cent., and the latter of 29.1 per cent. 4. In amputations of the same category, the time at which the operation is done exercises an important influence over the result; thus, amputations for acute affections of the bones or joints are much more fatal than those of chi'onic diseases of the same parts. Amputations for traumatic causes are usually divided by surgical writers into primary or immediate, and secondary or consecutive. Primary amputations are such as are done before the develop- ment of inflammation, a period rarely exceeding twenty-four hours, though, if there have been much shock, it may reach to forty-eight hours, or possibly still longer, from the time at wliich the injury was received. A better classi- fication is that of military writers who make a third class, the intermediate, which embraces all operations done during the existence of active inflamma- tion, reserving the term secondary for such as are done after the subsidence of inflammatory symptoms, and when the condition of the part somewhat assimilates the case to one of amputation for chronic disease. Yerneuil applies to these three divisions the terms antepyretic, intrapyretic, and meta- pyretic, respectively. It is now, I believe, universally acknowledged among military surgeons that primary amputations (except of the hip-joint and the upper part of the thigh) do better than others ; of those which are not primary, the secondary do better than the intermediate. It is, however, commonly said that in civil practice secondary amputations are more successful than primary, and this difference has been accounted for by the different hygienic circumstances by which soldiers and civilians are respectively surrounded. I believe that the usual statement upon this point is erroneous, and that a careful collation of statistics will show that in both civil and military practice, primary amputa- tions are followed by better results than others. To illustrate this point, I have drawn up the table which follows, and in which the results of primary amputations, or those performed in the pre-inflammatory stage, are compared with those of all others for traumatic causes. 1 Malgaigne (Arch. Gen., Avril et Mai, 1842), and Trelat (Legouest, op. citat., p. 707). 2 St. George's Hosp. Reports, vol. viii.; Med.-Chir. Trans., vol. xlvii.; Guy's Hosp. Rep., 3d s., vol. xxi. 3 Am. Journ. Med. Sciences, April, 1875 ; Boston City Hosp. Reports, 2d s., 1877, and Boston Med. and Surg. Journal, 1871. 110 AMPUTATION. Primary. Secondary and Intermediate. Observations prom Civil Hospitals. V 5 Reporter. Reference. <5 ft <=H "" 6 o £a! 49 34 69.4 20 13 65.0 Malgaigne. Arch, de Med., 1842. [vol. xvii. 64 15 23.4 28 10 35.7 James. Trans. Prov. Med. and Surg. Assoc, 18 7 38.9 5 2 40.0 South. Notes to Chelius, vol. iii. 74 39 52.7 43 26 60.5 Laurie. James, loc. cit. 169 62 36.7 53 37 69.8 Steele. Ibid. [367. 180 60 33.3 87 61 70.1 McGhie. Maeleod, Surg, of Crimean War, p. 50 9 18.0 6 1 16.7 Hussey. Ibid. [81. 48 18 37.5 43 19 44.2 Erichsen. Science and Art of Surgery, vol. i. p. 40 8 20.0 9 6 66.7 Parker. Cooper's Surg. Diet., vol. i. p. 121. 71 23 32.4 10 3 30.0 Fen wick. Ibid. 93 15 16.1 37 13 35.1 Callender. Med.-Chir. Trans., vol. xlvii. 108 49 45.4 43 22 51.2 Steele. Guy's Hosp. Rep.. 3d s. vol. xv. 37 12 32.4 24 7 29.1 Buel. Am. Journ. Med. Sci., 1848. 29 14 48.3 13 7 53.8 Lente. Trans. Am. Med. Assoc, vol. iv. 615 155 25.2 95 40 42.1 Morton. Am. Journ. Med. Sci., 1875. 241 84 34.9 87 32 36.8 Chadwick. Bost. Med. and Surg. Journ., 1871. 164 68 41.5 50 21 42.0 Gorman. Bost. City Hosp. Rep., 1877. 240 104 776 43.3 33.9 94 747 53 373 56.4 49.9 Golding-Bird. Guy's Hosp. Rep., 3d s. vol. xxi. 2292 Aggregates. It will be perceived from this table that, except in the reports of Malgaigne, Hussey, Fenwick, and Buel, the primary amputations have been invariably less fatal than the others ; while in the aggregate the mortality of the primary has been about 1 in 3, compared with a death-rate of 1 in 2 for the interme- diate and secondary operations. I do not know of any extended statistics to show the relative mortality of the two latter classes of amputations in civil practice ; but as far as they have been distinguished by writers on the subject, the general impression has been confirmed that intermediate operations are very fatal, and that those done when the inflammatory symptoms have sub- sided are comparatively successful. These numerical considerations, however, though interesting, scarcely give a fair view of the whole merits of the case ; for primary operations are natu- rally done in cases where there is no possibility of saving the limb, while con- secutive amputations are, on the other hand, performed in cases which are to a certain extent selected. Moreover, the least hopeful cases among any large number are eliminated by death before the secondary period is reached, so that even if the numerical chances of consecutive operations were the best, it would by no means be proved that more lives would not have been saved had more limbs been primarily amputated. The practical rule to be derived from what has been said, is that, in any case of injury in which it is evident that an amputation will be needed, the operation should be done as soon as possible after reaction has occurred, and before the injured part has become inflamed; but if by any chance this golden opportunity has been lost, and the intermediate or inflammatory stage has come on, operative interference must if possible be postponed until the inflammation has measurably subsided, and till the patient's condition has become assimilated to that of a case of chronic disease rather than of trau- matic lesion. CAUSES OF DEATH AFTER AMPUTATION. Ill To complete this part of the subject, I quote from Dr. Maeleod (Notes on the Surgery of the Crimean War, p. 307), the following summary of the results of primary and secondary amputations in military practice. Primary operations, 1047 cases, 374 deaths; mortality, 35.7 per cent. Secondary " 594 " 314 " " 52.8 " A percentage which, it will be observed, corresponds very closely with that derived from observations in civil hospitals. The statistics of amputation in the late war of the rebellion have not yet been all published ; but, as far as they go, they serve to confirm what has been already said : thus 180G primary amputations of the upper extremity recorded in Dr. Otis's Surgiccd History of the War, gave 821 deaths, or 17.08 per cent., while 1516 intermediate amputations gave 481 deaths, or 31.73 per cent., and 666 secondary amputations gave 163 deaths, or 24.47 per cent. Causes of Death after Amputation__The causes of death after amputation have been made the subject of special study by several writers, among whom may be particularly mentioned Malgaigne, James, Bryant, Holmes, and Birkett. The three last named gentlemen are among the most recent authorities on the matter, and I will terminate this chapter by quoting some of the conclusions appended to their excellent papers. Mr. Holmes finds from examining the records of 300 cases— " 1. That a considerable proportion of cases must occur in hospital prac- tice, in which death is really inevitable, although it is not known to be so at the time of amputation. . . . " 2. That of the fatal cases which remain, m about one-half death is due mainly to previous disease or injury. " 3. That secondary hemorrhage is hardly ever a cause of death, except in persons with diseased arteries. "4. That death from exhaustion hardly ever occurs without previous dis- ease, obviously proved both by symptoms and post-mortem appearances. l-5. That the other hospital affections (erysipelas, diffuse inflammation, and phagedaena or hospital gangrene) are rare in subjects previously healthy, and that, as a rule, they only prove fatal when they are the precursors of pyaemia. " 6. That therefore any attempt to estimate the dangers of amputation in hospital practice, or to diminish its mortality, must be based upon a knowledge of the conditions under which pyaemia occurs in cases treated separately, and in patients congregated in hospital wards." (St. George's Hospital Reports, vol. ii. pp. 321-322).1 Mr. Bryant's tables likewise include 300 cases, and from his "General Con- clusions" I select the following :— " That pyaemia is the cause of death in 42 per cent, of the fatal cases, and in 10 per cent, of the whole number amputated. "That exhaustion is the cause of death in 33 per cent, of the fatal cases, and in 8 per cent, of the whole number amputated. " That the following causes of death are fatal in the annexed propor- tions :— 1 Mr. Holmes's second paper, based on 500 cases (St. George's Hospital Reports, vol. viii.) confirms the above conclusions. 112 SPECIAL AMPUTATIONS. Of fatal cases Of whole number. Secondary hemorrhage . 7.0 per cent ., or 1.66 per cent Thoracic cc mplications . 5.6 " 1.33 " Cerebral do. . 3.0 " .66 " Abdominal do. . 1.4 " .33 " Renal do. . 3.0 ' " .66 " Hectic do. . 3.0 t .66 " Traumatic do. . 7.0 " " 1.66 " - Pyaemia is the chief cause of death after pathological^ amputations, after those of expediency, and after primary amputations for injury. Exhaustion is the chief cause of death after secondary amputations for injury, and ranks next to pyaemia as a cause of death after the primary, and those classed as pathological (see Med. Chir. Trans., vol. xlii. pp. 85-90). Mr. Birkett, from a study of 171 cases, in which the operation was per- formed either by himself or under his direction, concludes that "a large pro- portion of the patients submitted to amputation, when inmates of a metro- politan hospital, are the subjects of more or less advanced chronic disease of the thoracic or abdominal viscera," and that "the chances of death after operations appear to depend almost entirely upon the previous state of each patient's constitution" (Guy's Hosp. Reports, 3d s., vol. xv. p. 599). CHAPTER VI. SPECIAL AMPUTATIONS. Upper Extremity. Amputations of the Hand__Amputations of different parts of the hand are frequently rendered necessary by injuries, or by diseases of the bone, as in neglected cases of whitlow. As no mechanical contrivance can possibly equal the natural hand in utility, it should in all cases be the surgeon's object to save as much as possible; there is but one exception to this rule, and that is when in the case of the middle fingers it becomes necessary to go as high as the first interphalangeal joint; as there is no special flexor tendon for the proximal phalanx, it will, in such cases, be usually better to go at once to the metacarpo-phalangeal joint; but in the forefinger, even a single phalanx will be of use, as affording a point of opposition to the thumb, while the proximal phalanx of the little finger may be properly preserved, in order to give greater symmetry to the hand. Fingers—The fingers may be amputated at any of their joints, or through the phalanges : if the latter operation be decided upon, it may be done by cutting suitable flaps with a straight bistoury, and dividing the bone with cutting pliers or a small saw. Amputation of the terminal or middle pha- langes may be done by opening the joint from the back of the finger, dividing cautiously the lateral ligaments, disarticulating, and cutting a palmar flap of sufficient length to cover the stump. In this operation it must always be re- membered that the prominence of the knuckle is due to the upper bone, and that hence the incision must be made below the knuckle, or it will not expose the joint. The palmar flap may be made first, either by transfixion or other- wise, and the joint opened subsequently ; I think, however, the plan first mentioned is the best. Another method is to attack the joint from the side, AMPUTATIONS OF THE HAND. 113 cutting one lateral ligament, disarticulating, and then making a long lateral flap from the other side of the finger : this has been particularly recommended in the case of the fore and little fingers, but I do not see that it possesses any advantage over the common palmar flap operation. There is usually but little hemorrhage after the removal of a phalanx, and if any vessels bleed, they can generally be controlled by means of torsion; in some cases, however, the digital arteries are much enlarged, and require ligature. Amputation at the Metacarpophalangeal Joint is best done by the oval method, though it may also be conveniently executed by making two lateral flaps. In the oval operation, the point of the knife is entered just below the knuckle, on the back of the hand, and the blade is drawn obliquely downwards through the interdigital web, across the palmar surface of the finger, and obliquely upwards to the point of commencement; a few light touches of the knife free this oval flap, and disarticulation is then effected by cutting the extensor tendon (if it be not already divided) and the lateral ligaments. In the case of the forefinger the knife should be entered on the radial side, and in the case of the little finger on the ulnar side, instead of at the back of the joint. Some difference of opinion exists as to the propriety of removing the head of the metacarpal bone in these amputations. The hand may indeed be rendered more sym- metrical by its removal, but this gain of symmetry is more than counter- Amputation of part of a finger by cut- ting from above. (Erichsen.) Fig. 48. Fkr. 49. Amputation of an entire finger. (Skey.) Amputation of the left thumb. (Erichsen.) balanced by the loss of firmness and strength entailed; besides, the removal of the head of the metacarpal bone exposes the patient to the risk of inflam- mation and suppuration in the deep tissues of the palm, and thus renders the 114 SPECIAL AMPUTATIONS. operation more serious than it would be otherwise. Hence, if the metacarpal bone itself be uninjured, its head should be, as a rule, allowed to remain : if, however, it be decided to remove it, this can be easily effected by cutting it with strong pliers (Fig. 48), the section, in the case of the fore and little fingers, being oblique, so as to give a tapering form to the part when it is healed. The entire thumb, with its metacarpal bone, may be amputated by making an oval flap from the palmar surface : in the case of the left thumb (Fig. 49), the joint may be first opened by an oblique incision on the back of the hand, begin- ning above and a little in front of the joint, and coming down as far as the web which separates the thumb from the forefinger; the palmar flap is then made by thrusting the knife upwards to its point of entrance, and cutting down- wards and outwards ; in amputating the right thumb, it is more convenient to make the palmar flap first, by transfixion, the remaining steps of the ope- ration being done subsequently. The thumb alone is almost as useful as the other four fingers together ; hence, in operations on this important member, no part should be sacrificed that can by any possibility be preserved. Amputation through one or more metacarpal bones may be required, and may. be done by cutting from without inwards thick flaps of sufficient dimen- sions to cover the parts without undue stretching. In making these flaps, the palm should be respected as much as possible, the necessary incisions being preferably made through the dorsum of the hand. It is better to leave the carpal ends of the metacarpal bones, so as to avoid opening the wrist- joint. Any part of the hand that can be kept, should be scrupulously pre- served, as even a single finger with the thumb is far more useful than the Fig. 50. */"~~~ Partial amputation of the hand. (From a patient in the Episcopal Hospital.) best artificial substitute. Fig. 50, from a case under my care at the Episcopal Hospital, shows the result of an operation of this kind. If a metacarpal bone be injured without injury of its corresponding finger, the former may be ex- cised while the latter is retained, or the finger may, perhaps, be adapted to another metacarpal bone which has lost its own finger, as has been ino-eni- ously done by Prof. Joseph Pan coast, of this city. The risks of amputation below the carpus are slight, 7902 cases referred to in Dr. Otis's Surgical History of the War, having furnished but 223 deaths, of which 19 were after re-amputation at a higher point. The mortality of amputations through the hand is thus less than 3 per cent. Amputations of the Arm. 1. Amputations at the Wrist—The hand has occasionally been removed at the carpo-metacarpal articulation, or between the rows of carpal bones • the stumps thus formed are, however, irregular, and the carpal bones are apt to become subsequently diseased and to require removal. Hence, when it is AMPUTATIONS OF THE ARM. 115 necessary to invade the carpus at all, it is better to go at once to the radio- carpal joint, and amputate at the wrist. Amputation at the wrist-joint may be conveniently effected by the circular operation, by means of the elliptical incision, by making oval flaps cut from without inwards, or by cutting a single flap from the palm of the hand. The resulting stump is a very good one, though it is said to be less suited for the adaptation of an artificial limb than one that is shorter. Its principal ad- vantage is in its preserving the power of pronation and supination, though even this may be lost from inflamma- tory adhesions binding together the radius and ulna. Sixty-eight cases of this amputation recorded in Dr. Otis's Surgical History, gave only seven deaths, a mortality of but 10.6 per cent. 2. Amputation of the Forearm__. The best operation in this locality is, I think, the circular ; though excellent stumps may be produced by other plans, especially by the rectangular flap method of Mr. Teale. At one time I was in the habit of amputating the forearm by making antero-posterior flaps cut from without inwards, but having, on several occasions, met with dangerous secondary hemorrhage from the interosseous artery, which, in this operation, is apt to be cut obliquely, I have been led to prefer either the circular or Teale's, in neither of which is this risk so apt to be encountered. In any of the flap operations, particularly in the lower third of the forearm, trouble may be caused by the tendons project- ing from their sheaths. Under such circumstances, the surgeon should draw them down, and cut them off at as high a point as possible, that they may retract, and not interfere with the healing process. Perhaps the most brilliant operation on the forearm is that in which a dorsal flap is cut from without, and a palmar flap made by transfixion. The length of the flaps should be proportioned to the size of the limb, but two inches may be given as the Amputation at the wrist. (Erichsen.) Amputation of forearm by modified circular method. (Bryant.) average. Five or six vessels usually require ligature in amputations of the forearm, and of these the interosseous is that which is most likely to give trouble, from its tendency to retract between the bones, in which position its orifice may elude detection. 3. Amputation at the Elbow may be effected by either the circular or ellip- tical incision ; it may also be done, though less conveniently, by making an anterior flap by transfixion. It is sometimes recommended to leave the ole- cranon in place, dividing the ulna below it with a saw ; no particular advan- tage, however, attends this plan, and the olecranon, if left, is apt to become 116 SPECIAL AMPUTATIONS. necrosed, and interfere with the healing of the stump. Amputation at the elbow was done in nineteen cases during the late war, and was uniformly successful. 4. Amputation through the Arm—The arm may be removed at any part and by any of the methods which have been described; those which seem to me the best are the oval and the modified circular. The bone, however, is situated so nearly in the middle of the limb, that an elegant and useful stump may be formed by any operation, and indeed the arm is frequently indicated as the typical locality for making double flaps by transfixion. If this opera- tion be resorted to, lateral flaps are the best, and the outer should be cut first; the principal precaution to be taken is to divide the musculo-spiral nerve with a clean sweep of the knife around the back of the bone, before applying the saw. In amputating the arm, the possibility of a high division of the main artery must be remembered ; occasionally the brachial will be the only vessel that requires ligature, though usually there will be bleeding from six or seven, or, if the parts have been long inflamed, twelve or fifteen. If the arm be amputated very high up, particularly if the limb be muscular, there may not be room for the application of the tourniquet in the usual place ; it may then be safely applied to the axillary artery, the arm being kept extended, so as to make the head of the humerus project into the axilla, where it forms a firm point of resistance against which to exercise pressure; or the surgeon may, if he prefer, have the subclavian artery compressed as it passes over the first rib, by means of a wrapped key in the hands of an assistant. Amputation at the Shoulder-joint.—This is in appearance a most formidable operation, and yet it is one of which the results are tolerably favor- able. Thus, 841 cases, recorded in Dr. Otis's Surgical History, gave 597 re- coveries and 244 deaths, a mortality of only 29.1 per cent. When performed for other than traumatic causes, it is still more successful. Amputation at the shoulder-joint may be practised in several ways, the most important being those commonly known by the names of Larrey, Dupuytren, and Lisfranc. 1. Larrey's Method___The surgeon enters the point of a short knife below and a little in front of the acromion process, and makes a deep incision about three inches long in the direction of the axis of the arm. From the middle of this incision, two others are made obliquely downwards (and slightly con- vex, if the limb be muscular), so as respectively to terminate at the points where the anterior and posterior folds of the axilla end in the tissues of the arm ; it is usually directed that the anterior incision should be made first, as the posterior circumflex artery is larger than the anterior, but if the sub- clavian be well commanded over the first rib, there need be no fear of hemor- rhage, and it will then be most convenient to make the posterior incision first, that its position may not be obscured by bleeding from the other. The sur- geon next disarticulates, rotating the arm first outwards so as to make tense the subscapular muscle, which he divides with a perpendicular stroke of the knife, then cutting the capsule and the tendon of the long head of the biceps, and finally rotating the arm inwards so as to reach the supra- and infra-spina- tus muscles, and the teres minor. The lateral incisions are lastly connected by a transverse cut through the tissues of the arm, either from without or from within. Before this final incision (which divides the brachial artery) is made, an assistant should slip his thumb into the wound and control the ves- sel, which may always be found in the first muscular interspace from the anterior edge of the axilla ; the limb being removed, the vessels are to be secured, and the edges of the wound brought together so as to make a linear cicatrix. The appearance of the stump resulting from this operation is well AMPUTATIONS AT THE SHOULDER-JOINT. 117 shown in the accompanying illustration (Fig. 54), from the photograph of a patient on whom I performed this amputation at the Episcopal Hospital. Result of Larrey's amputation. (From Amputation at shoulder-joint by Larrey's method. a patient in the Episcopal Hospital.) 2. Dupuytren's Method__This method consists in making, either by transfixion or from without inwards, a large flap, embracing almost the whole < of the deltoid muscle, then disarticulating, and finally cutting a short flap (in which is the vessel) from the inside of the arm. This operation is more quickly performed than Larrey's, but makes a larger wound, and is not, I think, so generally applicable. In either method the principal difficulty is in Fig. 55. Amputation at shoulder-joint; Dupuytren's method. (Bryant.) disarticulating, to accomplish which (in the case of fracture preventing the use of the arm as a lever in effecting rotation) it may be necessary to intro- lib SPECIAL AMPUTATIONS. Fig. 56. duce the forefinger of the left hand into the capsule, and forcibly drag down the head of the bone so as to expose the ligamentous attachments. In making the deltoid flap by transfixion, the knife should be entered about an inch in front of the acromion process, and, being pushed directly across the joint and capsule, should be brought out at the posterior fold of the axilla. As in Lar- rey's operation, an assistant should slip his thumb into the wound, and secure the artery before the final incision is made. 3. Lisfranc's Operation consists in making antero-posterior flaps, which come together very much as the inci- sions in Larrey's method, over which it presents no particular advantage. The shoulder-joint can also be reached by a circular incision, as practised by Vel- peau and. others, and in fact all con- ceivable varieties of amputation at this point have been employed, and claimed as the best by different surgeons, though those which I have described have been most generally adopted. Amputation above the Shoulder, or amputation of the arm with a part or the whole of the scapula, and perhaps a por- tion of the clavicle, is occasionally re- quired in cases of accident or of dis- ease. No special rules can be given for the performance of this operation, to which, whenever possible, excision of the parts concerned is to be preferred. In cases of injury, the surgeon must make his flaps as best he may, in view of the extent and direction of the laceration, and in cases of amputation for tumors, etc., must be guided by the size and shape of the morbid growth. The results of this operation have been more favorable than might have been anticipated: thirteen cases1 are on record, which, though the arm and a part or the whole of the scapula were torn off by accidental violence, terminated favorably, while thirty-one2 cases in which the arm and part or all of the scapula, with or without a portion of the clavicle, were removed by the surgeon at the same operation, gave twenty-three recov- eries and only eight deaths. Result of amputation by Dupuytren's method. (From a patient in the Episcopal Hospital.) Lower Extremity. Amputations of the Foot—The phalanges of the toes seldom require amputation, but, if necessary, this little operation may be conveniently done, 1 Rogers, in Am. Journ. of Med. Sciences, Oct. 1868 ; and N. Y. Med. Journal, Dec. 1870. Add Kathaletzky's case, Lond. Med. Rec, Dec. IT, 1873. 2 Rogers {X. Y. Med. Jour mil, Jan. 1869) gives thirteen cases, to which are to be added successful operations by Crosby (included by Rogers among cases of excision of the scapula subsequent to previous amputation at the shoulder), Watson, Charles, Young, Wishaw, Jessop, Esmarch, Hendry, O'Grady, Gundrum, and Pa'rise (two cases), with one at the Pennsylvania Hospital, and fatal operations reported by Jack- son, McLeod, Fayrer, Parise, and Langenbeck. AMPUTATIONS OF THE FOOT. 119 as in the ease of the fingers, by opening the joint from the dorsum, and cover- ing the stump with a plantar flap. Amputation at the Metatarso-phalangeal Joint is best done by the oval incision. It must be remembered that the web reaches about half-way between the joint and the end of the toe ; hence the incision must be placed high, or the joint will be missed. Disarticulation is facilitated by forcibly flexing the toe, and dividing the extensor tendon by a transverse incision. It is some- times recommended that in amputating the great toe, the head of the metatarsal bone should be also removed; I do not think this desirable, as by so doing a very important point of support to the arch of the foot is taken away, an evil which would not be compensated for by the greater symmetry of the re- sulting stump. Amputation of the Great Toe, with a part or the whole of its Metatarsal Bone, may be required. If the anterior portion or head only is to be removed, an oval incision may be employed, which is prolonged backwards for a suffi- cient distance on the side or back of the foot. The bone may be divided by cutting pliers or by a chain saw. If the whole bone is to be removed, it is better to shape an antero-lateral flap, by entering the knife on the back of the foot, between the first and second metatarsal bones, and on a level with the tarsometatarsal joint, cutting forwards to the ball of the toe, then across to a point corresponding to the position of the web, and then backwards again along the inner edge of the sole; this flap is dissected up, taking care to keep it as fleshy as possible. The knife is then re-entered between the metatarsal bones, and made to cut directly for- wards through the web. Then press- ing the toe away from the next one, the surgeon, with the point of his knife, cautiously effects disarticulation, and separates the part to be removed, taking care not to wound the dorsal artery of the foot. Hemorrhage hav- ing been checked, the flap is brought down and attached by points of suture in the usual way. Amputation of the Fifth Metatarsal Bone may be effected by the oval in- cision, made so as to avoid wounding the sole. The point of the oval is usually made On the dorsum of the foot, Remo;^ metatarsal bone of great toe ; flap and may be extended in a Curve down- formed ; joint being opened. (Erichsen.) wards and outwards to the edge of the sole, thus forming a curved triangular flap, which is dissected down to give more space. A somewhat similar modification of the oval incision is practised by A. Guerin, in amputating the metatarsal bone of the great toe. Amputation of two or more of the Metatarsal Bones may be conveniently done by the oval operation, the point of the oval beginning on the dorsum above the joint at which disarticulation is to be effected, and its branches spreading to embrace the requisite number of toes. Amputation through the Continuity of all the Metatarsal Bones is best done by cutting a short dorsal and a long plantar flap, the latter of which may be made, if preferred, by transfixion, sawing the bones on the same level, and bringing up the long flap, so as to free the cicatrix from pressure in walking. The resulting stump is well formed and useful. Amputationof the Entire Metatarsus (which is said to have been practised by the North American Indians as a means of preventing the escape of prisoners) 120 SPECIAL AMPUTATIONS. Fig. 58. Amputation at the tarso-metatarsal joint. (Skey.) mav be effected by making a long plantar and a short dorsal flap. The general line of the articulation is irregularly oblique, the base of the first metatarsal being much lower than that of the fifth. The second metatarsal dips in between the first and third, while this again articu- lates at a lower level than the fourth or fifth. The plantar flap may be cut first from without inwards, as directed by Mr. Hey, or disarticulation may be effected first, and the long flap made last, as prac- tised by Lisfranc. The guides to the articulation are the pro- minent tuberosity of the fifth, and the tubercle of the first metatarsal bone (Lisfranc), or the tuberosity of the fifth me- tatarsal, and the prominence of the scaphoid (Hey). The French operation is a pure disarticulation, but Hey sawed across the projecting internal cuneiform bone. This amputation is somewhat difficult of execution, and is now seldom performed. Chopart's Amputation removes all of the tarsus except the astragalus and the calcaneum. As in the case of the last described operation, the plantar flap may be made first, or not until after p/jcr. 59_ disarticulation has been effected; the former plan is, in some respects, the best, as allowing the flap to be more regularly shaped. The incision should start on the outside of the foot from a point midway between '- the external malleolus and the tube- i rosity of the fifth metatarsal bone, ^> and on the inside from a point about * half an inch behind the prominence * of the scaphoid. Disarticulation l may be much facilitated by forcibly << bending the foot down, so as to make l ^ tense the anterior ligaments of the joint. The scaphoid bone has often been left, unintentionally, in performing this operation, the resulting stump being nevertheless quite satisfactory. Care must be taken, in the after- treatment, to prevent retraction of the heel, which is apt to occur, and which may require division of the tendo Achillis. Mr. Hancock has collected 152 cases of Chopart's amputation, of which 120 resulted in recovery with ser- viceable stumps, 2 in re-amputation, and 11 in death, while in 15 the result was uncertain, and in 4, though life was preserved, the stumps were not satis- factory. The mortality of terminated cases is thus only about 8 per cent. Sub-astragaloid Amputation—In this operation all the bones of the foot are removed except the astragalus. Lisfranc did this amputation by cutting • a dorsal flap, Lignerolles with two lateral flaps, and Malgaigne by taking a single flap from the inner part of the plantar surface. The best plan, how- Chopart's amputation. (Bryant.) AMPUTATIONS OF THE FOOT. 121 ever, and that which I have myself followed, is to make a flap from the heel, as in Syme's operation (to be presently described), which flap is then brought over the astragalus and attached to a short dorsal flap in front. Mr. Han- cock has collected twenty-two cases of this operation, the results of which appear to have been usually satisfactory. Pirogoff's Amputation___In this operation the whole of the foot is taken away except the posterior part of the os calcis, which is brought up and placed in contact with the sawn extremities of the tibia and fibula, from wliich the malleoli have been removed.1 The operation is thus done: a somewhat oblique incision, convex forwards, is carried across the sole of the foot from one malleolus to the other, and the flap thus marked out dissected backwards for about a quarter of an inch ; a second incision, slightly convex forwards, is then made across the front of the ankle, so as to open the joint; the astragalus is next disarticulated, when the surgeon, applying a narrow-bladed saw or a " Butcher's saw" to the upper and posterior part of the calcaneum, behind the astragalus, divides it obliquely downwards, in the line of the plantar incision. The malleoli and articulating surface of the tibia are then likewise sawn off, and the two cut surfaces of bone approximated. If Butcher's saw be used, the position of the blade may be reversed for the latter part of the operation, so as to saw off the malleoli from behind forwards. This amputation makes an admirable stump, the remaining portion of the calcaneum becoming firmly attached to the bones of the leg, and the natural length of the limb being re- tained. It is particularly adapted to cases of injury, though it may also be employed in those of disease, provided that the calcis itself be not involved. Hancock has collected 70 cases of PirogofPs amputation, done by British sur- geons, death occurring in only six, while a useful stump is known to have resulted Fig. 60. Fig. 61. PirogoflF's amputation. Application of saw to os calcis. Bony union between calcaneum (Erichsen.) and tibia, after Pirogoff's amputa- tion. (Hewson.) in 57. Five required re-amputation. Seventy-seven operations collected from all sources by Gross (of Nancy) and Pasquier, gave only eight deaths, while useful limbs were known to have been obtained in 44 cases. Stephen Smith and Hewson have particularly investigated the merits of Pirogoff's amputa- 1 Dr. Quimby has modified this operation by leaving the malleoli and pressing up the sawn os calcis between them. 122 SPECIAL AMPUTATIONS. tion, and the latter believes it to be, in one point, superior to any1 operation done higher up, in that it enables the patient to run upon his stump as well as to walk. The accompanying cut (Fig. 61), from Hewson's paper, sliows very well the bony union between the calcaneum and the tibia in a successful case of this operation. The same precautions as to retraction of the heel are necessary in the after-treatment of this, as in that of Chopart's operation ; the purpose was well accomplished in Hewson's cases by applying a weight of four or five pounds to the back of the leg, by means of a broad strip of adhe- sive plaster. Amputation at the Ankle-joint (Syme's Operation)—The following is Mr. Syme's own description of this operation : " The foot being held at a right angle to the leg. the point of a common straight bistoury should be introduced immediately below the fijjuia, at the centre of its malleoliuiprojection, and then carried across the integuments of the sole in a straight line to the same level on the opposite side. The operator having next placed the fingers of his left hand upon the heel, and in- serted the point of his thumb into the incision, pushes in the knife with its blade parallel to the bone, and cuts close to the osseous surface, at the same time pressing the flap back- wards until the tuberosity is fairly turned, when, joining the two ex- tremities of the first incision by a transverse one across the instep, he opens the joint, and, carrying his knife downwards on each side of the astragalus, divides the lateral liga- ments, so as to complete the disar- ticulation. Lastly the knife is drawn round the extremities of the tibia and fibula, so as to expose them suffi- ciently for being grasped by the hand and removed by the saw. After the vessels have been tied, and before the edges of the wound are stitched to- gether, an opening should be made through the posterior part of the flap, where it is thinnest, to afford a de- pendent drain for the matter, as there must always be too much blood retained in the cavity to permit of union by the first intention." This operation has been varied by other surgeons, some making the heel flap longer,2 and others shorter than directed by Syme himself. Again, some only dissect back the flap to the point of the heel, dividing the tendo Achillis and completing the separation of the calcaneum after disarticulation. How- ever it be done, an excellent stump results, provided that care be taken to keep close to the bone in making the heel flap, so as not to destroy its vascular connections. The death-rate of Syme's operation is but small, 219 cases col- lected by Hancock having given but 17 fatal terminations, a mortality of less 1 Mr. Syme also claims this advantage for his operation at the ankle-joint. 2 Dr. J. A. Wyeth, of New York, has shown by numerous dissections that the chief blood supply to the heel flap is from the calcaneal branches of the external plantar artery, and that hence a long flap is more likely to preserve its vitality than a short one. Syme's amputation. (Skey.) AMPUTATIONS OF THE LEG. 123 than 8 per cent. The stump is, according to Stephen Smith, better than that of Pirogoff's operation, for use with an artificial limb. Maeleod and J. Bell modify Syme's operation by preserving the periosteum of the os calcis. Other Amputations on the Foot___Mr. Hancock has ingeniously combined PirogofPs with the sub-astragaloid amputation, preserving the ankle-joint, and bringing the sawn surface of the os calcis into contact with a transverse section of the astragalus ; in this operation the head of the latter bone is also removed. In the course of lectures (before the Royal College of Surgeons), published in the Lancet for 18G6, in which this operation, which may be called Hancock's, is described, the same surgeon ably advocates the propriety of looking upon the foot as a whole, for operative purposes, and of dividing the tarsal bones with a saw, without regard to the position of the joints, taking care merely to remove all parts that are diseased or irretrievably injured. This is a revival of the old teaching of Mayor, of Lausanne, and, though con- trary to the generally received views of modern surgery, is, I think, founded in reason ; acting upon this principle, I myself in one case removed the front portion of the foot, sawing tlirough the scaphoid bone, the posterior part of which was healthy, and removing the anterior diseased surface of the calca- neum ; the case did perfectly well. By this proceeding amputations of the tarsus are greatly simplified, it being merely requisite to make antero-poste- rior flaps of sufficient size, and to saw off the diseased or injured parts of the foot. The statistics of amputations of the foot and ankle are quite favorable; thus, in our late war, 790 amputations of the toes gave but six deaths, 119 partial amputations of the foot gave eleven, and 67 of the ankle-joint gave nine (Circular No. 6, S. G. O., 1865, p. 45). Amputations of the Leg__The leg may be amputated at any part, the rule being to give the patient, in every case, as long a stump as possible. It was formerly customary, in the case of laboring men who could not afford to procure costly artificial limbs, to amputate just below the tubercle of the tibia, that a peg might be adapted which would press on the front of the knee : but by using a short peg with a socket, the limb can be fixed in the ex- tended position, so that the benefits of a long stump can now be equally well given to patients in all conditions of life. Amputation at the Lower Third of the Leg may be conveniently performed by the ordinary circular method, or by making two lateral flaps principally composed of skin, and dividing the muscles by a circular incision a short distance above. Amputation at the Middle or Upper Part of the Leg, provided that the limb be not too muscular, may be done by the common double-flap method, a short anterior skin flap being cut from without inwards, and a long posterior flap by transfixion. "When the calf of the leg is very large, this plan gives an unwieldy posterior flap, which must be trimmed before adjustment, and is even then clumsy and troublesome ; hence in such cases the flap should be cut from without inwards, or, better still, Sedillot's or Lee's method may be adopted. Sedillot's plan consists in cutting by transfixion a single flap from the outside of the limb, while the tissues on the inside are divided by a trans- verse incision slightly convex forwards ; after sawing the bones, the large flap is brought around and attached by stitches, forming a beautiful stump. Lee's method, like that of Teale, consists in making rectangular flaps, of which, however, the longer is formed from the tissues of the calf; it embraces only the superficial layer of muscles, the deep layer being transversely divided on a level with the line of the short flap. In whatever way the flaps are formed, the bones must be cleared for the 124 SPECIAL AMPUTATIONS. saw by a circular sweep of the knife, and in cutting between the bones special care must be taken not to turn the edge of the knife upwards, lest the tibial arteries should be cut at too high a point—an accident wliich by the subsequent retraction of the vessels might cause trouble in arresting the hem- Fig. 63. Flap amputation of the leg. (Erichsen.) orrhage. In applying the saw, the fibula should be divided before the tibia, as it is otherwise liable to splinter; it is often recommended to saw the edge of the tibia obliquely, under the impression that it is thus less likely to per- forate the anterior flap ; I believe, however, that, except from undue tension, this accident is not likely to occur, and that the risk of necrosis is increased by the oblique division of the tibial spine. If it be done at all, it is best done by rounding off the bone with a Butcher's saw, as recently advised by Mr. Porter, of Dublin. A preferable plan is, I think, to preserve a short flap of periosteum, which is allowed to fall over the sawn surface of the tibia, as recommended by Oilier, of Lyons. Four or five arteries usually must be tied in amputations of the leg, and in cases where the vessels are enlarged by the inflammatory process a much larger number may need ligature; while, on the other hand, if the section be made above the origin of the tibials, the popliteal alone may require atten- tion. A great deal of trouble is occasionally experienced in endeavoring to secure the anterior tibial, owing to its retraction above the section of the in- terosseous membrane. A very good plan in such a case is to turn the patient on bis face, when the weight of the stump will tend to extend the limb, thus bringing the artery into the direction of a straight line, and making it much easier of access. For all amputations of the leg or parts below, the tourni- quet may be conveniently applied to the popliteal artery, a large compress being placed over the vessel, and the plate of the instrument fixed at a point diametrically opposite, above the knee. Amputation at the Knee-joint is comparatively a modern opera- tion. Its introduction into general surgical practice is principally due to the efforts of Velpeau, though it has probably been more frequently resorted to in Great Britain and in this country than on the continent of Europe. It may be done by either the circular or the elliptical incision, or by means of flaps. Elliptical Method.—In this operation, which bears the name of Baudens, the surgeon enters his knife three fingers' breadth below the tuberosity of the tibia, cutting at first transversely, then obliquely upwards and around the limb to a point in the popliteal space one finger's length above the joint; the incision then passes transversely across the back of the limb, and is continued obliquely downwards to its point of commencement. This oval flap is dis- AMPUTATION AT THE KNEE-JOINT. 125 Fig. 64. sected up to the line of the joint, and disarticulation easily effected by sever- ing the ligamentum patella?, and the lateral, crucial, and posterior articular ligaments. The semilunar cartilages are usually removed, though A. Guerin advises that they be al- lowed to remain. The articular cartilages may properly be left, though, if preferred, they may be removed by sawing around the condyles of the femur with Butcher's saw, or the condyles them- selves may be removed in the same way ; the statis- tics of the operation show, however, according to Dr. Brinton, that it is rather better to allow the condyles to remain. Some difference of opinion prevails as to whether or no the patella should be removed. I think, with Mr. Erichsen and Mr. Pollock, that it is better to retain it, and its retrac- tion may be prevented, as suggested by the first named surgeon, by turning up the flap and dividing the insertion of the quadriceps femoris muscle. Anterior Flap Method___This, wliich is the best of the flap* methods, consists in making a Jong. rather square, cutaneous flap from the front of the leg, disarticulating, and cutting a short posterior flap by transfixion. The posterior flap method, in which a large fleshy flap is formed from the calf, is easier of execution, but less satisfactory in its re- sults ; in it the patella is removed. The lateral flap method, of Rossi, was a good deal employed during our late war, and has the advantage of affording room for drainage at the lowest part of the wound. In any form of knee-joint amputation, the popliteal artery, with perhaps some of its branches, and the articular arteries, will require ligation. The statistics of knee-joint amputation have been investigated by Dr. John H. Brinton, of this city, in an elaborate paper in the Amer. Journ. of Med. Sciences for April, 1808. He finds that 164 cases from American and foreign sources gave 111 recoveries and 53 deaths, a mortality of 32.31 per cent. Of 211 cases recorded in the office of the Surgeon-General, U. S. A., 106 died, or 50.2 per cent. The annexed table shows the respective mortality of amputations of the leg and of the thigh, compared with those of the knee- joint, in cases of gunshot injury. Cases. Deaths. Mortality, per cent. Amputation of the leg1 . . . 3278 1089 33.22 do at the knee-joint2 . . 296 181 61.15 do of the thigh1 . . . 3516 2715 77.22 Long anterior flap at knee. (Erichsen.) In amputation at the knee-joint for chronic disease, the mortality is given by Dr. Brinton at 22.58 per cent., a death-rate which does not differ materi- ally from that of amputation under similar circumstances either just above or just below the joint; the death-rate of this amputation for traumatic causes generally, he gives at 40.62 per cent. Amputation through the Condyles of the Femur, or at the knee as dis- tinguished from the knee-joint, is best done by Carden's method, the superi- ority of which over that proposed by himself has been candidly acknowledged 1 See Table on page 108. 2 See Dr. Brinton's paper, and Legouest, op. cit., p. 735. 12(5 SPECIAL AMPUTATIONS. by Prof. Syme. In this operation a single broad flap is taken from the front of the knee, the condyles being sawn through on a level with a simple trans- verse incision made below. The patella is removed, and the condyles may be advantageously divided in a curved line by using Butcher's saw. This operation gives an excellent stump, and is particularly applicable to cases of disease of the knee-joint, for which, indeed, it is claimed by Mr. Syme to be in every way superior to the operation of excision. Its results are very favorable, thirty cases of all kinds having given in Mr. Carden's hand a mortality of but five, or sixteen and two-thirds per cent. The resulting stump is longer and more serviceable than that from amputation of the thigh, and the medullary cavity not being involved, there is less risk of diffuse sup- purative osteo-myelitis and consequent pyasmia. Amputations of the Thigh__Amputation of the thigh is frequently required in cases of both disease and injury. The operation may be done at any part of the limb, and the mortality is directly proportional to the proxi- mity to the trunk of the line of section. Supra-condyloid Amputation of the thigh is the name proposed by Stokes, of Dublin, for a modification of Carden's method of amputating at the knee ; in this modification an oval flap is taken from the front of the leg,*there being also a posterior flap fully one-third of the length of the anterior; the femoral section is made at least half an inch above the antero-superior edge of the condyloid cartilage, and the cartilaginous surface of the patella is removed by means of a small saw. Amputation at the Lotoer Third of the thigh may be conveniently done by the ordinary double-flap operation. Mr. Erichsen recommends Vermale's operation, or that by lateral flaps, for this situation, and I doubt not that an excellent stump may be obtained by this method. The operation, however, which I have always practised myself in amputating at the lower third of the thigh, is the antero-posterior flap method, and I have found it perfectly satis- factory. The anterior flap is cut first, from without inwards, and should be about four inches in length, extending to the upper edge of the patella; it should be rather square in shape, with the corners rounded off, and should embrace all the tissues down to the bone. The posterior flap, which contains the main artery, is made by transfixion, and should be about the same length as the other, thus allowing for the inevitable retraction of the muscles at the back of the thigh. Both flaps are then turned back, when a circular sweep of the knife clears the bone for the application of the saw. When the flaps are adjusted, it will be found that the bone is well covered by the front flap, and the resulting cicatrix is drawn entirely behind the line of pressure. Seven or eight vessels usually require ligature, though, if the case be one of chronic joint disease, the number may be larger. Amputation at the Middle or Upper Third of the thigh, if the limb be not too muscular, may be done in the same way, by antero-posterior flaps, one or both made by transfixion, according to circumstances. But if the limb be a large one, a better stump can be made by resorting to the modified circular operation, as practised by Syme and Liston, making short skin flaps, and dividing the muscles at a higher point by a circular incision (see Fio- 41) The posterior muscles of the thigh always retract more than the anterior, and should therefore be cut rather longer. In amputating at the upper portion of the thigh, there is scarcely room for the application of the tourniquet and the surgeon therefore commonly has to rely upon manual compression of the femoral artery, as it passes over the brim of the pelvis, though in some ea«es the aortic tourniquet might perhaps be advantageously employed. If manual pressure be resorted to, the assistant who has charge of this department 4ould AMPUTATION AT THE HIP-JOINT. 127 grasp the great trochanter with the fingers of the hand corresponding to the limb to be removed, and press firmly on the artery as it emerges from beneath Poupart's ligament with the thumb of the same hand; the opposite thumb is superimposed to assist and regulate the pressure, and to prevent any risk of slipping. In cases of injury, the form and extent of the laceration will often compel the surgeon to make irregular flaps, and to cover his stump as best he may under the circumstances. Oblique flaps may be employed in such a case, or a single long flap from any part of the thigh ; it is more important to make the amputation at as low a point as possible, than to follow any one or other particular mode of operating. Amputation through the Trochanters maybe occasionally required in cases of injury, or of malignant tumor involving the lower part of the femur. It is a procedure of less risk than exarticulation of the whole limb, and, in cases of malignant disease, appears to be no more likely to be followed by a return of the affection, than the graver operation. It is, moreover, very easy to con- vert this amputation into a disarticulation, by dissecting out the head and neck of the femur, if these parts be found to be diseased. Tecde's Amputation by Long and Short Rectangular Flaps makes a beau- tiful and most serviceable stump when applied to the thigh, but is objection- able on account of requiring the bone to be sawn at a much higher level than would be necessary with the ordinary operations: thus, if the laceration of the soft tissues extended to the upper border of the patella, and the thigh were only sixteen inches in circumference (by no means a large measurement), the long flap would need to be eight inches square, and the bone would be divided at just about its middle, fully four inches higher than would be re- quired by the common double-flap operation. Amputation at the Hip-joint__This, which may fairly be con- sidered the gravest operation in the whole range of surgical practice, is a procedure of comparatively recent introduction. The first case which is usually classed as an amputation at the hip-joint is that in which Lacroix (1748) removed the right thigh at the joint, on account of gangrene, which affected both limbs, and had been produced by the use of ergot. The ampu- tation had been nearly completed by nature, and he merely divided with scissors the round ligament and the sciatic nerve. Four days afterwards he amputated, through the line of separation, the left thigh at the trochanters : the patient, who was a boy of fourteen, survived the last operation for eleven days. Perault, in 1774, performed a somewhat similar operation, in a case of gangrene from external violence, the patient recovering. The first genu- ine case of hip-joint amputation through living parts was done by Kerr, of Northampton, about the same time, on a girl of eleven years, suffering from hip disease complicated with psoas abscess and pulmonary phthisis; she died on the eighteenth day. The first case of this amputation for gunshot injury was Larrev's, in 1793, while the first successful case in military practice was that of Mr. Brownrigg, in 1812. A great many different plans have been suggested for effecting disarticula- tion at the hip-joint—Farabeuf has collected more than forty-five—but I shall content myself Avith describing five principal methods, viz., the oval, the modified circular, that by a single flap, that by antero-posterior, and that by lateral flaps. Oval Method___This has not been employed very often. It is done by entering the point of a strong but short knife on the outside of the limb, either over the trochanter or below the anterior superior spinous process of the ilium, and making two oblique incisions, one forwards and downwards, and 128 SPECIAL AMPUTATIONS. the other backwards and downwards, to meet in a transverse line on the inside of the thigh. The muscles are divided in the same lines or a little higher, and disarticulation being effected from the outside of the joint, any remaining tissue is severed, as in Larrey's shoulder-joint amputation, by a single stroke of the knife. Malgaigne recommends a preliminary longitudinal incision, by which the operation is still more assimilated to that of Larrey on the shoulder. On a slender limb this form of amputation would give an admirable stump, but it is obvious that under opposite circumstances the adductor muscles of the thigh would form a cumbrous mass, which would require retrenchment before the wound could be properly closed. Modified Circular Operation___This is done by cutting, from without in- wards, short antero-posterior cutaneous flaps, and then dividing the muscles on a level with the joint by a circular incision. This method has been suc- cessfully employed by several American surgeons, including the late Dr. J. Mason Warren, of Boston, and is particularly adapted to cases of tumor encroaching on the upper part of the thigh. Single Flap Method__eln this operation, a single, large, anterior flap is cut, t either by transfixion (Mauec), or from without inwards (Plantade, Aslimead). ! .'J The soft parts on the back of the limb are divided by a circular incision, either before or after disarticulation.^ In other forms of this operation the flap has been taken from the inside, or even from the back of the limb. The single flap method might be desirable in a case in which the laceration of the soft parts was such as to forbid any other, but, when the surgeon has a choice of operations, it is better to employ either the oval or modified circular, or the double-flap method of Guthrie, which will be presently described. Fig. 65. Amputation at the hip by the long anterior and short posterior flap. a. The femoral and profunda vessels, with branches of the anterior crural nerve, b. The great sciatic nerve and its companion artery. A large branch of the sciatic artery is seen in front, c. The muscular mass from the tuber ischii and the obturator externus muscle. Large branches are seen on either side from the profunda and gluteal, d. The psoas and other muscles immediately in front of the joint. (Holmes.) Antero-posterior Flap Method—There are two varieties of this operation, which bear the names, respectively, of Beclard and Guthrie. Beclard's operation consists in making both flaps by transfixion. It is thus performed: AMPUTATION AT THE HIP-JOINT. 129 The point of a long straight knife is entered a little above the position of the great trochanter, thrust across the limb, dipping slightly backwards so as to graze the back of the cervix femoris, and brought out at the innermost part of the gluteal fold ; a posterior flap is thus cut from the gluteal muscles, and the surgeon then re-entering his knife at the same point, pushes it in front of the joint, and, bringing it out as before, cuts an anterior flap from the front of the thigh. The plan which is more commonly adopted in Fig. 66. ter, differs merely in that the .-' flaps are cut from without in- _ wards; the operation is done^j with a small knife, and the posterior flap should be cut first. It is not quite so rapidly executed as the operation by transfixion, but is more certain of affording well-shaped flaps, ^x~ and, I think, gives a better Eesult of hip.joint amputation by Guthrie's method. Stump ; this Operation has been (From a patient in the Episcopal Hospital.) several times employed in this country, and is that to which I have myself resorted in three cases in which I have had occasion to perform this operation. Lateral Flap Method.—This method, as its name implies, consists in making tjvo flaps, from the outside and the inside of the limb. Larrey and Lisfranc made both flaps by transfixion, the former cutting the inner flap first, while the latter began with the outer. Dupuytren modified this operation by shaping the internal flap from without inwards. Neither of these plans ap- pears to present any advantages over those which have been previously described. Whatever method be employed in amputating at the hip-joint, the surgeon must take special precautions against the occurrence of hemorrhage, for a very few jets from the femoral artery, in this situation, will almost insure the death of the patient. Larrey directed that the main vessel should always be secured in the groin, as a preliminary measure, and this plan has been since frequently followed. It seems to me, however, that the extensive separation of the artery from the surrounding tissues, which is unavoidable in this preliminary liga- tion, must expose the patient to greater risk of secondary bleeding, than when the vessel is simply picked up by forceps or tenaculum, after division, as in other amputations. Hence, I think it better to rely upon mechanical means to control the circulation, or, in the absence of these, to trust to the manual pressure of intelligent assistants. 9 130 SPECIAL AMPUTATIONS. The circulation can be conveniently controlled by compressing the aorta, either with Lister's instrument (Fig. 2S), a modification of Dupuytren's compressor, or with the apparatus which has been repeatedly used in this city under the name of the abdominal tourniquet, and wliich is merely an enlarged form of that devised by Mr. Skey (Fig. 27). Spence prefers to make pressure by putting a thick pin-cushion over the aorta, and keeping it in place by surrounding the body with an elastic band. In addition to the aortic compressor, it is desirable to have in readiness a large flat sponge, as suggested by Mr. Butcher, for application to the whole posterior flap, while the surgeon's attention is given to securing the main artery which is in the anterior. In order to prevent the loss from the general circulation of the blood which is in the limb, an ingenious suggestion of Dr. Erskine Mason should be adopted ; this consists in rendering the part bloodless by the application of Esmarch's bandage and tube, the latter being fixed just below the line of incision, and kept in place during the operation. Although the benefits derived from the use of the aortic compressor in this operation are unquestionable, yet the pressure necessarily exercised upon the important nervous structures contained in the abdominal cavity must be at least undesirable, if not positively injurious ; hence the vessels should be secured promptly, that this pressure may not be continued longer than is absolutely necessary. The point at which the pad of the compressor should be applied is on a level with the umbilicus, and, usually, a little to its left side, though this must be determined by feeling for the pulsation of the aorta; it is well, before screwing down the pad, to roll the patient gently over to the right side, that the bowels (which should have been previously emptied by a dose of castor oil and an enema) may, as far as their mesenteric attachments will allow, fall out of the line of pressure. Should it be determined to rely on manual compression, this may be applied to the abdominal aorta (if the patient be very thin), to the external iliac artery just within the brim of the pelvis, or to the femoral as it emerges from beneath Poupart's ligament; the hands of an assistant should moreover follow the knife of the operator, and catch the artery in the anterior flap as soon as it is cut, or, if the flap be made by transfixion, before the section is completed. Dr. Woodbury, of this city, and Dr. Van Buren, of New York, have suggested that the iliac artery should be compressed by an assistant's hand introduced into the rectum, and an instrument for making pressure from the same direction has been devised by Mr. R. Davy, of London. After the operation the stump may be closed in the usual way, the deep parts of the wound being approximated by the use of suitable compresses. The statistics of hip-joint amputation are more favorable than might be expected from the severity of the operation: of 286 cases of all kinds recorded in Circulars No. 7, S. G. O., 1867, and No. 2, S. G. O., 1869, 60 are known to have recovered and 223 to have died, while the result in three cases is undetermined; beside these, there were eight cases of re-amputation of stumps, of which four died and four recovered. Liining, of Zurich, has collected 497 cases, with a total mortality of 70 per cent. My own tale of cases is three operations with one recovery and two deaths. The following tables exhibit—-first, the comparative mortality of hip-joint and thigh ampu- tations, for the causes met with in civil life, and for gunshot injuries ; second, the comparative mortality of these operations, according as they were per- formed for injury or disease ; and third, the statistics of hip-joint amputation for gunshot injuries, with reference to the periods at which the operations were performed. AMPUTATION AT THE HIP-JOINT. 131 Table showing Results of Hip-joint, as compared with Thigh Amputation, for Causes incident to Civil Life, and for Gunshot Injuries. Civil Practice. GrssHiii Wousus. Aggregates. Amputation. Cases. Deaths. Mortality, per cent. Cases. Deaths. Mortality,' n percent. I CaSeS" Deaths. 223 4168 Mortality, per cent. Hip-joint,1 Thigh, 2 Ill 2429 65 1053 58.56 43.35 175 3516 158 2715 90.29 77.22 ! 286 5945 77.97 70.11 Table showing Mortality of Hip-joint, and of Thigh Amputation, for Injury, and for Disease. Amputation for Injury. For Disease. Locality. Cases. Deaths. Mortality, per cent. Cases. Deaths. Mortality, per cent. At hip-joint3 . . . . . In continuity of thigh* . 47 964 35 576 74.5 59.7 42 1465 18 477 42.9 32.5 Table showing Results of Hip-joint Amputation for Gunshot Injuries, according to the Period at which the Operation was performed. [Copied from Circular No. 2, S. G. 0., 1869, p. 112.] Period of operation. Cases. Died. Recovered. Doubtfnl. Death-rate. Primary . . . . Intermediate . Secondary Re-amputations 1 79 76 20 8 75 70 13 4 1 6 7 4 CO • • • 98.68J 92.10 65.00/ 50.00 Aggregates 183 162 18 3 -90.005 CHAPTEEYII. EFFECTS OF INJURIES IN GENERAL; WOUNDS. External violence or injury, of whatever kind, affects the state of the part to which it is immediately applied, and the general condition of the patient at the same time. Hence the effects of injuries are said to be both local and general or constitutional. The local effects of external violence 1 Circular No. 7, S. G. O., 1867, p. 18, and Circular No. 2, S. G. O., 186!), p. 112. 2 See Erichsen's Surgery, vol. i., p. 80, and Table in Chapter V., p. 108. 3 Erichsen, op. cit., p. 127. « Ibid., p. 80. 5 Doubtful cases omitted in computing percentages. 132 EFFECTS OF INJURIES IN GENERAL. vary according to the nature of the violence and the circumstances under which it is inflicted ; the constitutional effects, though very different in degree, are the same in kind for all forms of injury. Constitutional Effects of Injuries. These may be either immediate or remote. The immediate constitutional effect of any injury is called shock, which, if present in an aggravated degree, constitutes collapse. £■* - Shock or Collapse is a condition, of the essential nature of which, it must be confessed, we are as yet in ignorance. It is often spoken of as purely an affection of the nervous system, and an analogy is drawn between this and hemorrhage as an affection of the vascular system ; yet this view is contradicted by the fact that very serious lesions of the nervous system are not necessarily, nor indeed commonly, accompanied by shock. Experimental physiology has shown that large portions of the brain can be cut away from birds, without the development of this condition, except in so far as would be accounted for by the mechanical injury, and a similar experience is revealed by the study of morbid anatomy. No one would pretend to say that the for- mation of an abscess in the brain, or the degeneration of large tracts of the spinal cord, is accompanied by shock, and yet this ought to be the case if shock were purely an affection of the nervous system. In fact, here, as we saw in studying the process of inflammation, it is impossible reasonably to mark out and divide the nervous from the vascular system, or either from the parenchymatous structures around them, and say this is, and that is not, the seat of the affection. Shock is the general or constitutional effect of injury, and as the synergy of health unites all the tissues of the human body in normal life and action, so under the effect of injury they are still united by sympathy, and one tissue cannot suffer without the others. Still, this sympathy is brought out through the agency of the nervous system, by a process of reflex action in fact, and, accordingly, it is not surprising to find that the symptoms of shock can be artificially induced by irritation applied directly to certain nerve structures. Drs. Mitchell, Morehouse, and Keen, of this city, who have devoted special attention to this subject, give the following explanation as to the probable mode in which the symptoms of shock are brought about: "These very interesting states of system," they say, " may be due, it seems to us, either to an arrest or enfeeblement of the heart's action through the mediation of the medulla oblongata and the pneu- mogastric nerves, or to a general functional paralysis of the nerve centres, both spinal and cerebral, or finally to a combination of both causes -,"1 and from an experimental investigation of the subject, Dr. C. C. Seabrook con- cludes that the phenomena of shock are due to paralysis of the vaso-motor centres. Hence, while it is incorrect to speak of shock as exclusively an affection of the nervous system, it is through the agency of that system that its pheno- mena are brought about, and it is to a clearer understanding of the laws of nervous action that we must look for more definite and precise ideas as to the essential nature of this curious physical condition. A good deal of confusion exists as to the meaning of the word shock, from this condition not being distinguished from others which often coexist with it, especially cerebral and spinal concussion and mental perturbation. Thus, a violent blow on the head may doubtless be accompanied by shock, but it will 1 Circular No. 6, S. G. 0., 1864, p. 2. SHOCK OR COLLAPSE. 133 also probably he accompanied by cerebral concussion, an entirely distinct affection, and yet one which is not unfrequently spoken of by surgical writers as a typical instance of shock. Again, mere mental emotion, trepidation, or fright, may cause fainting or even death, and yet this is not shock in the true sense of the term. That true shock is a purely physical condition is seen from its occurrence in the lower animals, even in those wliich are cold-blooded, and from its being met with after operations done while the patient is under the full influence of an aiuvsthetie, and while mental emotion is therefore out of the question. Still, so intimately connected are mind and body, that it is often in practice difficult, if not impossible, to separate the mental condition from the purely physical state of shock. Causes of Shock—While in general terms it is correct to say that every injury produces a certain amount of shock, yet there can be no doubt that certain classes of injury are more liable to be followed by this condition than others, that shock is particularly apt to follow injuries of certain parts, and that the susceptibility to shock of any individual may vary with the particular circumstances to which he is subjected at the time of receiving the injury. Gunshot wounds have always been looked upon as especially apt to be fol- lowed by shock. " AVhen a bone is shattered," says Mr. Longmore, "a cavity penetrated, an important viscus wounded, a limb carried away by a round- shot, pain is not so prominent a symptom as the general perturbation and alarm which supervene on the injury. . . . This emotion is in great measure instinctive; it is witnessed in the horse mortally wounded in action no less than in his rider; it is sympathy of the whole frame with a part subjected to serious injury, expressed through the nervous system." Severe lacerated and contused wounds, such as are produced by railroad and machinery accidents, are very frequently followed by shock in a marked degree. One of the most decided instances of shock that I have ever witnessed was in the case of a lad whose thigh was caught in a machine called a "lapper," in a rope factory. The whole limb, from the toes to above the middle of the thigh, was marked by punctures from the teeth of the machine, which were of steel and over three inches long; the thigh was broken, one of the punctures rendering the fracture compound, while another penetrated the knee-joint. There was comparatively little hemorrhage, and absolutely no exhibition of mental emo- tion ; yet there was profound shock, from which even partial reaction did not occur until nearly thirty hours after the accident. Burns and scalds, involv- ing a considerable extent of surface, are apt to be attended with severe shock, which not unfrequently proves fatal without the occurrence of reaction. Other things being equal, the degree of shock is usually proportionate to the severity of the injury received, but the modifying circumstances are so many and so effective, that the exceptions to this rule are almost as numerous as its instances. The degree of shock varies with the part of the body injured; in the case of the extremities, the shock appears to be greater as the lesion is nearer the trunk, while wounds of the abdominal cavity are attended with more shock than those of the chest. Drs. Mitchell, Morehouse, and Keen infer from the cases which they have examined, that gunshot wounds of the upper tltrrd of the body are more likely to be attended with shock than those of other regions. The shock attending injuries of the head or spine is very apt to be compli- cated by concussion or paralysis. Wounds of the testicle are frequently accompanied by a state of shock, much more marked than can be accounted for by the severity of the injury. The various circumstances by which a patient is surrounded at the moment of receiving an injury, greatly influence the degree of shock experienced. Anything that tends to weaken a patient increases the liability to shock, and 134 EFFECTS OF INJURIES IN GENERAL. thus hemorrhage, previous ill-health, certain forms of visceral disease, etc., are all found to have an unfavorable influence upon the results of operations by increasing the risk of shock. The most remarkable examples of the influ- ence of surrounding circumstances are, however, seen on the field of battle : one man, moved by a sense of duty and heavy responsibility, will continue in the front, though he has received a severe and, perhaps, painful injury; while another, not necessarily a coward, may be completely unmanned by a com- paratively slight scratch, and, forgetting everything else, cry like a child, or scream like a maniac. Symptoms of Shock___In a slight case of shock there may be merely a momentary, almost imperceptible, change of color, with a feeling of sinking in the precordial region, and perhaps slight qualmishness. In more marked cases there are evidences of great prostration; the patient lies helpless, and almost unable to move, the muscular relaxation affecting sometimes even the sphincters ; the whole surface is very pale, even the lips appearing utterly bloodless ; the skin seems shrunken, and the flesh softened; the surface is bathed in a cold sweat; the features are sunken, the eyelids drooping, and the whole appearance is that of impending dissolution. The heart's action is always feeble, sometimes preternaturally slow and intermitting, but more usually fluttering and rapid ; the pulse is commonly small and compressible, and in bad cases almost or altogether imperceptible. The respiration is feeble and gasping—sighing, as it is termed—or it may be so weak as scarcely to be noticed. There is often vertigo, dimness of vision, and slight deafness ; though, on the other hand, there may be perfect mental clearness, and unnatural sen- sibility to light and sound. There may be various nervous manifestations, such as hiccough or subsultus, and in slighter cases, or during recovery from those which are more severe, there is frequently vomiting. The temperature in cases of shock has been particularly investigated by Wagstaffe, who finds that a marked difference exists in the depression in tem- perature observed during collapse in fatal and in non-fatal cases. Thus, assuming the normal temperature to be 98.4° Fahr., a fall of 2° or more affords ground for a very gloomy prognosis. In exceptional cases, however, a very low temperature (91.2°) has been found compatible with recovery, and one still lower (81.75°) with existence.1 According to Redard, who has also paid attention to this subject, if the temperature be below 35.5° Cent, (about 96° Fahr.), the injury will almost certainly prove fatal, and no operation should be performed ; while in any case in which reaction as regards tempe- rature is not observed within four hours from the moment of injury, the prog- nosis must be considered unfavorable. When death occurs directly from shock, it is from the heart ceasing to act; post-mortem examination shows the heart (especially the cavities of the right side) and the great venous trunks distended with blood, which is sometimes fluid, and always coagulates with difficulty. In recovery from shock, the patient passes through the stage of reaction; the pulse gradually becomes stronger and more regular, the respiration grows deeper, and, after a few pro- found sighs, is perhaps fully re-established, vomiting often occurs, the tem- perature rises, the color improves, and the patient, from lying on his back, turns to one or the other side. The stage of reaction often passes too far, a feverish condition being developed, with great mental excitement, constituting Traumatic Delirium (see page 136), or the reaction may be incomplete, and that state come on to which Travers gave the name of ''prostration with ex- citement." There seems to be no definite relation between the different stages of shock, as to their duration and severity. The first stage, or that of de- 1 Nicolaysen reports a case in which, from exposure to cold, the temperature fell to 76.4° F., and yet the patient recovered. SHOCK OR COLLAPSE. 135 pression, may be so slight, and last so short a time, as to escape observation, the stage of excitement, accompanied sometimes by the wildest delirium, being the first that attracts the surgeon's attention. Curious cases illustrat- ing this statement may be found in works on military surgery, and it is sug- gested by Longmore, Legouest, and others, that the state of great excitement in which a soldier in action naturally must be, may probably determine the occurrence of these phenomena. When shock proves directly fatal, it is, as has been said, through the heart that death occurs. Shock may, however, be complicated with other condi- tions, the result of the local effects of injury, the symptoms of which may gradually supersede those proper to shock, and life may thus be extinguislied in other ways. Thus there may be concussion of the brain or spine coexist- ing with shock ; or an important viscus, such as the liver, may have under- gone laceration, when death may occur before reaction, and yet not from shock, but from internal hemorrhage or incipient peritonitis. Treatment of Shock___The object of the surgeon in managing a patient suffering from shock is, of course, to bring about reaction. As death from shock depends on the heart ceasing to act, the treatment must be directed to increasing the force and the regularity of the cardiac pulsations, and, in some few cases, this may perhaps best be done, as pointed out by Air. Savory, by resorting to venesection. It is known that after death from shock the heart is filled with blood, and is, in fact, paralyzed from distension ; it is known, from experiments on the lower animals, that in such a condition, even after all pulsation has ceased, the heart's action can be restored by mechanically relieving the organ by a puncture in the right auricle, or in the jugular vein ; hence the inference is reasonable, and is confirmed by experience, that when —as in shock—death is imminent from engorgement of the right side of the heart and venous trunks, relief may be afforded by bloodletting. To make this as effective as possible, the blood should be drawn from the jugular vein. It is. of course, only in extreme cases, and in such as have not already suf- fered from hemorrhage, that this mode of treatment can be required, and it should be looked upon as an extreme remedy. In all cases of shock, stimulation, both internal and external, should be-^** employed. Dry heat is to be applied to the surface by means of hot bottles, hot bricks, etc. ; sinapisms may be placed on the abdomen and chest, and cordial draughts administered if the patient be able to swallow, and if not, stimulating enemata resorted to instead. The general treatment of this con- dition has been already referred to in Chapter III., in discussing shock as a cause of death after operation, and I will merely repeat here that the arterial stimulants administered should be preferably such as are evanescent in their effects, as the preparations of ammonia; though in any severe case the use of brandy will be found essential, and, indeed, is often retained by the stomach better than anvthing else. Subcutaneous injections of ether may be some- times employed with advantage. As during the stage of depression, absorp- tion is greatly impeded, if not altogether checked, it is idle to give food until at least partial reaction has occurred, and even then it should be given with caution, and in small quantities at a time. For the same reason, opium, wliich is an invaluable remedy in these cases, is more effective when given hypodermically than by either the mouth or rectum. In any case, as long as the heart's action continues, there is hope ; and if natural breathing fail, artificial respiration should be resorted to, and con- tinued systematically and perseveringlv. Electricity is often used to excite the heart to renewed activity, but, at least in my own experience, without much benefit. McCJuire, of Richmond, Va., recommends large doses of quiiiia, before operations, as a prophylactic against shock. 136 EFFECTS OF INJURIES IN GENERAL. Traumatic Delirium—When reaction occurs, it is often excessive. In the treatment of Traumatic Delirium (p. 135), the surgeon must keep in mind that he is dealing with increased action, not with increased power. In fact, this condition always approaches more or less to Travers's "prostration with excitement," though the degree of debility of course varies in different cases. The symptoms of Traumatic Delirium are very much those of the ordinary Delirium Tremens, and indeed, in the case of hospital patients, many of whom are habitually hard drinkers, it is often quite impossible to draw an exact line, and say which condition is actually present. There is the same brightness of eye, heat of head, slight acceleration of pulse, constant and irrepressible muscular action, and sleeplessness with wandering delirium and rapid succession of spectral delusions, usually of a frightful and painful character. I do not believe that depletion is ever necessary in cases of pure traumatic delirium ; if complicated with cerebral inflammation, the case may be different, but this is a question which will be referred to in its proper place. The head should be slightly elevated and kept cool by means of ice- bags, or Petitgand's apparatus (Fig. 7), and the patient kept as quiet as pos- sible, in a rather dark room ; as there is usually constipation with a furred tongue, a mercurial cathartic may be given, though profuse purging should be avoided. An anodyne and diaphoretic mixture will almost always be proper, to which, if there be great cerebral excitement, small doses of tartarized an- timony may perhaps be cautiously added. The most important remedy in the treatment of traumatic delirium is opium, which should be given freely, and with brandy or whiskey in quantities proportioned to the debility of the patient. Food is quite as important as medicine, and should be regularly administered in a concentrated form, in small quantities at frequent in- tervals. Amputation during Shock___Before leaving the subject of shock, there is one question which demands consideration, which is, whether or no an am- putation should be performed during the continuance of this condition. As a general rule there can be no doubt that it is right to wait for reaction to oc- cur, before subjecting the patient to the additional source of depression which must come from the operation, and in any case it would be proper to wait a short time and endeavor to procure reaction in the way that, has been directed. In some instances, however, especially in the cases of compound fracture produced by railroad or machinery, the mangled limb seems by its presence to act as a continual source of depression, and in such cases prompt amputa- tion, even during the existence of a certain amount of shock, will give the patient a better chance than delay. Particularly is this the case when the injured part is very painful, and when bleeding is going on from small ves- sels that cannot be controlled. Under these circumstances it is a good plan to try the effect of anaesthesia; if the inhalation of ether produces an amend- ment in the patient's condition, making the pulse fuller and stronger, it is probable that the depression is purely one of shock from the external injury, and the surgeon will be justified in resorting to immediate operation. If, on the other hand, in spite of the anodyne and stimulating effect of* the anes- thetic, the patient continue to sink, there is grave reason to apprehend that some severe visceral lesion is superadded to the obvious external injury, and under such circumstances operative interference will not be advisable. The surgeon may be aided in coming to a decision under these circumstances by observing the temperature of the patient; if this be below 96° Fahr., no operation as a rule is admissible (see p. 134). Remote Constitutional Effects of Injuries___These are even more obscure than those effects which are immediately produced. The state LOCAL EFFECTS OF INJURIES. 137 of system to which the older writers gave the name of sve-andmxf or insidious shock has already been referred to (p. G7). It is probably due, at least in the majority of cases, to the formation of coagula either in the heart itself or in the great venous trunks ; this is a very fatal condition, and not unfrequently causes death after operations. Heart clots may kill the patient directly, by mechanically impeding the cardiac action, or portions of a clot may become detached and be carried by the circulation into other parts of the body, where they may prove fatal by plugging important vessels, such as the branches of the pulmonary artery, the internal carotids, etc. This process is called embolism, and the fragments of clot are called emboli or embola. Embolism by particles of fit, is an occasional cause of sudden death in cases of injury to the bones involving the marrow, as pointed out by AVagner, Busch, Czerny, and Boettcher; and a remarkable case of embolism of the pulmonary artery by a portion of the liver, following rupture of that organ, has been reported by Marshall, of Nottingham. Fat-embolism from rupture of a fatty liver, has been noted by Hamilton, of Edinburgh, and from a simple flesh wound of the thigh, by Dr. W. H. Bailey, of New York. There are other obscure constitutional conditions which result from injuries, often probably tlirough secondary lesions of the central nervous system. In other cases, again, from some local change, the general nutrition of the body may be affected through the medium of the blood. The neuralgic condition which sometimes follows injuries, and which has been particularly studied by Verneuil, may often be relieved by large doses of quinia. Local Effects of Injuries. These may be classified as the effects of violence, embracing contusions, wounds, fractures, and dislocations, and the effects of chemical agents (espe- cially heat and cold), embracing burns, scalds, frostbite, etc. There are like- wise certain remote local effects of injuries, which have not as yet been thoroughly traced out; thus many chronic affections of bones and joints origi- nate from injuries, while external violence must be considered as at least the exciting cause of the development of many morbid growths, whether innocent or malignant. Contusions___In a contusion the skin is not broken. There is always, however, laceration of the subcutaneous tissues, sometimes very slight, as in the ordinary bruise, but sometimes causing complete disorganization of a limb or other portion of the body. When all the tissues of a part are completely crushed, it is sometimes said to be pulpefied. The skin itself, though not broken, may be so much injured as to lose its vitality, and slough. Every contusion is attended with more or less extravasation of blood ; if in small amount, this constitutes ecchymosis, the blood undergoing certain changes in the process of absorption, which give rise to the "black and blue" appearance of an ordinary bruise. If the extravasation of blood be in larger amount, it constitutes a thrombus (when clotted), or a haematoma when remaining as a tumor containing fluid blood. Beside the extravasation of blood, a contusion is always accompanied by the exudation of a serous fluid ; this may be very slight and superficial, as seen in the wheal or elevated ridge produced by the stroke of a whip, or it may arise from deep-seated injury, when it makes its appearance in the form of vesicles and bullae, as is especially seen in parts in which the bones are subcutaneous, as over, the tibia and ulna. The subcuta- neous hemorrhage or extravasation which accompanies a contusion is seldom productive of serious consequences, unless from rupture of a large artery. Mr. Erichsen has, however, recorded an autopsy in the case of a boy beaten 138 EFFECTS OF INJURIES IN GENERAL. to death by his schoolmaster, in which the fatal issue appeared to have been principally due to this cause. The amount of extravasation varies with the part affected; where the areolar tissue is of loose structure, as in the eyelids, it is very great, and the swelling correspondingly well marked. The causes of contusion are simple pressure, blows, and falls, or, in other words, direct and indirect violence. The symptoms are local pain and tenderness ; swelling (from extravasation and exudation), preceded perhaps by a temporary depres- sion or indentation from the force of the blow ; momentary loss of color, fol- lowed by increased redness, and subsequently by various modifications of hue owing to the changes in the extravasated blood ; increase of temperature, etc. In cases of severe contusion, vesications make their appearance in the course of from twelve to twenty-four hours, and by their size and number indicate the extent of subcutaneous injury. The diagnosis of contusion is usually easy. In some cases, however, the appearances are almost identical with those of incipient traumatic gangrene (which may indeed result from con- tusion), and then the nature of the case must be determined by negative evi- dence, by the absence of the characteristic gangrenous odor, by the tempera- ture of the affected part, the constitutional symptoms, etc. In some situations, as in the scalp, difficulty of diagnosis arises on account of the extravasation, which in this position imparts to the surgeon's fingers very much the sensation of a depressed fracture. There is a ring of hard tissue with a soft central depression, which often deceives the hasty observer; by firm pressure the bone can be usually felt in its natural position, at the bottom of this depres- sion, and the surrounding hard tissue may be observed to be really elevated above the normal level. A thrombus is sometimes mistaken for a solid tumor, and a haematoma for an abscess ; the diagnosis under these circum- stances must be made from the history of the case, from the absence of inflam- matory smptoms, etc. Though extravasated blood is usually absorbed, it occasionally becomes encysted, remaining fluid for an indefinite period and thus becoming a starting-point for the development of a tumor, or it may coagulate and remain as a clot, or after coagulation become again liquid (Baker, St. Bartholomew's Hosp. Reports, vol. ii. pp. 201-223); according to Paget and others, the blood extravasated in contusion may actually become organized, acquiring more or less the characters of connective tissue, but it more frequently acts as a foreign body, exciting inflammation around, and being eventually discharged with the products of the resulting suppuration. The prognosis of contusion, unless some vital organ be involved, is usually very favorable. Provided that the skin be uninjured, the severest laceration will commonly be recovered from without difficulty ; but if the atmosphere be admitted to the injured tissues by the smallest wound, or by secondary sloughing of the skin, the characters of a subcutaneous injury are lost, and wide destruction of parts may ensue. Contusions of bones and joints, and of nerves, are, as we shall see hereafter, often followed by secondary conse- quences of the gravest nature. The treatment of ordinary bruises is best conducted by the application of slightly stimulating embrocations, such as the soap liniment of the Pharma- copoeia, the tincture of arnica, or simply diluted alcohol. The absorption of extravasated blood may be assisted by gentle friction or kneading__a mode of treatment which the French have systematized under the name5 of massage. In severer cases, the part should be wrapped in some warm and soothing dressing, such as lint soaked in oil, with laudanum, or in lead-water and lauda° num, in order to keep up the natural temperature, and prevent, if possible, the occurrence of gangrene. All tight bandaging or firm pressure should be strictly avoided. If gangrene should occur, the question of amputation may arise, and should be decided on the principles laid down in Chapter X. WOUNDS. 139 If a thrombus form, the surgeon may endeavor to promote its absorption by moderate pressure and gentle friction; all rough handling should be avoided, lest suppuration be induced. In case of a collection of fiuid blood persisting in spite of treatment, a puncture may be made, and, after the escape of the blood, pressure employed, with a view of inducing the walls of the cavity to adhere; if this fail, or if suppuration occur, a free opening must be made, and the case treated as one of ordinary abscess. Strangulation of Parts__Somewhat analogous to the condition of a part which has been severely contused, is that of a part which has undergone strangulation, from the pressure of a tight bandage or other cause of constric- tion. Strangulation is often intentionally employed by the surgeon in the treatment of various affections, such as noevus, vascular tumors, hamiorrhoid*, etc. In such cases the strangulated part becomes mortified, and is removed by the formation of granulations in the line of constriction. The fingers oc- casionally become accidentally strangulated by being carelessly thrust into tight rings. The ring can generally be removed by soaking the finger in iced water, which causes the part to shrink, or by the use of a silk cord, tightly wrapped around the finger and slipped under the ring, which is then worked off in the process of unwrapping. If these expedients do not avail, a director should be insinuated under the ring, which must then be divided by a file or by cutting-pliers. The penis is sometimes strangulated, either by being in- troduced into a ring, or, as has occasionally happened in the case of children, by the nurse tying a tape around the organ to prevent the child from wetting its bed. Unless the constriction be promptly removed, the most serious con- sequences will probably ensue, sloughing of the part being almost inevitable, and even death having occasionally followed this accident. AVounds. A wound is a division or solution of continuity of the soft tissues, produced by violence; an open wound is one in wliich the division of the skin is as free or nearly so as that of the deeper tissues, while a subcutaneous wound is one in which the opening in the skin is comparatively very small. AVounds are further classified by surgeons, according to their nature and causes, into incised, lacerated, contused, punctured, and poisoned wounds. Gunshot wounds, and the peculiar form of injury known as brush-burn, are varieties of contused wounds. Incised Wounds.—As its name implies, an incised wound is one made by a clean cut with a knife, razor, or other sharp instrument. These wounds are constantly intentionally inflicted by the surgeon, in amputating limbs, removing tumors, cutting for stone, etc. They are also frequently produced by accident, from the careless use of penknives or razors, or, among farm- laborers, from that of scythes or axes ; many of the wounds produced by broken glass are incised, though these may also partake of the nature of lace- rated wounds ; the cut-throat of the suicide is an incised wound; the sabre- cuts met with in war, being inflicted with a heavy blow, approach to the nature of contused wounds. The pain of an incised wound varies according to the nature of the instrument with which it is inflicted, the part in which it is situated, and the manner in which it is produced. The sharper the knife, the less the suffering which.it causes ; wounds of the face or hands are more painful than those of the trunk; wounds made from within, less painful than those from without. The reason of these differences is very apparent: a clean cut with a sharp knife produces less dragging and tearing of sensitive parts 140 EFFECTS OF INJURIES IN GENERAL. than a haggling incision with a dull one; those parts which are most abun- dantly furnished with nerve filaments are most sensitive to pain, and by first dividing the trunks of nerves, their branches are paralyzed, and there will then be less suffering than under opposite circumstances; hence the advan- tage (before the days of anaesthesia) of the transfixion operation over other forms of amputation. It is well known that a wound rapidly inflicted is less painful than one more deliberately produced, and it has therefore been sug- gested by B. W7. Richardson, and by Andrews, of Chicago, to use a blade connected with a rapidly revolving wheel, and it has been claimed that in this way operative surgery might be rendered painless; it seems to me, however, that such a contrivance would in practice be unmanageable, not to speak of the erroneous principle involved in its conception, which would endeavor to substitute mechanical ingenuity for the immediate personal attention and responsibility of the operator. The amount of hemorrhage from an incised wound varies of course with the number and size of the vessels cut. AVounds of the face bleed more freely than those of the extremities, and wounds of the scalp are attended with very profuse hemorrhage, not only from the vascularity of the part, but because, on account of the denseness of the surrounding structures, there is not the same opportunity for contraction and retraction of the vessels, as in parts of looser texture. The existence of inflammation or other circumstances may cause the vessels of a part to be much enlarged ; hence an incision into in- flamed tissue will bleed more freely than one into normal structure. In some peculiar cases, in which what is called the hemorrhagic diathesis exists, the slightest wound—even that caused by lancing the gums of children—may cause fatal hemorrhage. Beside the pain and bleeding which attend an incised wound, there is always more or less retraction of its edges or lips, which constitutes the gaping of the wound. The amount of this retraction depends upon the nature of the tissue involved, its condition at the time when the wound is inflicted, and the direction of the wound itself. Tissues which are elastic or which contain muscular fibres retract more than fibrous tissues ; the following is given by Nelaton as the order in which the soft parts gape when wounded, viz., skin, elastic tissue, cellular tissue, arteries, muscles, fibrous tissues, nerves, carti- lages. A wound of a part in wliich there is much tension, from inflammation or from any other cause, will gape more than one in the same part under ordinary circumstances. Thus an incision into an erysipelatous limb, or over the female breast during the process of lactation, will gape more than if those parts were not in a state of tension. Again, the direction of a wound affects the degree of retraction of its lips ; an incision in the direction of the mus- cular fibres of a part will gape less than one which crosses that direction at right angles, and in general terms we may say that longitudinal wounds gape less than those which are transverse. Process of Healing in Incised Wounds___Incised wounds may heal in one of three ways, or, as more frequently happens, partly in one and partly in another of the three. The modes in which incised wounds heal are__1* by immediate union, or by the first intention; 2, by adhesion; and 3, by granu- lation, or by the second intention. Healing by scabbing, or incrustation, is a variety of the first or second methods, according to circumstances ; while the so-called secondary adhesion (third intention, or union of granulations'), is a mere modification of the third method—the union by granulation, or by the second intention. 1. Immediate Union, or Union by the First Intention (Hunter)___To understand the processes concerned in the healing of wounds, the reader must bear in mind what was said in the first chapter as to the nutritive and INCISED WOUNDS. 141 formative changes due to the inflammatory process. It is by means of these changes that the repair of wounds is in every instance effected. For a short time, varying from a few minutes to an hour or two, after the reception of a wound, it remains inactive ; its edges then become somewhat red, warm, swollen, and painful—it has, in fact, become the seat of the inflammatory process. Now, if the wound be a clean cut, if it contain no foreign body nor clotted blood, if its lips be in close and accurate approximation, and if the tissues concerned be homogeneous (that is, if skin be apposed to skin, cellular tissue to cellular tissue, etc.), under the most favorable circumstances of gene- ral health and hygienic surroundings, the inflammatory process may stop in its first stage, that of temporary hypertrophy. The parenchyma in both lips of the wound is distended with nutritive material, a few wandering cells per- haps pass across the line of incision, the apposed surfaces adhere together, and the wound is healed by immediate union, or the first intention, without the formation of lymph, and, of course, without any resulting scar. This mode of healing is very seldom met with, at least in this country. I believe that I have seen it in cases of very slight cuts of the fingers, inflicted by the sharp blade of a penknife, and once in the face, in at least a portion of a clean incised wound. Sir James Paget has seen this mode of union in a case of excision of the breast. The cases which we read of every day in the journals, of union by first intention after amputation, are, I believe, really instances of the second method by which wounds heal, that by adhesion. 2. Union by Adhesion___In the accomplishment of this process, the inflam- mation reaches its second stage, or that which is accompanied by the first formative change, viz., lymph production. This is what Paget calls union by adhesion (the name which I have adopted), or by adhesive inflammation —that distinguished surgeon and pathologist considering that the first mode of union is accomplished without any inflammation whatever; it is, however, I think, more consonant with the modern views of the inflammatory process, to look upon that process as necessary for the repair of wounds under all cir- cumstances, and to regard immediate union, as I have done, as effected by inflammation limited to its first stage, that of temporary hypertrophy without lymph production. For union by the mode which we are now considering, lymph is essential. AVhether this lymph be the result of cell proliferation, or whether it originate in the escape of white blood cells from the vessels, can- not at present be considered as determined; in its appearances, physical pro- perties, and other characters, it is identical with the inflammatory lymph described in Chapter I. To obtain union by adhesion, the patient must be in good condition, the wound healthy, and containing no foreign body or blood, its lips not bruised or otherwise injured, but accurately adjusted, and the cut surfaces strictly in apposition and excluded from the air. The inflam- mation must not pass beyond its second stage, or this form of union cannot be obtained. Perhaps the fairest examples of this mode of healing are to be seen in cases of plastic operation, as for harelip, lacerated perineum, etc. It is possible that in these cases immediate union may be sometimes obtained, but the presence of a slight scar after healing shows that, at least in the immense majority of cases, the union has been by adhesion or through the medium of lymph. Union by adhesion should always be aimed at in the treatment of stumps and of most operation wounds, and may be generally secured throughout the greater part of the incision. Scalp wounds, and wounds of the face and neck, commonly unite in this way, as do also, though more rarely, incised wounds of other parts of the body. Superficial wounds, when their edges are brought together, often unite without difficulty under a scab, formed by the hardening, over the line of incision, of effused blood and serum, intermingled with hair, dust, and other 142 EFFECTS OF INJURIES IN GENERAL. foreign particles; the healing under such circumstances maybe by immediate union, though it is more often by adhesion. In either case, this healing under a scab constitutes what has been called heeding by scabbing, by incrustation,^ or by subcrustaceous cicatrization. It is a mere variety of one or other of the methods already described. Some confusion is often created by the appli- cation of the phrase " union by the first intention," by modern writers, to that process which I have described under the name, proposed by Paget, of " union by adhesion." The latter name is, 1 think, more correct, and more expressive of the process which actually occurs in the ordinary primary union of wounds, and the term "first intention" should, I think, be reserved for those rare cases of immediate union without lymph, to which it was applied by the illustrious John Hunter, though that surgeon erroneously believed that the union in such cases depended on the organization of an interposed layer of effused blood. 3. Union by Granulation, or by the Second Intention—In this mode of healing, the inflammatory process reaches its third stage, that attended by the second formative change, or the production of pus. The cut surfaces become covered with granulations, precisely identical in structure and cha- racters to those met with in a healing ulcer (see page 47), and the free sur- face is bathed with pus. The granulations gradually fill up the gap, and, when they have reached the level of the surrounding skin, cicatrization occurs just as in the repair of ulceration, which has already been fully described. The union by secondary adhesion, or by the third intention, is identical with the mode of union now under consideration, except that the granulating sur- faces are so apposed that they unite and grow together, thus expediting the healing process. Union by granulation is that commonly met with in large wounds, such as those produced by amputation, or where, from excessive inflammation, from a large number of ligatures acting as foreign bodies, or from other causes, union by adhesion cannot be obtained. Treatment of Incised Wounds___The object of the surgeon, in the manage- ment of every incised wound, should be to obtain, if not immediate union, at least union by adhesion. The credit of establishing the rule which is now universal, at least in England and in this country, to attempt to get primary union whenever possible, is due, in great measure, to the teachings of the British surgeons of the last century, especially Sharp, Alanson, Hey, the Bells, and Hunter, although it is probable that such a course was occasionally pursued in much earlier times. Its advantages are obvious ; not only is the time occupied by the healing process much shorter when adhesion is obtained than when union occurs by granulation, and the resulting scar less conspicuous and disfiguring, but the patient is saved the exhausting consequences of pro- longed suppuration, and is, in a great measure, preserved from the risk of the secondary affections which often complicate wounds, such as erysipelas, vari- ous forms of blood poisoning, etc. In making the attempt to procure primary union, there are three principal indications presented to the surgeon ; these are (1) to arrest and prevent hemorrhage, (2) to remove all foreign sub- stances, and (3) by suitable dressings to adjust the cut surfaces closely and accurately, to prevent the access of atmospheric air, and to prevent the in- flammatory process from passing beyond its second stage, or that of lymph formation. (1.) If the hemorrhage be of the nature of general oozing from small ves- sels, it may be commonly controlled by position, or by the use of cold, of pressure, or of various styptics, as will be described in another chapter ; if the bleeding be from larger vessels, these must be treated by ligature, by acupres- sure, or by torsion, the comparative merits of which plans will be fully dis- cussed when we come to speak of wounds of arteries. INCISED WOUNDS. 143 (2.) Hemorrhage having ceased, the surgeon must carefully but gently cleanse the wound, so as to remove all foreign substances which may have lodged between its lips. This may be conveniently done by means of a stream of running water (as supplied by the " ward carriage," Fig. 10) ; or if sponges be used, they should be new and soft, and very gently handled. As Sir James Paget well puts it, '' AVounds should not be scrubbed, even with sponges." Air. Callender employs camel's-hair brushes. To determine the freedom of a wound from foreign bodies, the surgeon may put in service his hands as well as his eyes, it being sometimes possible to detect with the finger a grain of sand or spicula of bone, which, embedded in muscle and tinged with blood, might escape ocular observation. (3.) Dressing of Incised Wounds___As a rule, wounds should not be dressed until all oozing has ceased. A great deal used to be said about the glazing of a wound, and it was supposed that this glazing consisted in the exudation from the bloodvessels of a fibrinous material (lymph), which formed the bond of union. But, whatever be the origin of this lymph (a question of purely theoretical interest), there is no reason to suppose that it is formed more readily, or of abetter quality, before than after the closing of a wound ; hence, as soon as hemorrhage has ceased, the sooner the lips of the wound are ap- proximated the better. In closing wounds, the surgeon makes use of sutures, plasters, and bandages. The various materials employed for sutures have been already described in previous chapters, and it will be sufficient to say here, that, for ordinary purposes, lead or malleable iron wire is the most suit- able and convenient. The needles used by surgeons Fig- 67. are of various sizes and shapes, as shown in Fig. 38; it is occasionally ad- vantageous to have a strong needle mounted in a handle (Fig. G7), and with an eye at its point, like the '• naavus needle," for use in situa- tions difficult of access, or when the tissues to be penetrated are unusually dense. A'arious needles have been devised for spe- cial use with wire, but present no particular advantages over those generally employed. The various forms of suture commonly used by the surgeon may be enumerated as the interrupted suture, the continued or glover's suture, the twisted or harelip suture, and the quilled suture. The interrupted suture (Fig. 68), which is that most frequently used, consists, as its name implies, in a number of single stitches, each of which is entirely independent of those on either side. In applying it, the surgeon holds one lip of the wound with the fingers of the left hand, or with forceps, and introduces, with a quick thrust, the needle previously threaded, about two lines from the cut edge ; he then takes the opposite lip in the same way, and '----------; ■ -j------ passes the needle, in this case from within ^NNt outwards, taking care that there shall be no | J i undue tension or uneven dragging of the wound. ^ I Some surgeons employ two needles, passing The interrupted suture. Mounted needle, armed with a ligature. 144 EFFECTS OF INJURIES IN GENERAL. both from within outwards ; but this causes unnecessary delay, and offers no advantage over the common mode. Each stitch may be secured as it is introduced, or all may be passed, their ends being left loose to be fastened subsequently. If silk be employed, it is tied in a reef-knot ; if wire, it is simply twisted. If the mounted needle (Fig. 67) be employed, it must be thrust through both lips of the wound before being threaded (the suture being thus passed as it is withdrawn), and must, therefore, be re-threaded for each stitch. The distance between the points of the interrupted suture, and "the depth to which each stitch is passed, vary with the nature and extent of the wound; as a rule, the skin and superficial fascia only should be included in the stitches, and there should be an interval of from half an inch to an inch between the consecutive points of introduction. The continued or glover's suture (Fig. 69) is principally used for wounds of the intestines, though it is occasionally employed in other situations where the tissues are of loose structure, as in the eyelids. It is made with silk or with a fine thread, which passes across the wound continually in the same direction ; it is the stitch employed in the manufacture of gloves, whence it derives its name. The twisted or harelip suture (Fig. 70) is an excellent method of uniting wounds where great accuracy and firmness are desirable. It consists of metallic pins or needles, thrust through both lips of the wound, the edges being kept in contact over the pin by figure of 8 turns with silk thread or Fig. 69. Fig. 70. Fig. 71. The continued, or glover's suture. The twisted suture. India-rubber suture. with wire, according to the fancy of the surgeon. For the figure of 8 turns may be substituted delicate rings of India-rubber, constituting the " India- rubber suture" of M. Rigal (Fig. 71), which has been used in this city by Dr. A\. L. Atlee, in the dressing of cases after the operation of ovariotomy. The twisted or harelip suture, as its name implies, is principally used after the operation for harelip. The pins should be of steel, which may be . may have entered the wound. The finger constitutes the best L_7 probe for all parts within its reach, but for exploration of the If deeper portions of the wound, various bullet-probes may be em- | ployed. Nelaton's probe differs from the ordinary form of the V instrument, in being capped with unglazed porcelain, wliich, by receiving a metallic streak, surely indicates the presence of a leaden ball, if the latter come in contact with it.1 It was by means of this probe that the eminent French surgeon, whose name it bears, was enabled to demonstrate the presence of a ball in the wound of the celebrated Italian General, Garibaldi. Longmore speaks favorably of Lecomte's " stylet-pince," or "probe-nippers," by which the surgeon can withdraw a minute portion of the foreign body for examination. Culbertson, of Ohio, has devised a meerschaum probe which serves the purpose of Nelaton's instrument, and is besides provided with a roughened surface to catch and withdraw filaments of clothing, etc., which may be in the wound. Electric probes, containing two insulated wires, have been devised by Favre, of Marseilles, and others, for the detection of balls, the effect of the metallic contact being to Fig. 76. probe. Bullet-forceps. complete the circuit, and thus indicate the nature of the foreign body. An older instrument is the drum or reverberating probe of L'Estrange, an Irish 1 Dr. Highaway, of Cincinnati, is said to have employed for this purpose durin°- the Mexican war, the stem of a clay tobacco pipe. ' TREATMENT OF GUNSHOT WOUNDS. 163 surgeon, which is provided with a small sounding-board to indicate to the ear the nature of the body struck. Deneux suggests the use of a probe carrying a mass of charpie dipped in dilute acetic acid; by contact with the ball the acetate of lead is formed, and the presence of the metal may then be demonstrated by means of suitable reagents. Uhler, of Maryland, injects nitric acid, and then tests the injected fluid for lead and iron respectively. If the course of the ball be very circuitous, advantage may be derived from the use of flexible probes, such as those of Sayre, Steel, Sarazin, and other surgeons. For the extraction of balls, forceps of various kinds may be employed, or if the ball be imbedded in bone, it may sometimes be removed by the tire fond, or screw extractor (Fig. 77); while if superficial, it may often be readily turned out with a scoop, or with the extremity of an ordinary Fig. 77. Screw extractor. grooved director. In other cases, again, a ball is most conveniently reached by means of a counter-opening. Beside the information afforded by the finger or probe as to the presence and position of foreign bodies, the surgeon can thus obtain valuable knowledge as to the condition of the wound itself, and, in case the bone have been injured, as to the extent of its comminution. The splinters of bone produced by gun shot injuries were classified by Dupuytren into primary, secondary, and tertiary splinters or sequestra. The primary are such as are entirely detached, and should be immediately extracted, as they will otherwise produce irritation, acting as foreign bodies ; the secondary sequestra are partially detached, and if very loose should be removed, but if pretty firm may be pushed back into place ; the tertiary should always be preserved, as their vitality is not much impaired, and they serve a most useful purpose in assisting recovery by strengthening the new-formed callus. Dressing___The wound being freed from all foreign bodies, loose splinters, etc., the surgeon proceeds to dress it. It was formerly the almost universal custom to enlarge gunshot wounds with the knife, and this practice, under the name of debridement, is still pursued by many European surgeons. It is doubtless useful in some cases, when there is much swelling, especially in the suppurative stage, to make more or less free incisions to relieve excessive ten- sion, just as would be done in the case of any other wound, in which the original opening did not give sufficient vent; but in the immense majority of cases of gunshot injury this treatment is not at all necessary. Gunshot wounds are to be treated on the ordinary principles which guide the surgeon in the management of other injuries, and require no special or exclusive dressing. Cold water was most extensively employed during our late war, and as a primary application answers very well; if too long con- tinued, however, it produces a depressing influence on the part, the granula- tions becoming pale and flabby, and showing an indisposition to heal. In civil practice I have found the best primary dressing to be laudanum, pure or diluted, as with other contused and lacerated wounds ; changing it for poultices or warm fomentations when the sloughs begin to separate, and again using more stimulating dressings, such as lime-water, etc., when the process of 164 GUNSHOT WOUNDS. granulation is fairly established. During the period of separation of the sloughs, if, from the position of the wound, there is reason to fear the occur- rence of secondary hemorrhage, it is well to apply a tourniquet loosely around the limb above the seat of injury, and to instruct an attendant in its use, that it may be screwed up on the first onset of bleeding. By the employment of this provisional tourniquet, as it is called, many lives may be saved that would otherwise inevitably be lost. Amputation and Excision in Gunshot Injuries.—Amputation may be rendered necessary in cases of gunshot injury by various circum- stances ; thus, if part of a limb be entirely carried away by a round shot, or by a fragment of a shell, there is nothing for the surgeon to do but to improve the form of the stump thus made, and endeavor to promote its healing. Many cases of gunshot fracture require amputation, either from extent of lesion of the bone itself, or from the concomitant injury to the soft parts. Especially do wounds of the main arteries and nerves of a limb, in conjunction with fracture, demand amputation. Even if the bone itself be not injured, it may be so extensively denuded that removal of the limb becomes the sur- geon's only resource. AYhen it is evident that, from the severity of the injury, amputation will be required, it should, in accordance with the principles enunciated in Chapter V., be performed as soon as possible after the occur- rence of reaction. It may, however, even in cases which at first promise well, be required, as will be seen hereafter, as a secondary operation, on account of the occurrence of hemorrhage, of acute suppurative osteo-myelitis, or of extensive necrosis. The introduction of Excision of Bones and Joints as a substitute for am- putation in military practice, is comparatively an affair of modern times ; the operation has, however, been so successful, at least in the upper extremity, that it may now be said that in most cases of injury of this part of the body, excision should be the surgeon's first thought, and should be preferred to amputation whenever the destruction of parts does not manifestly render the latter operation imperative. Shoulder___Gunshot fractures involving the shoulder-joint very often require excision. The statistics of the operation during our late war, as recorded by Dr. Otis, give a total of 1086 cases. The results are known in all but 135. The mortality was 31 per cent, for primary, 46 per cent, for intermediate, and 29.3 per cent, for secondary cases. This proportion is less favorable than that of shoulder-joint amputation, of which the mortality during our war was, according to the same authority, 29.1 per cent. Expectant treatment (re- served of course for selected cases) gave a death-rate of only 27.5 per cent. Culbertson's tables embrace 855 cases of excision, with 267 deaths, a mor- tality of 31.23 per cent. In spite of its slightly greater fatality, excision should, I think, be preferred to amputation in any case admitting of a choice between the two operations. Even if the humerus be split for a considerable distance downwards through its shaft, excision may still be practised, not a few instances having occurred during our war, in which very large portions of the humerus were removed by excision, a useful hand and forearm being thus preserved. Elbow—Excision of the elbow was frequently performed during our war, 764 cases being noted in Dr. Otis's Surgical History. In 716 of these cases, in which the results are known, there were 165 deaths, a mortality of 23 per cent. The death-rate, according to these figures, would appear to be slightly less than that of amputation of the lower third of the arm, 25.9 per cent., and hence excision should be preferred in all suitable cases. The secondary were more successful than the primary excisions, while the intermediate operations AMPUTATION AND EXCISION IN GUNSHOT WOUNDS. 165 were much the most fatal. According to Dominik, secondary excisions are also the most favorable as regards the utility of the limb. The same writer considers partial more successful than total excision of the elbow, and his view is adopted by Hueter, Langenbeck, and Gurlt; but the experience of our war, as given by Dr. Otis, is decidedly in favor of the more sweeping operation. Culbertson's tables give 598 cases of elbow excision with 113 deaths, a mortality of 19 per cent. Wrist.—Excision of the wrist-joint has not been much practised in military surgery ; the results of such operations as are recorded have been sufficiently satisfactory as regards life, but rather unsatisfactory as regards the utility of the preserved limb. Dr. Otis records 90 cases, of which 15, or 16.67 per cent, terminated fatally. Culbertson gives 70 cases with only 10 deaths. Hip.—Gunshot injuries of the hip-joint are universally regarded as among the gravest injuries met with in military practice. The comparative advan- tages of excision, amputation, and expectant treatment in those cases, have been fully and ably investigated by Dr. Otis, U. S. A., in Circular No. 2, S. G. O., 1869, and the statistics which bear upon the question are exhibited in the following tables :— Excisions. Cases. Died. Recovered. Death-rate. 39 33 13 36 30 11 3 3 2 92.3 90.9 84.6 Aggregate.................. 85' 77 8 90.6 Amputations. Cases. Died. Recovered. Doubtful. Death-rate. 79 76 20 8 75 70 13 4 1 6 7 4 3 98.68 92.10 65.00 50.00 183 162 18 3 90.002 Culbertson's statistics show very much the same mortality, 121 cases having given 106 deaths, or 89.07 per cent. The mortality in cases treated during our war by expectancy was 93 per cent., or, including cases in wliich the acetabulum was involved, 96 per cent. During the late Franco-Prussian war, as reported by Richter, 33 cases of wound of the hip, treated by expectancy, furnished 31 deaths, and 21 treated by excision 18 deaths, while 11 hip-joint amputations all terminated fatally. From these facts the conclusion is fairly drawn that, in any case of gunshot injury of the hip-joint, primary excision should be preferred to any other mode of treatment, and this simply to increase the chance of life, without reference to the utility of the preserved limb. Of course there may be such extensive destruction of parts as to put excision out of the question, and in 1 One (fatal) case should be omitted, as not strictly an excision, lessen the death-rate. 2 Doubtful cases omitted in computing percentages. which would 166 GUNSHOT WOUNDS. such cases the surgeon must still have recourse to what Ilennen called the "tremendous alternative" of hip-joint amputation, an operation which may also be required secondarily, after an unsuccessful attempt to save the limb. The accompanying illustration (Fig. 78), from a photograph, shows the con- dition of the bone in a case in which I performed (unsuccessfully) secondary amputation at the hip-joint, for gunshot fracture of the head and neck of the femur. The specimen is now in the museum of the Episcopal Hospital. Knee___" AVounds of the knee-joint," says Guthrie, " from musket-balls, with fracture of the bones composing it, require immediate amputation." Unfortunately, this rule still holds good. The statistics of excision of the knee- joint, for gunshot injury, have been particularly investi- gated by Cousin, Chenu, Lotzbeck, Klister, and Culbert- son. Cousin finds that 33 cases of total excision have given 5 recoveries and 28 deaths (85 per cent.), while 11 cases of partial excision have given but one recovery and 10 deaths (91 per cent.). Of the whole 44 cases, 38 proved fatal, a mortality of over 86 per cent. Chenu's figures derived from the records of the Franco-Prussian war, show a still larger death-rate, 37 complete excisions having given 33 deaths (89 per cent.), and 65 partial excisions 62 deaths (95 per cent.), or the whole 102 cases 95 deaths, a mortality of over 93 per cent. Lotzbeck's and Kiister's statistics, though somewhat more favorable, are still suf- ficiently gloomy, 66 cases collected by the former writer giving 48 deaths (nearly 73 per cent.), and 101 cases col- lected by the latter giving 66 deaths, a mortality of over 65 per cent. Culbertson gives 44 complete excisions with 33 deaths, and 16 partial excisions with 12 deaths, a mor- tality for either category of 75 per cent. Two successful cases have been recently reported by Mensel, of Gotha, and Niissbaum, of Munich. AYhen we compare the above figures with the death-rate of amputation in the lower third of the thigh (~>5 per cent, according to Legouest, 50 per cent, according to Maeleod), the conclusion is surely irresistible that excision of this joint should be banished from the practice of military surgery, and that the rule should still be re- garded as imperative, that every gunshot fracture of the knee-joint is a case for amputation, iff. fJ»~^ ^C^--.^ v-«^-^t" x4^*r&T J• «-*.—. Ankle—Fifty cases of complete excision of the ankle are reported by Grossheim as having occurred during the late Franco-Prussian war ; of these, 26 terminated in recovery, and 20 in death, the result in 4 cases not having been ascertained; partial excisions (including operations upon the tarsal bones) were more successful, 47 cases having given 33 recoveries and only 14 deaths. Forty-five cases tabulated by Culbertson gave 33 recoveries and 12 deaths. Gunshot Fractures of Shafts of Long Bones very commonly require ampu- tation. The preservation of a limb which is the seat of such an injury can less often be effected now than formerly, on account of the greater severity of the bone lesions produced by the use of the conoidal bullet and of the modern improved forms of firearm. The results of excision in such cases, during our war, are shown in the following table taken from Circular No. 6, S. G. O., 1865, and the second volume of Dr. Otis's Surgical History:__ Gunshot fracture of hip. AMPUTATION AND EXCISION IN GUNSHOT WOUNDS. 167 Excisions in contiuuity. Died. Recovered. Undeter-mined. Total. Mortality, per cent. Humerus.............. 191 109 10 32 27 5 4771 856 104 6 112 26 28 21 2 24 37 2 696 986 116 62 1852 33 28.5 Femur................. 11.2 9.6 84.2 Bones of leg............ 19.4 16.1 Fiff. 79. Comparing these figures, when the number of cases is sufficiently large to justify their being used for statistical purposes, with the results of amputa- tions of the same parts, as given in previous chapters, we may conclude that—(1) excision in the continuity of the bones of the forearm is permissible in favorable cases; (2) excision in the continuity of the humerus is more fatal than amputation of the corresponding parts, and is so often followed by non-union as to be in most cases an undesirable operation; (3) excision in the continuity of the femur is a bad operation, and should be definitively rejected from military practice; (4) excision in the continuity of the bones of the leg is less fatal than amputation, and might, therefore, be resorted to in selected cases, though the number of undetermined results at the date of issue of Circular No. 6 was still so large that this conclusion may very probably be ultimately re- versed ; (5) excision in the hand or foot is not an operation to be re- commended. Judging from my individual ex- perience, which is, of course, limit- ed, I should say that, except in the case of the radius or ulna separately, and perhaps of the fibula, excision in the continuity of the long bones is an undesirable operation. Those cases of resection of the shaft of the humerus or tibia, which I have ob- served, have either required subse- quent amputation, or have preserved limbs of very questionable utility: the case is very different from one of necrosis or ununited fracture, and, I believe, there is as yet no instance on record, of useful repro- duction of bone, in a case of excision in continuity, for gunshot or other traumatic injury. In the case of the separate bones of the forearm, however, most ex- cellent results may be obtained by excision. I have myself twice excised considerable portions of the radius, in cases of gunshot fracture, one being a primary (Fig. 79), and the other a secondary operation; both patients made good recoveries. ' In 164 cases bony union did not occur. 2 Subsequent amputation in nine cases. Result of partial excision of radius for gunshot injury. (From a patient in the Episcopal Hos- pilal.) 168 GUNSHOT WOUNDS. Of 7888 completed cases of gunshot fracture of the humerus, recorded in Dr. Otis's Surgical History of the AYar, amputation or excision was prac- tised in 4928, and conservative treatment was adopted in 2960, with a ratio of mortality of 24.1 per cent, in the former, and 15.2 per cent, in the latter category. These statistics show that in the upper extremity, at least, gun- shot fracture may very often, though in a numerical minority of cases, be recovered from without operation. In the lower extremity, the case is some- what different. The mortality of gunshot fracture of the upper third of the thigh is, indeed, less when treated by expectancy than after amputation, which, in this situation, is an extremely fatal operation ; in the middle of the thigh, the mortality is about the same under either mode of treatment; but in the lower third, or in gunshot injury of the knee-joint, amputation gives much the best results. These points will appear from the following table, condensed from one in Circular No. 6 :— Mortality per cent. Statistics of Gunshot Fractures. ,-----------"-----------, Amputation. Expectation. Upper third of femur.....75.00 71.81 Middle " " " .....54.83 55.46 Lower " " " .....46.09 57.79 Wound of knee-joint, with or without fracture . 73.23 83.76 In gunshot fracture of the leg, if the splintering of the bones be not very great, and if the vessels and nerves have escaped injury, an attempt may be made to preserve the limb, the mortality, according to Circular No. 6, being but 24 per cent, under all modes of treatment. Remote Consequences of Gunshot Injury—There are certain indirect or remote consequences of gunshot wounds which may demand the attention of the surgeon. These are principally manifested in the bones, the vessels, and the nerves. Bones___The vitality of a bone may be seriously impaired by a gunshot wound, which, at first, is supposed to have inflicted no injury upon it. The subjects of contusion and of contused wounds of bone, have been ably inves- tigated by Dr. John A. Lidell, formerly surgeon in the U. S. Volunteer Corps, who has published his views in an elaborate paper in the American Journal of the Medical Sciences for July, 1865. Dr. Lidell has traced seven distinct conditions, which may result from contusion of bone, and each of which is fraught with more or less danger to the patient; these are: 1. Ecchy- mosis of the osseous tissue ; 2. Ecchymosis of the medullary tissue ; 3. Simple osteo-myelitis (attended with production of new bone, both from the perios- teum and from the medulla) ; 4. Necrotic osteitis, or an inflammation of bone so severe in character as to terminate in necrosis; 5. Suppurative osteo- myelitis ; 6. Gangrenous or septic osteo-myelitis (both this and the last- named condition are almost certain to terminate fatally) ; and 7. Necrosis produced directly by the contusion of bone, without the intervention of either ecchymosis or inflammatory irritation. If the bone wliich is contused, be in the neighborhood of an articulation, the latter may undergo serious or fatal disorganization ; or if an important organ, as the brain, be adjacent, secondary visceral disease may ensue. Vessels—Traumatic aneurism of the circumscribed variety, occasionally, though rarely, follows a gunshot injury : the diffused traumatic aneurism is a more frequent result of these wounds, and constitutes a most serious affec- tion. I have seen one case of arterio-venous wound, resulting in aneurismal varix, produced by a musket-ball passing directly between the femoral artery and vein. INJURIES OF VEINS. 169 Nerves___Very curious nervous affections are occasionally observed as con- sequences of gunshot wounds. These affections may consist of paralysis of either motion or sensation, or both, of hyperesthesia, of choreic movements, etc. This subject has been particularly investigated by Drs. Mitchell, More- house, and Keen, of this city, whose labors in this department will be again referred to in a subsequent chapter.1 Encysted Balls___Balls sometimes become encysted, that is, surrounded by a layer of dense cellular tissue, within which they may remain without producing any irritation, for a very long period. There are well-attested cases on record, in which encysted balls have remained harmlessly in the tissues for forty or even fifty years; in other cases, again, after a variable interval, they excite inflammation by acting as foreign bodies, and may pro- duce serious or even fatal consequences. Especially when lodged in the lung or pleural cavity is this apt to be the case, so that it is given as a rule by many authorities, that any gunshot wound of the thoracic cavity, in which the ball remains lodged, will sooner or later cause death. CHAPTER IX. INJURIES OF BLOODVESSELS. Injuries of ArEixs. Subcutaneous Rupture of Veins occasionally occurs as a conse- quence of external violence, and is manifested by the extravasation of a large quantity of blood, which is, however, usually absorbed again in the course of a few days ; or the blood may coagulate, the clot subsequently exciting sup- puration, or possibly becoming organized, as pointed out in Chapter VII. More rarely, the blood may become encysted in a fluid state, constituting what is sometimes called a venous aneurism. Open Wounds of Veins are not unfrequently met with in civil prac- tice, and occasionally give rise to most serious consequences. Hemorrhage from a Wounded Vein is marked by the even and rapid flow, and the dark'2 color of the effused blood. In certain situations, as at the root of the neck, or under peculiar circumstances, as when veins are affected by varicose disease, the hemorrhage may be so profuse as to endanger life AYounds of the internal jugular vein are indeed extremely fata acci- dents, eighty-five cases collected by Dr. S. AY. Gross having been followed by deWin no less than thirty-seven instances. Hemorrhage from super- ficial veins can usually be readily controlled by pressure, or even by position Thus the most profuse bleeding, from rupture of a vein in a varicose ulcer of the leg, may often be checked, simply by elevating the limb. The large ' See also remarkable cases reported by Dr. J H. Brinton Urn. Journ. of Med. deuces Oct 1870 p. 435), and by Dr. B. Rhett {Ibid., Jan. 18/3, p. 90). Dr H A Potted of Geneva, N. Y., has observed in eight cases of spinal injury, that the biood drawn from a vein is of arterial hue ; this observation lias, however, not been confirmed by others. 170 INJURIES OF BLOODVESSELS. superficial veins on the back of the hand are often wounded by accidents from broken glass ; in such cases I have found it a good plan to transfix both ends of the bleeding vessid with a metallic suture, thus arresting the hemorrhage and closing the wound at one and the same time. In any case in which pressure cannot conveniently be applied, the surgeon should not hesitate to use a ligature. There was formerly a great prejudice against the practice of tying veins, from the supposition that it was liable to induce pyamiia, but now that modern researches have shown that there is no necessary connection between that process and inflammation of the veins or phlebitis, the theo- retical grounds for opposition are removed, and it is established by clinical observation that the risks of tying veins are much less than was formerly believed. The lateral ligature, which was first practised by Mr. Travers in a case of wound of the femoral vein, consists in pinching up the bleeding orifice, and throwing around it a delicate ligature, so as not to obliterate the calibre of the vessel; this plan, which has theoretical merits, is found in prac- tice to be very apt to be followed by secondary hemorrhage, so that it is now generally abandoned, the vein being tied as an artery, above and below the bleeding point. The process by wliich nature arrests bleeding from a vein is essentially that which will be presently described in speaking of wounded arteries, a clot forming in the vessel, and the cut edges subsequently uniting through the development of local inflammatory changes. After ligation, which corrugates but does not divide the coats of the veins, a clot forms on the distal side of the ligature, which gradually cuts its way through, as in the case of an artery, though in a shorter time in proportion to the size of the vessel. Phlebitis may follow a wound of a vein, and was formerly supposed to be the cause of pyaemia, which occasionally occurs and proves fatal after such an injury : this subject will be fully discussed in another part of the volume. Entrance of Air into Veins__The most frightful and fatal conse- quence of venous wounds, though fortunately one which is rare, is the entrance of atmospheric air, and its transfer to the heart. This accident is principally met with in cases of wound of the internal jugular, or of the other large veins situated at the root of the neck, or in the axilla, and this part of the body is accordingly often spoken of by surgeons as the " dangerous re- gion." It has, however, occurred in other parts of the body; thus, in a case of the late Prof. Mott's, serious though not fatal symptoms followed the en- trance of air into the facial vein where it crosses the lower jaw, while this accident occurring in the femoral vein is supposed to have been the cause of death in a case of thigh amputation during the Crimean war.1 The mode in which air is pumped into the veins is easily understood : during the act of inspiration, a vacuum is created in the thorax, to supply which air rushes through the trachea or through any other opening into the interior of the chest; thus, in the ease of wounds of the pleura, air is sucked in during in- spiration, to such an extent as often to induce collapse of the lung and pneumo- thorax, and in the same way, if a large vein in the neighborhood of the thorax be wounded, and be prevented from collapsing by the natural connec- tions of the part, by the position of the patient, or by a structural change in the vessel itself (to which the Erench give the name of canalization), the act of inspiration will mechanically and necessarily pump air into the open vein, 1 It is probable, also, that the entrance of air into the uterine veins is an occa- sional cause of sudden death after delivery, and after various operations upon the womb. (See an able paper by Dr. Greene, of Dorchester, in Amer. Journ. of Med. Sciences for Jan. 1864, pp. 38-65.) ENTRANCE OF AIR INTO VEINS. 171 precisely as it does through any other aperture into the chest. The local signs of entrance of air into a vein, consist in a peculiar sound, variously described as of a hissing, gurgling, sucking, or lapping character, and in the appearance of frothy bubbles in the wound. The constitutional symptoms are equally well marked. The patient cries out, impressed with a sense of certain and rapidly impending death, and falls almost instantly into a semi- collapsed state, moaning and perhaps struggling; the pulse is almost imper- ceptible, the action of the heart tumultuous but feeble, and the respiration difficult and oppressed. Death may occur immediately, but more commonly after an interval varying from a few minutes to an hour or more; or, if the quantity of air introduced be but small, recovery may gradually ensue, partial paralysis sometimes continuing for several hours or even a much longer time subsequent to the accident. The cause of death in these cases is somewhat obscure; Air. Erichsen be- lieves it to be the frothy condition of the blood, produced by the action of the heart, which prevents the due transfer of the circulating fluid through the pulmonary tissue, and thus secondarily causes a deficient supply of blood to the brain and nerve centres, inducing death by syncope. Sir Charles Bell believed that death was caused by the direct transference of air to the base of the brain, and, in confirmation of this view, Prof. Gross's observation may be referred to, viz., that animals may be rapidly killed by the injection of air into the carotid artery. Dr. Cormack attributed the fatal result directly to paralysis of the right side of the heart from gaseous distension, while Air. Moore maintained that death was due to the entrance of air to the heart, impeding the action of the cardiac valves and thus stopping the circulation, a view which has recently received experimental confirmation from AI. Couty. Other experiments also, by Kowalewsky and AYyssotsky, sIioav that frothy blood accumulates in the right side of the heart, mechanically hindering the normal circulation, and thus causing death by anaemia of the aortic system. Treatment___As a preventive measure, the surgeon should exercise extreme caution in all operations about the root of the neck, or deep in the axilla, using as much as possible the handle instead of the blade of his knife. It might also be desirable to have the large veins compressed by an assistant, or protected by serre-fines, between the seat of the operation and the heart, and care should be taken not to place the veins in such a position as will prevent them from collapsing if wounded, whether by stretching the patient's head to the opposite side, by hastily elevating the shoulder, or by incautiously lifting a tumor from its bed. Air. Erichsen recommends that the patient's chest should be swathed by a firm and broad bandage, as a precautionary measure, so as to limit as far as possible the depth of the inspirations. Should a large vein in the " dangerous region" be wounded during an operation, or should the surgeon find such a wound in a case of cut-throat, etc., measures should instantly be taken to prevent the entrance of air, by the application of liga- tures above and below the aperture. AYhen this alarming accident has actually occurred, the first indication for treatment is obviously to prevent any further ingress of air, by making instant compression and then quickly apply- ing a ligature. The subsequent treatment must consist chiefly in endeavoring to keep up the action of the heart by appropriate means. Of these, the most promising appear to me to be artificial respiration and the administration of stimulants. The patient should be in the recumbent position, and the ex- tremities elevated so as to retain as much blood as possible in the central organs; to accomplish the same purpose, Mercier advised the application of tourniquets and compression of the abdominal aorta. Artificial respiration may be practised with suitable bellows, or simply by the surgeon's mouth. Sylvester's or Hall's method would scarcely be applicable in these cases, on 172 INJURIES OF BLOODVESSELS. account of the situation of the wound. The administration of oxygen gas by inhalation is recommended by AValsham and Couty, the latter of whom also advises venesection. Various other plans have been suggested, among which may be mentioned—(1) an attempt to suck out the air by means of a canula introduced into the wounded vein, into the right jugular vein, or even into the heart itself; (2) bleeding from the right jugular vein or from the tem- \'JL poral artery; (3) i tracheotomy); and (4) the injection of warm water into the heart. I am not aware, however, that there are any cases on record which prove the efficiency of any of these methods. Galvanism might rationally be applied to the cardiac region, though I should be disposed to trust more to the use of stimulants and to artificial respiration. Remote Consequences of Injuries of Veins__A clot may form in a vein as the result of injury (thrombosis), and may subsequently undergo disintegration, the fragments being carried to the right side of the heart and thence to the lungs, plugging the minute pulmonary arteries (embolism), and thus giving rise to the formation of what are commonly but incorrectly called metastatic abscesses. This condition, which is in no degree necessarily con- nected with phlebitis, will be again referred to in the chapter on pyaemia. On the other hand, a clot in a vein may undergo a process of gradual contraction, induration, and decolorization, becoming finally calcified, and constituting what is called a phlebolite, or vein-stone. These phlebolites, however, usually result from clots due to stagnation, without external vio- lence, and are consequently chiefly met with in the veins of the pelvis, genital organs, and lower extremities. Injuries of Arteries. Contusion of an Artery may exist, without giving at first any evi- dence of its occurrence. The secondary results of arterial contusion depend upon the severity of the injury; if this have been very great, a portion of the wall of the vessel may slough, and cause secondary hemorrhage or extra- vasation ; if the violence have been less, the vessel may undergo obliteration, or in very slight cases may recover without evil consequences. The oblitera- tion of an artery, occurring some hours or days after the reception of an injury, is usually attributed to the effect of inflammation ; I believe, however, that it is more commonly due to the plugging of the vessel, either by embol- ism (fragments of clot being carried from another part of the circulation), or more rarely to an actual thrombosis in situ, clotting taking place in the in- jured vessel itself. As a result of this obliteration, or infarctus as it is called by French writers, gangrene or serious visceral degeneration may occur, ac- cording to the size and situation of the vessel. Thus, in two cases of injury in the lumbar region, Dr. Moxon found complete thrombosis of the renal arteries, with corresponding incipient degeneration of the kidneys. Rupture or Laceration of an Artery may be either partial or complete ; partial laceration generally occurs without external wound, and involves the two inner coats of the artery, the elasticity of the outer coat pre- serving it from injury. This accident may form the starting-point for the development of an aneurism at a subsequent period ; or the torn inner coats of the vessel curling upon themselves may furnish a nidus for the occurrence of coagulation, which, as in the case of contusion, may cause gangrene of the part below the seat of injury ; or, again, the lacerated inner coats may turn downwards, and by their mechanical valvular action produce gangrene, by directly interfering with the circulation. Finally, a partial laceration may, WOUNDS OF ARTERIES. 173 after a longer or shorter interval, become complete, when death from internal hemorrhage may follow, as in a case of rupture of the external iliac artery ob- served by myself at the Episcopal Hospital. Complete rupture of an artery may occur subcutaneously, or in an open wound. In the latter case, the nature of the accident may be obvious from the profuse arterial bleeding, though in other instances, if the coats of the vessel are twisted upon themselves, there may Fie. 80. Rupture of External Iliac Artery. (From a specimen in the Museum of the Episcopal Hospital.) A. Common iliac artery. B. External iliac artery. C Internal iliac artery. D. Position of rupture. E. Clot overlying common trunk. F. Clot protruding from distal end of external iliac artery. be scarcely any hemorrhage, the artery, perhaps, hanging out of the wound and pulsating and yet no blood escaping. AYhen an artery is torn across subcuta- neously "there may be wide-spread extravasation, or the development of one or other form of traumatic aneurism, according to the size and position of the vessel. Wounds of Arteries___Non-penetrating wounds of arteries occasion- ally but very rarely, occur. In these, the external coat is divided, with, perhaps, a portion of the middle coat. There is no primary hemorrhage in these cases but the inner coat almost invariably yields after a few days, when fatal bleeding may ensue. Hence, a partially divided artery should always be ligated, as°a precautionary measure. Penetrating wounds of arteries, if very small (consisting of a mere punc- ture with a fine needle), may not be productive of evil consequences ; but it the puncture be larger, as with a tenaculum, secondary if not primary hemor- rhage will almost certainly follow. Incised wounds of arteries bleed more or lessCfreely according to the size and direction of the wound; thus, a longi- tudinal wound will, in consequence of the anatomical arrangement of the arterial coats, gape less, and consequently bleed less than one which has an oblique direction, while a transverse wound will bleed more than either. An 174 INJURIES OF BLOODVESSELS. artery which is completely cut across bleeds less, other things being equal, than one which is only partially divided; for the complete section of the ves- sel allows partial retraction and contraction to occur, and thus measurably lessens the size of the stream. A wound of an artery at the bottom of a nar- row and tortuous passage through muscular or other tissue, approaches to the nature of a subcutaneous laceration, and extensive extravasation may then occur with very little external bleeding; or the outer wound may actually heal, while the opening in the vessel remains patulous, in which case a form of traumatic aneurism may be developed. Hemorrhage from a Wounded Artery may usually be recognized by the bright vermilion hue of the effused blood, and by the fact that it is thrown out in jets corresponding to the pulsations of the heart, and does not flow in an even stream, as in cases of hemorrhage from veins. To this rule there are, however, exceptions; the blood from the proximal end of a divided artery always, I believe, presents the characters which have been described, but from the distal end, for at least an hour after the infliction of the wound, or until the collateral circulation has been established, the flow of blood re- sembles that from a wounded vein. In other cases, however, if the anasto- mosis be very free, as in the palmar arch, both ends of the cut vessel will bleed in jets, and pour out blood of a bright red color. The force of the jet varies with the size and position of the artery and the strength of the heart's action. A small branch wounded in close proximity to a main trunk, may bleed more furiously than a larger vessel divided at a more distant point, and, in general terms, the nearer a cut vessel is to the centre of circulation, the more profusely will it bleed. As the pulsations of the heart become weaker, the jet of blood has less force, and may finally cease with the occurrence of syncope, or may be arrested by the natural processes of contraction and re- traction which are set up in the wounded vessel. As already indicated*, there may be profuse bleeding without any external loss of blood. AYhen bleeding occurs into one of the cavities of the body, as the peritoneal, it constitutes internal or concealed hemorrhage; when into the areolar tissue of a part, it is known as extravasation. Extravasation may prove directly fatal, by the amount of blood abstracted from the general circulation, may cause gangrene by pressure, especially upon the neighboring venous trunks, or, if circumscribed, may give rise to a form of traumatic aneurism. Constitutional Effects of Hemorrhage__These are the same in kind, though differing in intensity, whether the bleeding proceed from arte- ries or veins, and whether the hemorrhage be apparent or concealed. The first effect of profuse hemorrhage is shown in the blanching of the surface ; the cheeks and lips become pale, and the conjunctiva unnaturally white. The pulse becomes small and rapid, the heart endeavoring by increased action to compensate for diminished power. The patient feels languid ; the respira- tion assumes a sighing character; the senses of sight and hearing are per- verted, being sometimes preternaturally acute, but more often dulled; the temples throb, the skin becomes cold, and at last, rather suddenly, the patient faints. During the state of syncope, the heart's action is very feeble, and the breathing almost entirely diaphragmatic. Death may occur in this con- dition from a continuance of the hemorrhage, but more commonly coagulation takes place in and around the mouth of the wounded vessel, and when con- sciousness returns, the bleeding is found to have spontaneously ceased. ATom- iting frequently occurs as syncope passes off. All the tissues of a patient who has lost much blood, appear soft and flabby, probably from the loss of HEMORRHAGIC DIATHESIS. 175 the natural fluids of the part, which are rapidly absorbed into the depleted bloodvessels. Profuse or repeated hemorrhage, beside the symptoms which have been above described, often gives rise to distressing nervous phenomena, such as amaurosis, delirium, convulsions, or even hemiplegia ; I have known death attributed to a cerebral clot, which the autopsy showed did not exist, the fatal result being simply and altogether owing to profuse and repeated secondary hemorrhages. In recovering from the effects of loss of blood, the patient sometimes passes through a condition of constitutional irritation, with extreme restlessness and delirium, to which the name of " hemorrhagic fever" has been not inaptly applied. The amount of blood which can be lost without serious consequences ensu- ing, varies greatly in different individuals. Infants and very old persons are, as a rule, more injuriously affected by hemorrhage than those in middle life. The amount of blood lost in ordinary childbirth might produce serious conse- quences under different circumstances, while, on the other hand, the mental state of a patient, as of one who has attempted suicide, or who believes him- self to be bleeding to death, may actually cause a fatal result after the loss of a really insignificant quantity of blood. Habitual or Periodic Hemorrhage may be met with in either sex. In the female it may take the place of, or alternate with, the natural menstrual flow, when it constitutes what is called vicarious menstruation. In the male sex, bleeding from the hemorrhoidal veins sometimes occurs at certain periods of the year, and seems to be occasionally beneficial by relieving a state of ple- thora. Some persons bleed habitually from the nose, without any apparent solution of continuity having taken place ; and Air. Moore mentions an ap- parently authentic case, in which a young woman had severe spontaneous hemorrhages from the skin of the finger. In these cases the blood seems to ooze from numerous minute orifices, and subsequently to collect in the form of drops, which then flow over the surface. Hemorrhagic Diathesis; Haemophilia—These are the names used in England and in this country for the remarkable affection which the French call Hemophylie, and the Germans Hdmophilie or B/uterkrankheit. Its chief manifestation, and that from which its name is derived, is a dispo- sition to profuse bleeding, which may be spontaneous, or may follow upon the slightest wounds. It is often hereditary, and those in whom it exists are in childhood often subject to affections of the joints, and to inflammations of the luno-s. It affects almost exclusively persons of the male sex, the female mem- bers of a family, though transmitting it to their posterity, being themselves usually exempt. The disease appears to depend on a peculiar condition of the blood (not mere want of plasticity, for it coagulates readily when removed from the bodv), and on a defective contractility of the arteries and capillaries. P. Kidd has observed, after death, great proliferation of the epithelioid cells linino- the small vessels, with degeneration of their muscular coat. Accord- ino- to AYachsmuth, the spontaneous hemorrhages may often be averted by smart purging with Glauber's salts, and, when they occur, may best be ar- rested by the administration of an infusion of arnica, or ergot in doses of five grains every half hour. The hemorrhages which follow wounds do not yield so readily to constitutional measures, and in these cases long-continued pres- sure, and the use of the actual cautery, appear to be the most promising modes of treatment. The existence of the hemorrhagic diathesis would of course be a contra-indication to the performance of any operation involving the use of the knife ; it is somewhat remarkable, however, that cases which have proved fatal, from this cause, have almost invariably been those of trivial accidental wounds, or of such slight surgical procedures as the extraction of 176 INJURIES OF BLOODVESSELS. a tooth, or lancing the gum,—the only recorded instance, as far as I know, of the hemorrhagic diathesis having caused death after an important opera- tion, being in a case of lithotomy reported by Air. Durham. Process of Nature in Arresting Hemorrhage__Before entering upon the subject of the treatment of arterial hemorrhage, it will be necessary to consider briefly the process adopted by nature in closing wounds of these vessels, a process which the surgeon endeavors to imitate by the appliances of art. The natural means by wliich arterial wounds are healed have been experimentally and very thoroughly investigated by Dr. J. F. D. Jones, whose monograph on the subject was published more than sixty years ago, since which time very little if anything has been added to our information concern- ing the matter. The temporary means employed by nature to arrest hem- orrhage are twofold: (1) the formation of a clot, and (2) the contraction and retraction of the cut end of the vessel itself. The formation of a clot, which is greatly facilitated by the diminished force of the heart's action (one of the constitutional effects of hemorrhage, as we have already seen), was first noticed and its importance pointed out by the celebrated French surgeon Petit, in 1731. This distinguished writer described an external clot which he called couvercle, and an internal clot which he called bpuchon. The in- ternal clot is somewhat conical in form, its base adhering to the sides of the vessel near its cut extremity, and its apex reaching upwards usually as high as the origin of the first anastomosing branch. It is formed gradually, and having served its temporary purpose, undergoes contraction and partial ab- sorption, and eventually appears to form a portion of the fibrous cord into which a closed artery is converted. The contraction of a divided artery, and its retraction within its sheath, begin immediately upon its division ; this step of the process was first indicated by Morand in 1736, who did not deny, as some of his followers have done, that the formation of a clot is of tem- porary utility, though he clearly declared his conviction that the permanent closure of the vessel must depend upon the cicatrization of the artery itself. The retraction of the vessel within its sheath allows the blood to come in contact with the irregular surface of the latter, and thus facilitates the forma- tion of the external coagulum, while its contraction as regards its calibre di- minishes the size of the stream, and thus tends to assist the formation of the internal clot, of which it likewise determines the shape. This contraction, as shown by Kirkland, extends to the origin of the nearest anastomosing branch. The permanent means by which a divided artery is closed, consist in the union of the cut edges by the development of local inflammatory changes, the continued contraction of the walls of the vessel upon the internal coagu- lum, and the final conversion of the lower end of the vessel into a dense, fibrous, impervious cord, into the construction of which a certain portion of the internal clot appears usually to enter. The exact mode in which the cicatrization of the cut extremity of the vessel is effected, is variously de- scribed by authors, according to the several views entertained as to the nature of the inflammatory process (see Chap. I.). Most surgical writers, following Dr. Jones, have attributed the healing of divided arteries to the effusion of plastic matter from the vasa vasorurn ; the advocates of the cellular path- ology consider the process to be one of cell proliferation from the vessel's walls; Prof. Beale and Mr. Lee consider the union to be due to the develop- ment of germinal matter, derived from the white corpuscles of the blood, while Billroth (practically returning to the old doctrine of Petit), attributes the healing of wounds of both arteries and veins to the organization of the internal coagulum, through the multiplication of the white blood-corpuscles, aided perhaps by the entrance of wandering cells from the surrounding tissues. TREATMENT OF ARTERIAL HEMORRHAGE. 177 AVithout entering into a discussion of this question, which must be con- sidered to a great degree one of purely theoretical interest, I may say that whatever be the method by wliich injuries of other tissues are repaired, by the same method, in all probability, are wounds of arteries united ; and this method, as I have endeavored to show in previous chapters, is in all cases by means of that natural process wliich, for want of abetter name, we call inflam- mation. AYe may, however, from what has been said, derive this practical lesson : that as the repair of an artery after injury appears to require the co- operation both of the walls of the vessel and of the contained blood, no means of arresting hemorrhage can be looked upon as philosophical, which ignores the efficiency and attempts to dispense with the aid of either of these agents. The application of this remark will be seen directly, when I come to speak of the local means of treating arterial hemorrhage. The changes which have been above described are best marked in the closure of the proximal or cardiac end of a divided artery. Those which take place in the distal extremity are the same in kind, though less in degree ; especially is this the case as regards the internal coagulum, which in the dis- tal end of the vessel is smaller than in the proximal, and indeed in some cases entirely deficient; a circumstance which, as pointed out by Guthrie, may probably account for a fact which has long been recognized by surgeons, that secondary hemorrhage usually occurs from the distal extremity of a wounded vessel. In the case of partially divided arteries, the process is essentially the same ; a clot forms between the sheath and the vessel itself, and compresses the latter; this pressure may likewise be aided by the formation of a clot in the external wound. The permanent closure of the arterial incision is effected, as in the case of complete division, by the inflammatory process. Very slight wounds, especially if longitudinal, may close without the calibre of the artery being obliterated; if, however, the size of the wound be equal to one-fourth of the circumference of the vessel, the latter will almost inevitably be con- verted into an impervious cord at the seat of injury, and it is probable that, in these cases, the healing process is assisted by the formation of an internal, as well as an external coagulum. AYhen such a wound heals without the obliteration of the calibre of the artery, the inner coats of the latter do not unite very firmly, and an aneurism is apt to be subsequently developed. In an artery as large as the axillary or femoral, it may be stated, in general terms, that a wound of one-fourth of the circumference of the vessel will, if untreated, either cause death by hemorrhage, or give rise to a traumatic aneurism; in the rare instances in which neither of these consequences ensues, the vessel will, in healing, be converted into an impervious fibrous cord. Treatment of Arterial Hemorrhage. The treatment of arterial hemorrhage should be both local and constitu- tional. The constitutional treatment consists in keeping the patient quiet in a recumbent position, and in avoiding any sudden elevation of the head or of the arms, which might induce fatal syncope. Food and stimulants should be cautiously administered in small quantities at a time, and, if there be vomiting, may be given by enema. Hypodermic injections of ether have been successfully used by Hecker, Alacan, and others, in the collapse of post- partum hemorrhage, and I have myself employed them with advantage in cases of profuse bleeding during operations. Opium should be freely used, and is a most valuable remedy in these cases. Drugs adapted to increase the plasticity of the blood, such as the muriated tincture of iron or the acetate of 12 178 INJURIES OF BLOODVESSELS. lead, may be administered, or ergot may be used, as recommended by AVachs- muth in cases of the hemorrhagic diathesis. As a last resort, transfusion of blood should certainly be tried, in the manner and with the precautions recom- mended in Chapter IV. The statistics of this operation in cases of hemor- rhage, as given by Landois, are very favorable, 99 cases having afforded not less than 65 recoveries, while 11 of the 31 fatal cases (the result in 3 was doubtful) were moribund at the time transfusion was practised. For the amemia left after recovery from the primary effects of hemorrhage, a long course of tonics, and especially of the preparations of iron, may be required. The loss of blood in some cases is never entirely repaired during life, the patient remaining permanently blanched, though otherwise apparently in good health; or the debility resulting from hemorrhage may act as a predisposing cause for the occurrence of tuberculosis or other morbid condition. The local treatment of arterial bleeding consists in the adoption of various measures, which may be either of a temporary, or of a permanent nature. Hemorrhage from a wounded artery may be temporarily checked by pressure. This may be applied directly at the seat of injury, or indirectly upon the main artery of the part, at a point between the wound and the centre of the circu- lation. In the latter case compression is usually best exercised by the appli- cation of the tourniquet, the various forms of, and the modes of using, which instrument have been sufficiently described in a previous chapter. In deal- ing with certain arteries, as the subclavian, to which a tourniquet cannot be applied, effectual pressure may be made with the handle of a large key (pre- viously wrapped, so as to protect the skin), or other suitable implement; or if the clavicle be much displaced—as by an aneurismal tumor—Syme's plan might be employed, wliich consists in making an incision in the line of the artery, upon which direct pressure is then made by introducing the finger through the wound. For the permanent arrest of arterial hemorrhage, the surgeon may have recourse to the use of—1, cold; 2, position; 3, pressure; 4, styptics; 5, cauterization; 6, torsion; 7, ligation; or 8, acupressure. 1. Cold is an efficient means of arresting hemorrhage from many vessels of small calibre. In some cases the presence of clotted blood in a wound ap- pears to encourage further bleeding by acting just as a warm poultice would do, and the surgeon often finds that, upon sweeping away the clots and ex- posing the wound to the air, the hemorrhage ceases spontaneously. Hemor- rhage from small vessels may often be arrested by pouring a stream of cold water over the part, or if the bleeding come from one of the mucous outlets of the body, as the mouth, nostrils, rectum, or vagina, by introducing small pieces of ice. Care must be taken, however, in the use of cold, not to con- tinue its application too long, lest injurious depression or even sloughing should ensue. The application of hot water is said to have been successfully employed in cases of vaginal hemorrhage. 2. Position may often be usefully employed to arrest, or, at any rate, to assist in arresting arterial hemorrhage. If the wound be in the lower limb, the part should be elevated by means of pillows or an inclined plane, so that, by the laws of hydraulics, the force of the circulation in the injured part may be diminished, and an opportunity given for the occurrence of the natural processes of repair. The same plan may be adopted for wounds of the upper extremity; while in treating wounds of the arteries of the forearm or of the palmar arch, it will be found advantageous to forcibly flex the elbow—a modification of Hart's method of treating aneurism, which has afforded good results on more than one occasion. PRESSURE, STYPTICS, AND CAUTERIZATION. 179 3. Pressure, which, as we have seen, is the common mode of temporarily checking hemorrhage, may be also efficiently used for its permanent arrest. It may be applied directly to the bleeding point by means of the graduated compress, or by the use of serrefines, or of small forceps ; or indirectly, by bandaging the limb and flexing the proximal joint over a roller, or, in the case of bleeding from cavities, by plugging the part with lint or compressed sponge. Sometimes pressure may be efficiently applied by means of a weight, as a bag of shot, or even loose shot, as was done in Dr. Smyth's remarkable case of successful ligation of the innominate artery, which will be again referred to. The graduated compress is made by laying together a number of pledgets of lint of gradually increasing dimensions, so that when com- pleted the mass has the form of an inverted cone about an inch in height; the apex of this cone is applied directly upon the bleeding point, all clots having been previously removed from the wound, and the compress is held in place by adhesive strips, while firm pressure is made upon it by means of a piece of cork or metal, secured with a bandage. In positions where the proximity of a bone gives a firm substance against which the vessel may be compressed, as in the case of wounds of the temporal artery, this will be found a very efficient mode of controlling hemorrhage. 4. Styptics___These agents, when employed alone, are not of much use, except in checking capillary oozing or the bleeding from very small vessels. The simplest and most convenient is ordinary diluted alcohol, the employment of which in operations has already been adverted to. The styptic of Pagliari, which has a good deal of reputation, particularly among French surgeons, contains alum and benzoic acid, and certainly seems in some cases to answer a very good purpose. Among the more powerful styptics may be especially mentioned the perchloride of iron, in substance, in solution, or in the form of the muriated tincture, and the persulphate, or Monsel's salt. The latter, in particular, is undoubtedly a very powerful agent, and, when properly used, capable of serving a very good end; its indiscriminate employment in all cases of surgical hemorrhage has, however, been productive of a great deal of harm, not only on account of its effect in hindering primary union, but because the rapidity of its action, and the facility with which it can be applied, have often induced inexperienced practitioners to neglect less easy but more trustworthy means of suppressing arterial bleeding. J+^-~~*. *. **t*^f In conjunction with pressure, styptics are more valuable than by them- selves ; by applying the styptic upon the apex of the graduated compress, or, in the case of hemorrhage from deep fistulous wounds or from the mucous outlets of the body, by plugging the cavity with lint or sponge soaked in the styptic, a very powerful impression may be produced. In a very interest- ing if inconclusive paper, published in the American Journal of Medical Sciences for October, 1865, Dr. J. M. Holloway advocates the employment of styptics, with pressure, in cases of consecutive hemorrhage from gunshot wounds, as often preferable to the use of the ligature ; and though, of course, a practice founded on universal experience is not to be revolutionized by the record of a few exceptional cases met with by any individual, still the instances mentioned by Dr. Holloway are of much interest, as showing that these means may occasionally prove successful even in dealing with such a large artery as the axillary. For bleeding after the extraction of a tooth, Moreau recommends plugging the cavity with cotton saturated with tincture of benzoin, and com- pression by means of a piece of cork fixed between the neighboring teeth. 5. Cauterization with a hot iron was, until within a comparatively short period, the principal means of arresting arterial bleeding at the com- 180 INJURIES OF BLOODVESSELS. mand of the surgeon. Although the ligature was re-invented and powerfully advocated by the illustrious Pare, in the middle of the sixteenth century, it was not generally adopted for a long time subsequently, and we learn from the writings of Sharpe, of Guy's Hospital, only a little more than one hundred years ago, that even in his time the cautery and styptics were still preferred to the ligature by many surgeons, not only on the Continent, but even in some parts of England. Although no surgeon at the present day, probably, would use the hot iron in any case in which a ligature could be applied, there are some circumstances under which the cautery must still be resorted to ; in some operations about the jaws, and in other cases in which, from the posi- tion of the bleeding vessel or from the condition of the surrounding tissues, other modes of controlling hemorrhage are not available, or fail upon trial, the hot iron is a valuable application. The various forms of the cautery have already been described and figured in the chapter on Alinor Surgery, and it will be sufficient to add here that when used for hemorrhage, as it is the coagulant and not the destructive effect that is needed, the temperature of the iron should not be raised above a black heat. 6. Torsion, as a means of controlling the hemorrhage from cut arteries, was known to the ancients, but subsequently passed through a long period of oblivion, having been revived in the early part of this century, principally by the efforts of French and German surgeons, among whom may be specially named Amussat, Velpeau, and Fricke. Since then torsion has been occa- sionally used by surgeons, generally in dealing with small arteries ; but the practice has within a few years received a fresh impulse, and is now strongly advocated by several writers as a mode of treatment applicable to vessels of all sizes; this movement has been most actively participated in by Prof. Syme, of Edinburgh, Prof. Humphry, of Cambridge, and Messrs. Bryant and Forster, of Guy's Hospital, London. Torsion may be practised in several ways : Syme, Humphry, and Tillaux, following Amussat, draw the extremity of the artery out from its sheath, and twist it until it is twisted off; the surgeons of Guy's Hospital, on the other hand, adopt Velpeau's plan of leaving the twisted end attached, that it may give additional security by act- ing as a mechanical plug. Free torsion (that is, with a single pair of forceps) is recommended by Bryant for vessels of moderate size, and for all vessels in the extremities ; limited torsion (in which the vessel is grasped with one pair of forceps and twisted with another) for such arteries as are large and loosely connected. An ingenious torsion-forceps has been devised by Dr. Hewson, of this city. AYhen it is not intended to twist off the end of the vessel, the number of turns should vary from six to eight, according to the size of the artery. The mechanism of torsion is as follows : the inner and middle coats are lacerated and curl upon themselves, forming a nidus for the coagulation of blood, just as after ligation, or in the ordinary natural process of repair already described ; the external coat is twisted into a cord, which serves tem- porarily as a mechanical plug, and is eventually surrounded by lymph and incorporated with the adjoining tissues, or more commonly separated and thrown off by sloughing, just as the end of a vessel which has been submitted to the ligature. The artery is permanently closed by the inflammatory pro- cess, at the point at which the middle and inner coats have given way. Tor- sion has now been so often successfully applied,"even to large vessels, that it cannot, I think, any longer reasonably be doubted that it is an effectual mode of controlling hemorrhage ; it is, according to Forster and H. Lee, even more applicable to large vessels than to small. I do not see, however, that it is at all a better mode than ligation, nor, I think, does it equal the latter in safety; this point will be again referred to after I have described the remaining modes LIGATION. 181 of controlling hemorrhage, ligation, and acupressure. A modification of the ordinary mode of effecting torsion has been recently suggested by Dr. S. Fleet Speir, of New York, who employs an instrument which he calls the "artery constrictor" (Fig. 81); its action somewhat resembles that of the Speir's artery constrictor. ecraseur, and it is designed to sever the internal and middle coats of the artery, thus allowing their invagination within the external coat, which is corrugated but not divided. The instrument is removed as soon as this has been accomplished. 7. Ligation___The use of the ligature, though apparently known to the ancients, was afterwards completely forgotten, so that its introduction into surgery by Pare, in the sixteenth century, has all the merit of an original discovery. It was not, however, until long after Pare's time that the use of the ligature became universal, or indeed general ; and the reason for this appears to have been not so much on account of innate obstinacy on the part of surgeons, as because the natural process by which hemorrhage is arrested not being understood, and ligation being consequently practised in a very defective manner, its results were correspondingly unsatisfactory. The ligature, as now used, is, I believe, when applicable, the very best method of checking arterial hemorrhage. The form and structure of the ligature, and its mode of application to the open ends of vessels, have already been de- scribed (page 98), and need not be again adverted to. AYhen it is necessary to secure an artery in its continuity, the ligature may be most conveniently passed beneath the vessel by means of an aneurismal needle (Fig. 82), or Fig. 82. Aneurismal needle, armed with a liagature. even an ordinary curved needle, or an eyed probe. The mechanism of the ligature in controlling hemorrhage is now well understood (thanks to the investigations of Dr. Jones), and the rules for its application thoroughly established. The illustrious John Hunter, even, did not appreciate the mode of action of the ligature, and accordingly we find that in his operations for aneurism he did not draw the noose tight, fearing to weaken the coats of the vessel__thus, as Dr. Jones subsequently showed, defeating the very object sought to be attained. The ligature should be applied with sufficient force to divfde, smoothly and evenly, the inner and middle coats of the artery, while the outer coat is constricted within the noose. In tying the larger vessels, 182 INJURIES OF BLOODVESSELS. the giving way of the inner tunics of the artery is sometimes distinctly per- ceptible to the surgeon. The divided inner coats curl upon themselves, and assist the formation of an internal coagulum, while the artery is permanently sealed by the occurrence of inflammatory changes, just as in the natural haemostatic process already described. The noose of the ligature is gradually loosened by ulceration, and finally cuts its way through, or comes out bring- ing with it the constricted portion of the external arterial coat. The clot which is formed on the distal side of the ligature is usually smaller than that on its proximal side ; in some cases one or even both clots may be absent, and yet the artery be securely closed, wliich shows that the formation of a clot, though of great assistance, is not in all cases absolutely essential for the success of the ligature. Dr. B. Howard, of New York, has published some experiments to show that it is not invariably necessary to draw the ligature so tight as to divide the inner coats, but that mere narrowing of the arterial tube with a loose ligature, is sufficient sometimes to secure obliteration of the vessel. This (which is a revival of the teaching of Scarpa) was indeed known from the cases of Hunter, who, as we have seen, did not tighten his ligatures in operating for aneurism ; but I am not aware of any clinical facts which show that a loose ligature has any superiority over a tight one, while the universal experience of surgeons is that it is less safe, and that it has the additional disadvantage of not coming away as readily as one which is tightly drawn. The best material for a ligature is, as has been already said, ordinary fine whip-cord or silk. A'arious attempts have been made from time to time to substitute other materials which it has been supposed would produce less irritation and might become encysted or absorbed. Thus Sir Astley Cooper and Dr. Physick made use of animal ligatures, catgut or some similar sub- stance, and this practice has since been occasionally adopted by others. Carbolized catgut has been recently extensively employed by Lister and other surgeons, but has not proved itself as certain a preventive of secondary hemorrhage as was at first anticipated. Its fault is, it seems to me, that it disappears without dividing the external coat of the artery, and thus does not securely occlude the vessel—in this respect being open to the same objection as acupressure. Metallic ligatures were employed in a series of experiments on the lower animals by Dr. Levert, of Alabama, about forty years ago, and since then have been occasionally used in operations on the human subject. Dr. Levert found that wire ligatures tightly secured around the arteries of dogs, produced obliteration of the vessels, and that, when both ends of the ligature were cut short, the loop became encysted, and remained in the wound an indefinite time without producing irritation. Similar results have been since obtained by Sir J. Y. Simpson and others. Dr. Howard, on the other hand, finds that wire ligatures, if drawn tight, produce marked inflammation and suppuration around the seat of ligation, and therefore recommends the use of loose wire ligatures. Metallic ligature threads have now been used a sufficient number of times in operations on the human subject, by Stone, Gross, Mastin, and other surgeons, to warrant the belief that they are safe agents, and may properly be applied in cases in which it is desirable to leave the noose in situ and close the wound over it, as in certain operations upon the abdominal cavity: even in these cases, however, it is probable that the antiseptic short-cut ligature of Prof. Lister would answer a still better pur- pose. Rules for Li gating Wounded Arteries___In the application of ligatures to wounded arteries, there are certain rules which should be indelibly impressed upon the surgeon's mind: these are— RULES FOR LIGATING WOUNDED ARTERIES. 183 1. In cases of primary hemorrhage, no operation should be performed upon an artery, unless it is at the moment actually bleeding. In cases of secondary hemorrhage, a different practice should be adopted, as will be pre- sently seen : but in dealing with a recently wounded artery, if hemorrhage have ceased, the surgeon as a rule should not interfere, because (1) there is a fair prospect that the bleeding will not return ; (2) the probability of discov- ering the source of hemorrhage is much less, when there is no stream of blood to point the surgeon's way, and (3) the incisions and manipulations which would be necessary in searching for the arterial wound would be a positive injury which would more than counterbalance any benefit that might probably be obtained. In certain exceptional cases, however, the surgeon should not hesitate to apply a ligature even under these circumstances ; for instance, if an artery were seen pulsating in a wound, it would be right to tie it even though it did not bleed, for in such a case the ligature could do no harm, and might prevent a great deal of subsequent mischief; again, if a patient were likely, for any reason, to be subjected to unusual risk of second- ary hemorrhage, as, for instance, if it were necessary for him to be transported to a distance, or if he were threatened with the invasion of delirium tremens, it might be proper to choose the lesser evil, and search for the wounded vessel, that it might be secured by a ligature. Under any circumstances the patient should be constantly watched, and if the wound were in an extremity, it would be right to apply a provisional tourniquet, so that, in case of secondary hemorrhage, all unnecessary loss of blood might be prevented. 2. In applying a ligature to a wounded artery, the surgeon should cut down upon it directly at the point from which it bleeds, and secure the vessel in the wound. This rule and the next were clearly laid down by John Bell, and most powerfully enforced by Guthrie, and yet, it is to be feared, are, even at the present day, too often practically ignored by operators. There are two principal reasons why this rule should be considered invariable : (1) because it is often impossible to tell what vessel is wounded, until it is exposed in the wound itself; and (2) because, even if this point could be determined, ligature of the main trunk above the wound would, in a vast number if not in the majority of cases, fail to arrest the bleeding. Thus it has happened that the superficial femoral artery has been tied for arterial hemorrhage from a wound of the thigh, and, bleeding continuing or recurring, it has been subsequently discovered that it was a branch of the profunda that was wounded; or the subclavian has been tied for supposed wound of the axillary artery, when the hemorrhage really came from the long thoracic. Again, if the main trunk be tied, the collateral circulation being quickly established, secondary hemor- rhage is extremely apt to occur from the distal side of the arterial wound; or if there be collateral branches given off between the point of ligation and the wound, bleeding may occur even from the proximal side of the latter, when, if a second ligature be applied in the wound, the double obstruction will (at least in the lower extremity) almost invariably cause gangrene of the limb. Still further, deligation of the main trunk exposes the patient sometimes to additional danger; thus, Liston having tied the external iliac for wound of a small branch of the common femoral, the patient died of peritonitis, a cause of death, it will be observed, which was directly connected with the operation, and entirely independent of the original injury. For these reasons, then, viz., that by this method only can the actual source of hemorrhage be determined ; that thus only can probable security be afforded against secondary bleeding; that if secondary hemorrhage should occur, this plan does not put out of the question further treatment; and that this plan does not entail any additional risk upon the patient, the rule should be invariable, that, whenever practi- cable, a bleeding artery should be directly cut down upon, and tied where it 184 INJURIES OF BLOODVESSELS. bleeds. In doing this, the surgeon should usually take the original wound as the guide for his incisions ; should, however, the wound be very deep, it may be more convenient to reach the source of hemorrhage by making a counter- incision in the course of the vessels, cutting upon the end of a probe introduced to the bottom of the wound. Hemorrhage during the operation should be guarded against by the use of a tourniquet, where this instrument is appli- cable, or by pressure made by an assistant on the main trunk ; in situations where this is impracticable, the surgeon should introduce one or two fingers into the wound, so as to compress the bleeding vessel while making the neces- sary incisions. This rule of tying an artery where it bleeds holds good for both primary and secondary hemorrhage; no matter what the condition of the wound may be, as long as there is a wound, it should be freely enlarged, and the vessel secured at the point whence the blood issues. This is often a dif- ficult and tedious proceeding, particularly in wounds that are swollen and granulating, but it is a proceeding that the surgeon should consider impera- tive, when the occasion arises; and it is surely very reprehensible for any operator, in view of the vast accumulation of recorded experience on the sub- ject from both civil and military practice, to persist in cases of arterial hemor- rhage in tying the main trunk of a limb, merely because it is easier than to tie the vessel in the wound, or, still worse, because it enables him to perform what is considered a more important operation. 3. A third rule, and one closely connected with the preceding, is that two ligatures should be applied, one to each end of the artery if it be completely divided, and one on each side of the wound, if the latter have not completely severed the coats of the vessel. The reason for this rule is obvious : in many parts of the body the arterial anastomosis is so free that a ligature to the proximal side alone will not even temporarily arrest the bleeding, the current of blood being immediately carried around to the distal extremity ; in other cases, though a proximal ligature may serve to check the hemorrhage for a short time, as soon as the collateral circulation is fully established, bleeding will again begin from the distal end of the vessel. If, as sometimes happens, the distal extremity of the vessel be so retracted and surrounded by the ad- joining tissues, that it cannot be found even after long and careful search, the surgeon may plug the wound with a graduated compress, the apex of which is imbued with the solution of the persulphate of iron, and good results may be hoped for from this proceeding ; but, whenever it is practicable, the distal as well as the proximal end of the vessel, should unquestionably be tied. If a large arterial branch be wounded immediately below its origin, it is safer to regard the injury as one of the main trunk, and apply ligatures immediately above and below the origin of the branch, as well as on the distal side of the wound in the latter 51 so, on the other hand, if a large branch be given off immediately above or below an arterial wound, it is proper, after tying the injured vessel in the usual way, to apply an additional ligature to the branch. If this should not be done, there would be risk of secondary hemorrhage from deficiency of the internal coagulum, which, as has been mentioned, extends only as far as the nearest anastomosing vessel. There are, it is true, a certain number of cases on record, in which the proximal ligature alone, or even the ligature of the main trunk at a distance from the wound, has arrested hemorrhage, which has not recurred; but.such cases are quite exceptional, and in no degree invalidate the force of this and the preceding rule of treatment, which might well be called golden rules. 1 Dr. T. B. Wilkerson, of North Carolina, has recently reported a case in which this plan was successfully carried out in a case of wound of the profunda femoris just below its origin. LIGATURE IN THE CONTINUITY OF ARTERIES, 185 4. However desirable it may be to tie a bleeding vessel in the wound, in certain situations it is impossible to do so : thus, in the case of wounds which penetrate the floor of the mouth, dividing branches of the external carotid, or in cases of hemorrhage into the mouth from the internal carotid, or within the pelvis from branches of the internal iliac, it is manifestly impossible to reach the seat of the wound, and the surgeon's only resource is to tie the main trunk. Again, in cases of secondary hemorrhage from wounds of the palmar arches, it may be necessary to deviate from the ordinary rule, and tie either the brachial, or the radial and ulnar arteries.1 Application of Ligatures in the Continuity of Arteries___In applying a ligature in the continuity of an artery, whether at the seat of wound or at a higher point, or in the Hunterian operation for aneurism, the surgeon is guided in making his incisions by the lines which he knows to correspond with the general course of the vessel. If there be a wound, that should, of course, be the starting-point for the incision, but in other cases the operator must rely upon the pulsation of the vessel if that can be felt, and if not, upon his general anatomical knowledge as to the course of the artery. It is well, especially when the artery lies deeply, to make the incision, as recommended by Hargrave and Skey, somewhat obliquely to the course of the vessel, which can thus be more readily found than if the incision were directly in its line. The skin and superficial fascia may be divided by the first stroke of the knife, but afterwards the surgeon should proceed with great caution, taking up each successive layer of tissue with delicate forceps, and making a slight notch for the introduction of a grooved director (Fig. 83), upon which the layer is then Fig. 83. Grooved director. carefully divided from below upwards. AYhen the sheath of the vessel is reached, the surgeon picks it up in the same way with forceps (Fig. 84, A), and makes an opening just sufficient to allow the passage of the needle which bears the ligature. This is then delicately introduced between the artery and the vein, and very cautiously brought around the former so as to include nothing except the vessel itself. The point of the needle, which must be well ground down and rounded, is then teazed through the opening in the sheath (Fig. 84, B), a process which may be facilitated by a gentle touch with the knife, one end of the ligature drawn out, and the other drawn backwards with the needle, which must be withdrawn as gently as it was introduced. The operation is completed by tying the artery firmly and tightly with the reef- knot (Fig. 84, C), and bringing both ends of the ligature out of the wound, which is closed with sutures and lightly dressed. If any small arterial branch should be cut during the operation, it should be twisted or tied, taking care to secure both ends ; the chief precautions to be observed in passing the needle are not to wound the vein, and not to include the latter or any portion of it, or a nerve, in the noose of the ligature. Entanglement of the vein would be very apt to cause phlebitis or gangrene, while ligature of the nerve would at least give unnecessary pain, and might 1 Ogston, of Aberdeen, has successfully tied the deep palmar arch by separating the abductor indicis from the radial side of the metacarpal bone of the index finger, through a dorsal incision. 186 INJURIES OF BLOODVESSELS. possibly expose the patient to the risk of tetanus. It would likewise cause paralysis of the parts below, which in some situations might be productive of very grave consequences. If, in pass- Fig. 84. ing the needle, there should be a gush of blood, more in quantity than could be accounted for by the sepa- ration of the sheath, making it pro- bable that the vein had been punc- tured, the surgeon should either suspend the operation and apply pressure, or should extend his inci- sion and reapply the ligature at a higher point. To allow a ligature to remain which passed partially through a vein, would be equivalent to form- ing a seton through that vessel, and would certainly expose the patient to the risks of phlebitis, thrombosis, gangrene, and, possibly, embolism and secondary pyamiia. It is almost needless to say that the surgeon should be careful not to miss the artery, and tie instead a nerve or . „ , .. „ r, ,. 4 even a portion of condensed fascia, A. Opening the sheath. B. Drawing ligature ^v<-" " f"1""" " ■ n round the artery. C Tying artery. (Bryant.) an accident which has Occasionally happened in the hands of the most skilful operators. If the artery be very superficial, the surgeon should be correspondingly careful not to go too deeply in his first incision, which some operators, indeed, prefer to make by pinching up a fold of skin, transfixing, and cutting from within outwards. In dividing the deeper structures, the side of the knife should be used rather than the point, and the edge should always be directed away from the artery. After tying an artery in its continuity, the limb below should be kept warm until the collateral circulation is fully established ; the ligature will usually drop between the first and third weeks, according to the size of the vessel; should it remain too long, gentle traction and twisting may be prac- tised, as in the case of ordinary ligatures on the cut ends of vessels. 8. Acupressure___Acupressure, or the means of controlling arterial hemorrhage by pressure with a needle or pin, was first introduced to the notice of the profession by Sir J. Y. Simpson, in December, 1859. It has since then been employed more or less extensively by a great number of surgeons, and, after having been alternately extolled and condemned, and having ex- cited in the city of its birth one of the most virulent professional controversies of modern times, has now gradually assumed its proper place as one of the modes, and, under certain circumstances, one of the best modes by which arterial bleeding can be arrested. Acupressure may be practised in several different ways, of which Prof. Pirrie and Dr. Keith, who have published a monograph on the subject, enumerate seven ; though for practical purposes the number might be reduced to four. In the first two of Pirrie's and Keith's methods, the vessel is compressed between a pin or needle and the soft tissues of the part ; in the third, fourth, and sixth, between a pin or needle and a loop of fine flexible wire ; in the fifth (or Aberdeen method), the pressure is made by passing a pin or needle beneath the artery, which is then twisted upon itself by a quarter or half rotation of the pin ; and in the seventh, the ACUPRESSURE. 187 vessel is compressed between the pin and any bony prominence which may be conveniently situated. The first method is thus described by Simpson : u It consists in passing a long needle twice through the flaps or sides of a wound, so as to cross over and compress the mouth of the bleeding artery or its tube, just in the same way as in fastening a flower in the lapel of our coat, we cross over and compress the stalk of it with the pin which fixes it, and with this view pass the pin twice through the lapel.....AYhen passing the needle in this method, the surgeon usually places the point of his left fore- finger or of his thumb upon the mouth of the bleeding vessel, and with his right hand he introduces the needle from the cutaneous surface, and passes it right through the whole thickness of the flap till its point projects for a couple of lines or so from the surface of the wound, a little to the right side of the tube of the vessel. Then, by forcibly inclining the head of the needle towards his right, he brings the projecting portion of its point firmly down upon the site of the vessel, and after seeing that it thus quite shuts the artery, he makes it re-enter the flap as near as possible to the left side of the vessel, and pushes on the needle through the flesh till its point comes out again at the cutaneous surface. In this mode we use the cutaneous walls and component substance of the flap as a resisting medium, against which we compress and close the arterial tube." The exact mechanism of the first method can be readily understood from the accompanying wood-cuts (Figs. 85, 86). In the second Fig. 85. Fig. 86. Acupressure; first method ; raw surface. Acupressure: first method; cutaneous surface. (Erichsen.) (Erichsen.) method, " a common short sewing-needle, threaded with a short piece of iron wire, for the purpose of afterwards retracting and removing it, is dipped down into the soft textures a little to one side of the vessel, then raised up and bridged over the artery, and then finally dipped down again and thrust into the soft tissues on the other side of the vessel" (Fig. 87). In the third Fig. 87. Fig. 88. Acupressure ; second method. (Erichsen.) Acupressure ; third method. (Erichsen.) method (Fig. 88), " the point of the needle is entered a few lines to one side of the vessel, then passed under or below it, and afterwards pushed on, so that the point again emerges a few lines beyond the vessel. The noose or duplicative of wire is next thrown over the point of the needle ; then, after being carried across the mouth or site of the vessel, and passed around the 188 INJURIES OF BLOODVESSELS. Fig. 89. Acupressure ; fifth method. (Erichsen.) eye end of the needle, it is pulled sufficiently tight to close the vessel; and lastly, it is fixed by making it turn by a half twist or twist around the stem of the needle." The fourth method is identical with the third, except that a long pin is substituted for the needle, the head of the pin remaining outside of the wound ; while the sixth differs from the fourth merely in the way of fixing the wire, the ends of which are, in this method, " crossed behind the stem of the pin so as to embrace the bleeding mouth between them, . . pulled sufficiently tight to arrest the hemorrhage, thereafter brought forward by the sides of the pin—one on each side—and finally fixed by a half twist in front of and close down upon the pin" (Pirrie and Keith, Acupressure, p. 44). The fifth, or "Aberdeen method," consists in passing a pin or needle through the soft tissues close to the artery, giving the in- strument a quarter or a half rotation, by which the vessel is twisted upon itself and then fixing the pin or needle by thrusting its point deeply into the tissues beyond (Fig. 89). This method seems to me the best and most generally applicable ; additional security may be given by superadding the use of a wire loop, as in the preceding methods. The seventh and last method consists, according to Prof. Pirrie, " in passing a long needle through the cutaneous surface, pretty deep into the soft parts, at some distance from the vessel to be acupressed—making it emerge near the vessel—bridging over and compressing the artery, dipping the needle into the soft parts on the opposite side of the vessel, and bringing out the point of the needle a second time through the common integument. In this method the soft parts are twice transfixed, and the artery is compressed be- tween the bone and the middle portion of the needle in front of the integu- ment, between the first point of exit and the second point of entrance." Mode of Repair of Arteries after Acupressure___This subject has recently been investigated by several writers, the results of whose observations may be stated as follows: There is no direct adhesion of the apposed walls of the vessel, as believed by Dr. Hewson and others, but, on the contrary, the sole process of permanent repair takes place at the cut end of the vessel; the end subserved by the needle is merely to remove the pressure of the blood cur- rent until this repair is accomplished. If, however, the needle be allowed to remain so long as to destroy the structure of the lining membrane of the ves- sel, then closure takes place at the line of this destruction, just as after the use of a ligature. The actual repair which goes on at the cut end of the vessel is due partly to changes in the walls of the vessel itself, and partly to changes in the contained blood, in fact to the same changes which we have already studied as taking place in the process of natural hasmostasis. A clot forms above the needle, and rests upon without adhering to the contracted portion of the artery below. The time during which the acupressure needle should be allowed to remain varies from twenty-four to sixty hours, accord- ing to the size of the vessel. If it be removed before the repair of the cut end of the vessel is complete, there will be risk of dislodgement of the clot (which is not adherent), and of hemorrhage ; while if it remain too long, it will excite suppuration in its track, just as any other foreign body. Modified Acupressure—Under the name of "artery compressor," Air. Porter, of Dublin, has described an apparatus for the temporary occlusion of an artery in cases of aneurism. It somewhat resembles Sir P. Crampton's "presse artere," and consists essentially of a bent probe and a wire, between ACUPRESSURE, TORSION, AND LIGATURE. 189 which the vessel is compressed, and which are so arranged as to be withdrawn at will. Dr. L'Estrange's apparatus for the same purpose consists of a double aneurismal needle, the blades of which close like the jaws of a lithotrite. In- struments of various kinds for the temporary occlusion of arteries have like- wise been devised by Deschamps, Desault, Assalini, Durest, Richardson, of Dublin, and others. Filopressure, or compression of a vessel by means of a wire, has been practised by various surgeons, among whom may be specially mentioned Air. Dix, Dr. Pollock, and Professor Langenbeck, and has been described as a modification of acupressure. It is, however, as shown by Simpson, an old mode of treatment, and, 1 may add, appears to be inferior to both acupressure and the ligature. It is practised by surrounding a vessel with a loop of wire, the ends of which are brought out separately through the flap or side of the wound, and twisted over a compress which serves to protect the skin. Uncipressure, or compression by means of a hook, is recommended by Aranzetti, of Padua, in cases of secondary hemorrhage from wounds of the palmar arch, etc. A'e'rteriversion is a name employed by Prof. Weber, of Cleveland, Ohio, for a mode of arresting hemorrhage suggested by himself, which consists in everting the cut end of an artery so as to invaginate the vessel within its own extremity, and then fixing the parts by the introduction of a needle point or delicate metallic peg. Comparison bet-ween Acupressure, Torsion, and Ligature.— From what has been said with regard to the mechanism by which each of these methods acts, and the pathological changes to which each gives rise, it will appear, I think, that the ligature is to be preferred, whenever the cir- cumstances of the case allow the surgeon to choose between them. The ob- jections urged against the ligature are, that (1) it acts as a seton, causing suppuration along its track ; (2) it confines a minute slough in the wound until it comes away itself; and (3) it may become prematurely detached and allow secondary hemorrhage. These objections, though theoretically just, seem to me to be practically of little or no value, for (1) healing without any suppuration is almost never met with (at least in this climate), in wounds of the size of those in which ligatures are used, and no trustworthy evidence has yet been adduced to show that the use of ligatures increases the amount of suppuration ; (2) the size of the slough embraced by the noose of the liga- ture, in cases that do well, is so minute as to be really not worth notice, and in cases where there is extensive sloughing, there is no reason to attribute that sloughing to the use of ligatures ; and (3) though hemorrhage may oc- cur upon the detachment of a ligature, it is (unless violence have been used in removing the ligature) due to a defect in the natural process of haemostasis, which, as we shall presently see, is quite as likely to occur with either torsion or acupressure as with the ligature. Torsion closes arteries just as the liga- ture does, and there is the same risk of hemorrhage on the separation of the twisted extremity, if it has been twisted enough to impair its vitality, as on detachment of the ligature ; while if it have been insufficiently twisted, there is the additional risk of the extremity of the vessel becoming untwisted, and thus allowing bleeding at an earlier period ; if, on the other hand, the end be twisted off, the vessel is in the same condition as if it had been tied, and the ligature immediately removed. If the acupressure pin be removed before it produces suppuration, the sole protection against hemorrhage is an incomplete union at the cut end of the vessel, and an unadherent clot above the point of constriction; if it be allowed to remain long enough to cause inflammatory changes in the arterial coats at the point of constriction, it defeats its own 190 INJURIES OF BLOODVESSELS. object, and acts as a ligature which has been tied and subsequently removed. That both acupressure and torsion are able to control hemorrhage from even large arteries is abundantly proved; that either does so any better than the ligature is, it seems to me, not proved; while to give the same security that is afforded by the ligature, either must be pushed so far as to be open to the identical objection which is urged against the ligature, viz., that of introduc- ing a foreign body into the wound, and, by so doing, impeding union by adhesion. I am not aware of any sufficiently extended statistics of torsion having yet been published, to warrant a numerical comparison of the results of this method, with those of the ligature. The reports of Alessrs. Syme, Hum- phry, Bryant, Forster, and Hill, have certainly been favorable, yet the ex- perience of other surgeons who are equally eminent has been opposed to the general employment of torsion ; and it is to be observed that Mr. Syme only recommended it in connection with the antiseptic method of Prof. Lister, while the whole number of cases in which it has been used in the human subject is as yet comparatively limited. As regards the statistics of acupres- sure, the most favorable series of cases yet published is that of Prof. Pirrie and Dr. Keith, and yet even this, when analyzed, shows at least no better results than are obtained by the use of the ligature. Thus, twelve amputa- tions reported by Prof. Pirrie gave three deaths, and yet in all but one case the operation was done for disease, and eight of the twelve patients were children. The theoretical assumption that acupressure guards against the common causes of death after operation, is not borne out by fact—erysipelas, sloughing, and pyaemia having occurred even in the very favorable experience of Messrs. Pirrie and Keith; while union by adhesion, except in Aberdeen, has been quite as rare with acupressure as with the ligature, and even in the few Aberdeen cases in wliich it is stated that not a single drop of pus was seen during the cure, it does not appear that the period of convalescence was any shorter than it is constantly found to be, when ligatures are used. AYhat, then, are the real advantages of acupressure ? Simply and solely, I believe, that it is more easily and quickly applied than the ligature, and that in its use the surgeon needs no assistant: hence, in cases of emergency, especially of secondary hemorrhage, it is often the surgeon's most available resource, and as such its modes of employment should be familiar to every practitioner. Torsion, on the other hand, is confessed even by its advocates to be a more tedious and difficult proceeding than the application of a liga- ture, and, therefore, seems to me, although possibly safer than acupressure, even less desirable for general use. Collateral Circulation___In whatever way an arterial trunk be oc- cluded, whether by disease or by surgical interference, the vitality of the parts below would be impaired but for the establishment of the collateral circulation. The immediate effect of a ligature, or other means of arterial occlusion, is to throw the force of the circulation into new channels, and hence, though the limb below the site of ligature is for a time less full of blood, the balance is soon restored, and after a few hours the activity of the capillary circulation is so much increased, that the part is not unfrequently both redder and warmer than in its natural state. The action of the capil- laries is, however, but temporary, the true collateral circulation being estab- lished through the inosculation of anastomosing branches, derived sometimes from the affected vessel itself, but more frequently from neighboring trunks on the same side of the body. Thus, if the superficial femoral be tied, the collateral circulation is established through the branches of the profunda, while after ligature of the common carotid, it is principally tlirough the infe- SECONDARY HEMORRHAGE. 191 rior thyroid and vertebral arteries that the circulation is maintained. Even after occlusion of the abdominal aorta, the collateral circulation is established in quite a short time, pulsation in the femoral artery having returned in less than ten hours, in the case of ligature of the aorta, reported by Mr. Stokes. In old persons, or in those whose arterial system is affected by atheromatous or fatty degeneration, the collateral circulation is less readily established and less perfectly maintained than in the young and healthy, the reason of this obviously being that the arteries of the latter are more elastic, and dilate with greater facility to accommodate the increased flow of blood through them. On the other hand, in cases of chronic aneurism, the obstruction has some- times gradually caused the establishment of the collateral circulation before ligation is practised, so that under these circumstances surgical interference may be even less resented than when employed for wounds of healthy arteries. This statement would appear to be contradicted by the well-known fact that gangrene is more frequent after ligature for aneurism, than after that for traumatic causes, but, as will be seen hereafter, the gangrene in the former case is usually from venous, not from arterial obstruction. Not only does anastomosis take place between collateral branches, but an indirect communication is sometimes re-established between the divided ends of the obliterated trunk. Finally the fibrous cord, which connects the divided extremities of the artery, occasionally becomes itself pervious, allowing a narrow but direct channel of communication between the proximal and distal ends of the vessel. The establishment of the collateral circulation is sometimes attended with pain, apparently from pressure of the enlarging vessels upon contiguous nerves ; this is most marked in cases of aneurism, in which additional pres- sure is caused by the coagulation of the blood contained in the sac. Secondary Hemorrhage__The most frequent accident after the use of the ligature or other artificial means of arterial occlusion, is unquestionably secondary hemorrhage. This may arise from a variety of causes, some of which are local and some constitutional. Among the local causes may be mentioned, (1) imperfect application of the occluding means ; as when the vessel has been tied so near its cut extremity that the noose slips off prema- turely, when the knot has been carelessly made, when a large amount of extraneous tissue has been included in the noose of the ligature, so that this becomes loosened before the vessel is healed, or (which is especially apt to happen with acupressure) when the vessel has been compressed only enough to check bleeding while the force of the heart is diminished by shock or by the use of an anaesthetic, but not enough to occlude the artery when reaction has occurred; (2) the giving off of a large collateral branch either imme- diately above or immediately below the point of occlusion, a circumstance which, though not necessarily a cause of secondary hemorrhage, is very apt to be so, from limiting the extent of the internal coagulum in the proximal, and more especially in the distal end of the vessel; and (3) a diseased con- dition of the coats of the artery itself: this may cause hemorrhage directly, either by allowing the ligature to ulcerate through the vessel prematurely, or by allowing rupture to take place above the site of the ligature; or more rarely indirectly, by giving rise to the formation, above the ligature, of an aneurism which subsequently bursts and permits the escape of blood. In other cases secondary, or rather consecutive hemorrhage may occur from vessels which escape the notice of the surgeon during an operation, or (in case of ligation in the continuity) from small anastomosing branches, which, though wounded, do not begin to bleed until enlarged by the establishment of the collateral circulation. The constitutional causes of secondary hemor- 192 INJURIES OF BLOODVESSELS. rhage may be said to be any conditions of system which interfere with the natural processes which we have seen to be essential for the closure of wounded arteries. Thus, a want of coagulability in the blood itself, the " hemorrhagic diathesis," visceral disease (especially of the liver), an unusually severe attack of ordinary traumatic or inflammatory fever, certain affections which are apt to occur after operations, especially erysipelas, pyaemia, hospital gangrene, or even ordinary sloughing, may all be considered as causes of secondary hemor- rhage. In the case of pyaemia, the hemorrhage often consists of capillary oozing—the parenchymatous hemorrhage of Stromeyer and Lidell—and is apparently due to mechanical obstruction, from thrombosis of the venous trunks of the part. J. H. Porter has described an intermittent form of hemorrhage, which he thinks is due to malarial influence. Occasionally a single secondary hemorrhage may prove fatal, but more usually there are a number of successive gushes, of which the first may be comparatively slight, the patient being gradually reduced to a state of extreme anaemia, and dying rather from repeated losses of blood, than from the quan- tity lost at any one time. AYhen hemorrhage occurs after ligature of an artery in its continuity, it is almost invariably from the distal extremity of the vessel. The reasons for this appear to be (1) that, as already remarked, the distal clot is smaller and less firm than the proximal, and (2) that, from the constriction of the ligature interfering more with its vasa vasorum, the distal end of the vessel is more exposed to sloughing than the proximal. Secondary hemorrhage may occur at any time after the application of a ligature, though it is most common about the period of separation of the lat- ter ; when it occurs earlier, it is usually owing to some defect in the mode of occlusion, to disease of the arterial tunics, or to some of the systemic condi- tions which have been referred to. Secondary hemorrhage is occasionally met with, weeks or months after the separation of the ligature; in these cases it is usually due to the occurrence of sloughing, or to the dissolution and reab- sorption, under the influence of constitutional causes, of the coagulum and inflammatory adhesions by which closure of the vessel was effected. Treatment of Secondary Hemorrhage___The constitutional treatment of secondary hemorrhage does not differ from that already described as appro- priate to the primary affection; the most valuable medicines, in this condition, are, I think, opium and ergot, which may be freely administered; special care should be taken to prevent any straining in defecation or violent cough- ing; quinia should be given if there is any malarial complication. The local treatment of secondary hemorrhage varies according as the bleeding proceeds from a stump, or from an artery ligated in its continuity. It should be pre- mised that the rule not to operate on an artery which has stopped bleeding, does not apply in either of these cases. As Air. Erichsen puts it, the surgeon in these cases may after the first, and must after the second bleeding adopt determined measures to prevent a return of the hemorrhage. 1. Secondary Hemorrhage from a Stump may, if in only moderate amount, be often checked by the judicious application of pressure, position, and cold. Should, however, these means fail, or should the bleeding be so free as to render it probable that it comes from a large vessel, the proper course to be pursued depends upon the condition of the stump itself; if the process of cicatrization in the latter be not far advanced, or, under any circumstances, if its cavity appear to be stuffed and distended with clots, the surgeon should without hesitation break up the adhesions, and search for the bleeding artery on the face of the stump itself, applying a fresh ligature to whatever vessel is found to be in fault. If, on the other hand, the stump be nearly healed, and do not appear to be stuffed with clots, it is proper to attempt to secure the bleeding vessel, or the artery of which it is a branch, immediately above the GANGRENE AFTER ARTERIAL OCCLUSION. 193 stump: this may be done by cutting down and applying a ligature, or, pre- ferably, by acupressing the vessel by Simpson's first method; this is one of the exceptional cases in which acupressure seems to be particularly applicable, and there would be every reason to hope, under such circumstances, that the temporary occlusion of the artery by the pin would be sufficient to allow the completion of the natural process of repair at the cut extremity of the vessel. Ligation of the main artery of a limb, for hemorrhage from a stump, is in most situations a bad operation, and should only be resorted to when prolonged search has failed to find the artery in the reopened wound (an event wliich may occur from the sloughing and disorganized condition of the part), and when the vessel cannot be secured immediately above the stump. The rea- sons for this are, that in many cases the operation would fail to check the hemorrhage, that it would expose the patient to great risk of gangrene, and that it would superadd an operation, in itself serious, to the dangers which already existed: hence, in some situations, even re-amputation might be a safer and better procedure than ligation of the main trunk. In some posi- tions, however, as after amputation at the shoulder-joint, or high up in the thigh, ligation of the main trunk may be the only resource available, and in such cases the vessels to be secured are the axillary for the upper, and the external iliac for the lower extremity. 2. Secondary Hemorrhage from an Artery previously Ligated in its Con~ tinuity is an accident of the gravest nature. In its treatment the surgeon may properly first try the effect of pressure, adjusting accurately to the bleed- ing point a graduated compress, and keeping it in position with a ring tour- niquet, or arterial compressor. In the case of some arteries, as the subclavian or iliacs, and generally in the case of vessels situated about the trunk, no other means are applicable, and the use of pressure should then be persevered in, though it must often prove ineffective. In the case of the upper extremity, if pressure fail, the surgeon should treat the vessel as one primarily wounded, cutting down and tying the vessel above and below the source of hemorrhage; if hemorrhage again recur, or if the bleeding vessel cannot be found or secured in the wround, a ligature may be applied with fair hope of success to the main artery at a higher point. Should this fail, amputation at the highest point of ligature should be resorted to. In the lower extremity, the case is somewhat different. If the bleeding be from the femoral artery, an attempt may be made to apply fresh ligatures in the wound, above and below the source of hemorrhage, and this course will occasionally succeed, though, as shown by Air. Cripps's statistics, carefully applied pressure is upon the whole the most promising remedy in these cases. The tibial vessels lie so deeply that it would be almost hopeless to attempt a second ligation in case of secondary hemorrhage after tying one of them, though it might perhaps be tried, if the condition of the patient warranted the effort. Ligation of the main trunk under these circumstances in the lower extremity would almost inevitably cause gangrene, and should not be attempted. Amputation at or above the site of ligature would be a safer operation, and should, I think, in this situa- tion, undoubtedly be preferred. Gangrene after Arterial Occlusion, whether from disease or from surgical interference, is due to a deficiency in the collateral circulation ; it is most often met with in the lower extremity, and in those whose arteries from age or other cause are in an inelastic condition, whether accompanied or not by positive degeneration. Among the exciting causes may be mentioned loss of blood (as from secondary hemorrhage), venous congestion (hence it is more frequent after ligations for aneurism than after those for wounds), ery- sipelas, the application of cold or of excessive heat, or the use of even mode- 13 194 INJURIES OF BLOODVESSELS. rately tight bandages. It is usually manifested from the third to the tenth day, and is commonly, on account of venous implication, of the moist variety ; occasionally, however, it assumes the character of dry gangrene or mummifi- cation. These conditions have been already described, in discussing the subjects of inflammation and of mortification as a cause for amputation, and need not therefore be again referred to. Much may be done to prevent the occurrence of gangrene after ligation of an artery, by wrapping the limb in cotton-wool, so as to keep up its temperature and protect it from external injury, and by placing hot bottles or hot bricks under the bedclothes, though not in contact with the limb. Should there be much venous congestion, gentle but methodical friction from below upwards might be practised, so as to assist in emptying the superficial veins. Should gangrene actually occur, amputation must be practised through the site of arterial occlusion, unless, when after injury of the femoral artery, the gangrene is limited to the foot, when, as pointed out by Guthrie, amputation below the knee will usually be sufficient. (See page 91.) Remote Consequences of Arterial Occlusion—Even when everything goes well after the ligation of a main artery, the limb is sometimes left for a long while numb and weak. In the case of the lower extremity, it is often cede- matous, and apt to become inflamed from apparently slight causes. In such cases the limb should be warmly clad, and supported with an elastic bandage, while care should be taken to avoid undue pressure, which might give rise to ulceration, or even gangrene. Traumatic Aneurism___Under this name are included several dis- tinct affections :— 1. The Diffused Traumatic Aneurism (so called), is, as Prof. Gross justly remarks, no aneurism at all, but merely a collection of arterial blood in the tissues of a part, differing from an ordinary case of wounded artery simply by there being no communication with the external air. This condition of affairs may result either from an originally subcutaneous lesion of an artery, or from the external wound healing before the arterial aperture itself is closed. It not unfrequently is a consequence of gunshot injury, the arterial wall being bruised though not severed by the contact of the ball, and giving way after an interval of perhaps several weeks, during which the external wound may have com- pletely healed. The diagnosis of this condition can usually be made wTith tolerable facility; there is an oblong, somewhat pyriform swelling, more or less elastic and fluctuating, and, if the arterial wound be tolerably free, accom- panied by a distinct impulse, and often by a marked thrill and aneurismal bruit. The limb belowr is oedematous, and the pulse very feeble or completely absent. As the disease advances, the skin covering the tumor becomes tense, thin, and discolored, and unless efficient treatment be adopted, the limb may become gangrenous, though more commonly the tumor will suppurate and open externally, allowing profuse secondary hemorrhage to occur. The treat- ment is the same as for an ordinary case of wounded artery. The circulation being temporarily controlled by pressure applied as already directed, the sur- geon lays open the tumor, turns out the clots, and applies ligatures to both ends of the affected vessel; this is most conveniently done by introducing a director into the mouth of the artery, dissecting it up for about an inch, and passing a ligature around it with an ordinary aneurismal needle. If the arte- rial wound be in such a situation that effective pressure cannot be made above it during the operation, the surgeon must proceed more cautiously, in the way recommended by Prof. Syme; in this case the incision should be at first merely large enough to admit one or two fingers of the left hand, which may plug the wound as they are introduced, and thus prevent hemorrhage, until, ARTERIO-VENOUS WOUNDS. 195 guided by feeling the current of warm arterial blood, they reach the aperture in the vessel; having thus control of the bleeding orifice, the surgeon may now enlarge his incision, turn out the clots, and still keeping up pressure with the left hand, endeavor to pass a ligature with the right; in doing this, a mounted needle, eyed at the point (Fig. (>7), or a short curved needle, held with suitable forceps, may prove of more service than the ordinary aneurismal needle. In some instances, especially in military practice, the safety of the patient will be more promoted by amputation, than by any attempt to secure the vessel by ligation ; particularly is this the case when the brachial artery is wounded near its origin, the aneurismal tumor encroaching upon the axilla; under such circumstances I believe amputation at the shoulder-joint to be often the best mode of treatment. 2. There is another form of traumatic aneurism, of which the pathology is the same as of that which has been described, but in which the extravasation is less extensive, and in which an adventitious sac has been formed by the condensation of the surrounding areolar tissue. This, which is, clinically speaking, a Circumscribed Traumatic Aneurism, commonly results from punctured wounds, and is rarely met with except in the course of the smaller arteries ; it may be treated by laying open the sac and tying the vessel above and below ; or, if in a position where this operation would be undesirable, as in the palm of the hand, the main trunk may be ligated with the prospect of a favorable result. AYhen met with in connection with a large artery, a proxi- mal ligature may be applied as close as possible to the sac, without opening the latter. 3. Another form of circumscribed traumatic aneurism is that which has f, been called "Hernial," and which results from the protrusion of the inner "l^y~<~ coats of the vessel through a wound or laceration of the outer tunic. This' form of aneurism is extremely rare, its existence indeed being doubted by/ many writers. 4. The True Circumscribed Traumatic Aneurism results from a punctured wound of an artery (generally a large one), which has healed, the cicatrix afterwards yielding, and a true sac being thus formed from the external coat of the vessel and its sheath. The treatment consists in compression or in ligation of the artery at as short a distance as possible above the sac. Should, however (in any of these forms of circumscribed traumatic aneurism), the sac burst, allowing the aneurism to become diffused, or should suppuration or gangrene appear imminent, the proper course would be to lay open the part freely, and apply ligatures above and below, as in the case of the so-called diffused traumatic aneurism already described. Arterio-venous Wounds.—Occasionally an artery and its contiguous vein are simultaneously wounded, the external wound healing, but a commu- nication remaining between the two vessels. This accident most frequently follows upon punctures, as of the brachial artery in bleeding, though it may also result from a gunshot wound, as in a case to which I have already referred. The preternatural communication between an artery and vein may assume two distinct forms, known respectively as aneurismal varix and vari- cose aneurism. Aneurismal Varix consists in a direct communication between an artery and a vein, part of the arterial blood finding its way into the vein, which is dilated and somewhat tortuous ; the symptoms are the presence of a small, somewhat oblong, compressible tumor, with a jarring sensation communicated to the hand, and a buzzing or rasping sound, rather than the ordinary aneu- rismal whirr. The sound is more distinct above than below the tumor, and the limb is usually somewhat weaker and colder than natural. The condition 196 INJURIES OF BLOODVESSELS. is not progressive, and requires, as a rule, no treatment beyond the support of an elastic bandage : should anything further be needed, the artery must be tied above and below its aperture. Varicose Aneurism___In this form of arterio-venous aneurism, there is a distinct sac, which communicates also with a vein, which is itself always Fig. 90. ABC D A, aneurismal varix; B, C, and D, varicose aneurisms ; a, artery ; v, vein; s, sac. (Bryant. varicose. It differs from an aneurismal varix, in that the arterio-venous communication is indirect, through an interposed aneurismal sac. Its symp- toms are a combination of those of aneurismal varix and of ordinary trau- matic aneurism : the tumor gradually enlarges, and becomes more solid from the deposition of fibrin, there is a distinct impulse added to the jarring sensa- tion of the aneurismal varix, and there is an aneurismal whirr superadded to the rasping sound heard in the former affection. The sac in this form of dis- ease has two openings, one into the artery and one into the vein, and thereby is much in the condition of the sac of a traumatic aneurism which has become diffuse by rupture; hence the proper treatment consists in laying open the tumor and tying the artery above and below; in doing this, it must be borne in mind that the first incision (wliich opens the dilated vein) merely exposes the external orifice of the sac, and that this must be laid open by a second incision, when the aperture of the artery will be found more deeply seated. Annandale advises that both artery and vein should be secured with double ligatures, and reports a case of traumatic popliteal arterio-venous aneurism successfully treated in this way. For the varicose aneurisms met with at the bend of the elbow, A^anzetti recommends simultaneous compression of the brachial artery and the basilic vein. Lines of Incision for Deligatiox of Special Arteries. I have gone so fully into the discussion of the principles which should guide the surgeon in the management of arterial hemorrhage, and of the various accidents which follow arterial wounds, that I do not think it necessary or even desirable to recur to the subject in connection with each special artery. I purpose merely, therefore, in this place, to indicate as concisely as possible the lines of incision to be adopted in applying ligatures to the several arteries, whether the operation be required on account of injury or of disease. The statistics of the various ligations will be fully considered under the head of Aneurism. Innominate or Brachio-eephalic Artery—This vessel may be reached by an incision at least two inches long, corresponding to the anterior LIGATION OF INTERNAL CAROTID. 197 edge of the left sterno-cleido-mastoid muscle, and extending in the form of an j across the top of the sternum, and in the line of the right clavicle (Fig. 91). Care must be taken to avoid the thyroid plexus of veins, the middle Fig. 91 Ligation of the innominate artery. A. Innominate. B. Carotid. C Subclavian. D. Inferior thyroid vein E. Sterno-mastoid muscle. F. Sterno-hyoid and sterno-thyroid muscles. (Skey.) thyroid artery, and the pneumogastric and phrenic nerves. The needle should be passed behind the artery, from without inwards, so as to avoid the innominate vein which lies on its outer side. Common Carotid___This vessel may be tied either above or below the point at which it is crossed by the omo-hyoid muscle (Fig. 92). In either case, the guide to the artery is the inner edge of the sterno-mastoid muscle, the patient's head being thrown backwards, and inclined to the opposite side. The incision for the upper operation (which is the best, when practicable) extends from near the angle of the jaw to a little below the cricoid cartilage; for the lower operation, from a little above the cricoid cartilage to about three inches downwards, along the edge of the sterno-mastoid muscle. The ligature should be passed from without inwards, avoiding the jugular vein and pneumogastric nerve. In opening the sheath, care should be taken to avoid the " descendens noni" nerve, wliich, however, it is said, has been occasionally divided in this operation, without unpleasant consequences resulting. External Carotid___This vessel may be reached by an incision parallel to, but half an inch in front of, the inner edge of the sterno-mastoid muscle, and extending from near the angle of the jaw to a point corresponding to the middle of the thyroid cartilage. Internal Carotid__Should it be thought proper in case of a wound of this vessel to attempt its ligation rather than that of the common trunk, an incision may be made as for ligation of the latter in its upper part, the vessel being traced to its bifurcation, and ligatures then applied above and below the bleeding orifice. Dr. AY. 0. Byrd, of Illinois, has reported a case in which he (unsuccessfully) tied the common carotid and both its branches for gun- shot injury. 198 INJURIES OF BLOODVESSELS. Vertebral Artery__This vessel may be reached by an incision corre- sponding to either the anterior (Alaisonneuve) or the posterior border (Smyth) of the sterno-mastoid muscle. The guide to the artery is the transverse pro- cess of the sixth cervical vertebra. Fig. 92. Ligation of carotid and facial arteries. (Bryant.) Superior Thyroid__This vessel may be reached either by an incision across the upper part of the neck, from the side of the hyoid bone obliquely outwards and downwards to the edge of the sterno-mastoid muscle, or by an incision of about two inches along the inner border of the latter muscle. Lingual Artery.—This may be tied through an incision an inch long, made in a direction downwards and forwards, immediately behind the corner of the hyoid bone (Fig. 95). The superior laryngeal nerve should be care- fully avoided in passing the needle. Podraski and Hueter recommend an incision along the upper border of the hyoid bone. The platysma myoides being divided, and the submaxillary gland turned upwards, the artery is found immediately beneath the fibres of the hypoglossus, in the so-called triangle of Lesser. The Facial Artery is most easily secured where it crosses the lower jaw (Fig. 92) ; the Occipital, as it emerges from beneath the splenius muscle, behind the mastoid process of the temporal bone (Fig. 93) ; and the Temporal, immediately above the zygoma (Fig. 94). Subclavian Artery.—The Rigid Subclavian may be tied in the first part of its course, that is, between the trachea and the scaleni muscles, by the incision recommended for ligature of the innominate ; on the left side the LIGATION OF SUBCLAVIAN ARTERY. 199 vessel is so deeply seated as to render the operation almost impracticable, though if it be attempted, the same incision (reversed) should be employed. This operation has, I believe, been performed but twice on the living subject —by J. K. Rodgers, of New York, and by McGill, of Leeds, the latter sur- Fie. 93. Fie. 94. Ligation of the occipital artery. (Skey.) Ligation of the temporal artery. (Skey.) geon's operation being indeed not strictly a ligation, but an attempt to cure a subclavian aneurism by exposing the vessel and temporarily compressing it Fie. 95. Ligation of subclavian and lingual arteries. (Bryant with torsion forceps. Either subclavian may be tied in the third part of its course, or exterior to the scaleni muscles, by an incision about three inches 200 INJURIES OF BLOODVESSELS. long, corresponding to the upper border of the clavicle, the shoulder being drawn down, and the head turned to the opposite side ; in dividing the super- ficial fascia, care must be taken not to Avound the external jugular vein. After cutting through, if necessary, some of the fibres of the sterno-mastoid mus- cle, the surgeon cautiously works his way down to the outer edge of the scalenus muscle, in the angle between which and the first rib, the vessel lies: the needle should be introduced from below upwards. The artery may be tied in the second part of its course, by the same incision, the anterior scale- nus muscle being cautiously divided upon a grooved director ; the parts to be specially guarded from injury in this operation are the phrenic nerve, the jugular vein, the thyroid axis, and the pleura. Mr. Skey recommends for ligature of the subclavian in its outer part, an arched incision, which " is commenced about two and a half or three inches above the clavicle, upon, or immediately on the outer edge of the mastoid muscle, . . . carried slightly outwards and downwards towards the acromion, and then curved in- wards along the clavicular origin of the mastoid muscle." Axillary Artery__This vessel may be tied either below the clavicle or in the axillary space. For the former operation, an incision either straight or semilunar (in which case it must be convex upwards) is made below the clavicle from near its sternal end to near the attachment of the deltoid mus- cle. The fibres of the pectoralis Fig. 96. major require division, and care must be taken to avoid the cephalic vein and acromial thoracic artery. The needle is passed from beloAV upwards. To secure the artery in the axilla, an incision of about three inches is made along the border of the latissimus dorsi muscle, though many surgeons prefer an incision more oblique to the course of the vessel; the ligature may be passed from within outwards, between the roots of the median nerve, which, in this position, lie on either side of the artery. Brachial Artery__This ves- sel may be tied in its upper part by an incision along the inner edge of the coraco-brachialis muscle, or in its middle and lower parts by an in- cision corresponding to the ulnar edge of the biceps. The artery lies very superficially in its whole ex- tent, and is perhaps more easily tied than any other in the body. The ulnar nerve lies to its inner side, while the median nerve, which above is to the outside of the vessel, crosses in front of it at about its middle. In operating upon the Ligation of the brachial, radial, and ulnar arte- brachial artery, its occasional high lies; also of the palmar vessels. (Miller.) division must be borne in mind. GLUTEAL AND SCIATIC ARTERIES. 201 Radial Artery.—This vessel, in its upper part, lies between the supi- nator longus and the pronator teres muscles ; and, below, between the former and the flexor carpi radialis. It may be reached in any portion of its course by an oblique incision crossing a line from the middle of the arm, at the bend of the elbow, to the ordinary place of feeling the pulse. The radial artery behind the thumb may be exposed by an incision about an inch long, across the proximal ends of the metacarpal bones of the thumb and forefinger. Ulnar Artery___The general course of this vessel may be described by a line drawn from the middle of the bend of the elbow, obliquely inwards, to a point half-way down the forearm, and thence parallel to the ulnar edge of the latter, but an inch to its outside. The radial border of the flexor carpi ulnaris may be considered a guide to the vessel in the middle part of its course. Interosseous Artery__This vessel may be reached by an incision similar to that required for ligation of the ulnar in its upper third. The operation has been successfully performed by Alichel, of Nancy, but is very seldom required. Abdominal Aorta__The aorta may be reached by a curved incision on the left side of the body, convex towards the vertebra?, and extending from the cartilage of the tenth rib to near the anterior superior spinous pro- cess of the ilium, the length of the wound being about six inches. The various structures being divided down to the peritoneum, this membrane is cautiously pushed backwards, the surgeon tracing up the common iliac to its bifurcation, about an inch above which the ligature should be applied; the needle is passed around the aorta from left to right, and from behind forwards, special care being taken not to injure the vena cava, which lies to the right, nor the filaments of the sympathetic nerve, which lie in front of the vessel. Common and Internal Iliacs—Either of these arteries may be reached by a curved incision, five to seven inches long, passing from above the anterior superior spinous process of the ilium, about half an inch above Fig. 97. Poupart's ligament, to the external abdominal ring; the peritoneum is care- fully stripped upwards, and the needle passed from within outwards, around whichever vessel is to be secured. In tying the interned iliac, the surgeon must be specially cautious not to wound the external iliac vein, which lies in the angle formed by the bifurcation of the common artery. Gluteal and Sciatic Arteries. .—The former vessel may be reached by an incision in a line from the posterior superior spinous process of the ilium, to a point midway between the tuber ischii and the great trochanter; the latter by a similar incision, about an inch and a quarter below the position of that already described. Ligation of the common iliac. (Liston.) 202 INJURIES OF BLOODVESSELS. External Iliac—This vessel may be tied by Listen's modification of Abernethy's method, or by that recommended by Sir Astley Cooper. In the first operation an incision is made from about two inches within the anterior superior spinous process of the ilium, in a curved line, inwards and down- wards, to an inch and a half above the middle of Poupart's ligament; the wound, which is convex downwards, should be three or four inches long. All the tissues being carefully divided down to the peritoneum, the latter is cautiously pushed and held out of the way, while the artery is secured by passing the needle from within outwards. Cooper's incision (Fig. 98), is Fig. 98. Ligation of the external iliac and superficial femoral arteries. (Bryant.) about three inches long, parallel to and a little above Poupart's ligament, and reaching from near the anterior superior iliac spine, to a point above the inner border of the abdominal ring. The external oblique tendon bein» divided, the spermatic cord appears, and beneath it the artery may readily be found. The disadvantages of this operation are the risks of woundinc the epigastric artery and circumflex artery and vein ; hence, in most cases, Abernethy's is the best incision, especially as it can very easily be extended upwards, so as to allow the common trunk to be reached, if that should be found necessary. LIGATION OF POSTERIOR TIBIAL. 203 Femoral Artery—The Common Femoral artery can be readily reached by an incision made directly downwards from Poupart's ligament, in the line of pulsation of the vessel; the operation of ligation is, however, not very safe in this situation, and the external iliac is usually tied in preference to the common femoral. The Superficial Femoral artery may be tied in any portion of its course, though the operation is best done at the apex of '• Scarpa's triangle," where the artery is crossed by the sartorius muscle (Fig. 98) ; the incision for this operation should be three or four inches long, beginning about two inches below Poupart's ligament, midway between the anterior superior iliac spine and the symphysis, and carried down- wards in the axis of the limb, somewhat obliquely to the edge of the sartorius muscle. The femoral vein in this part of its course lies to the inside of the artery, and the needle should, therefore, be passed from within outwards. The femoral artery may also be tied at a lower point, where the sar- torius muscle will still be the guide for the sur- geon's incision, the vessel, which at first lies inside of this muscle, afterwards crossing beneath it, and finally being external to it. The Profunda, or Deep Femoral Artery, may be reached by an incision similar to that employed for the common femoral, the latter vessel being traced down to its bifurcation, and the deep femo- ral tied about half an inch below the origin of its circumflex branches. Ligation of the popliteal at its upper and lower parts, a. The popliteal vein. 6. The popliteal artery, c. The posterior saphe- nous vein. The popliteal nerve, on the outside of the artery, has been omitted in the diagram. (Miller.) Popliteal Artery___This vessel may be reached in its upper third by an incision along the outer border of the semi-membranosus muscle, and in its lower third by an incision between the heads of the gastrocnemius (Fig. 99). The vein in the former situation lies to the outer, and in the latter to the inner side of the artery ; in either case the needle should be introduced between the two vessels. Anterior Tibial___This artery may be found, in its upper third, in the space between the tibialis anticus and extensor communis muscles. The in- cision is made rather more than an inch outside of the spine of the tibia, and should be about three inches long. In its lower half the artery may be found just outside of the extensor proprius pollicis tendon, which, in this situation, is the guide for the surgeon's incision. Care must of course be exercised in passing the ligature, to avoid the venae comites and the peroneal nerve. On the dorsum of the foot, this artery may readily be found between the tendons of the extensor pollicis and extensor brevis digitorum. Its course corresponds to the line of the first metatarsal interspace. Posterior Tibial___This artery may be tied in the calf of the leg, or just above the ankle : in the former position, the operation should only be done for hemorrhage, when the wound must be made the guide for the inci- sion, which should be in the direction of the fibres of the gastrocnemius, and about four inches long. Above the ankle, the artery may be easily reached by a semilunar incision, concave forwards, about three-fourths of an inch 204 INJURIES OF BLOODVESSELS. behind the inner malleolus, and from two to three inches in length ; the needle should be passed from behind forwards, so as to avoid the accompany- ing nerve. Fig. 100. Fig. 101. Ligation of the anterior tibial at various parts. Ligation of the pos' erior tibial at various parts. The wounds are supposed to be held asunder. The wounds are supposed to be held asunder. The ligature is under the vessel. (Miller.) The ligature is under the vessel. (Miller.) Peroneal Artery__If this vessel should require ligation, which can only be in case of wound, an incision must be made similar to that recom- mended for ligation of the posterior tibial in its upper third, except that in this instance it will of course be on the outer or fibular side of the calf. The artery will be found lying in a groove between the fibula, flexor pollicis mus- cle, and interosseous ligament. INJURIES OF NERVES. 205 CHAPTER X. INJURIES OF NERVES, MUSCLES AND TENDONS, LYMPHATICS, BURS^E, BONES, AND JOINTS. Injuries of Nerves. Contusions—Xerves are frequently subjected to contusion; the effects of this injury, which is manifested by local pain and a tingling sensation (pins and needles, as it is popularly called) along the course of distribution of the nerve fibres, are commonly evanescent, though in persons of a hysteri- cal or nervous disposition they may be more permanent, giving rise, in some instances, to a distressing form of neuralgia; or the neurilemma may become thickened as a consequence of the bruise, causing by pressure a form of par- tial paralysis, or, more rarely, a secondary morbid condition of the nerve centres. Laceration or Rupture of nerves sometimes occurs as a subcutaneous injury, as in cases of dislocation, when the lesion may be a direct result of the injury, or may be caused by the force used in attempts at reduction. Paralysis sometimes exists in these cases from the first, or may come on several weeks subsequently, and be attended with muscular atrophy; according to Duchenne, sensation is less impaired in these cases than motion. The treatment should consist in the use of electricity, douches, and suitable gymnastic exercises. Punctured Wounds of nerves usually result from the pricks of needles, or of the lancet in venesection. Partial paralysis and neuralgia may result, and may affect not only the parts supplied by the injured nerve, but adjoining parts as well, as in cases recorded by Graves and others. In some instances, general convulsions have been observed, and in one case, quoted by Mitchell ^ - from Swan, relief was afforded only by making a free incision above the seat of injury. Complete Division of a nerve causes paralysis of the parts supplied, ^ ^ with a diminution of temperature, and certain nutritive changes which have \ \ been studied by Mr. Paget, and more recently and more fully by Drs. J Mitchell, Morehouse, and Keen, of this city, and by Dr. Middleton Michel, of Charleston, S. C. These nutritive changes may be classified as diminished \ * tension with muscular atrophy and contraction; a peculiar alteration of the , skin and its appendages, manifested by a glossy appearance, loss of hair, in- * ' i eurvation of nails, and the occurrence of eczematous eruptions ; subacute, j v| rheumatoidal, articular inflammations (arthropathies) ; absence of perspira-, A \^ tion from the affected part; the whole accompanied in many cases by a \ \ peculiar and very distressing burning pain. In some rare instances the'tO*^ temperature of the affected part is absolutely higher than the normal standard. ^-' Repair of Nerves after Division__The divided ends of a cut nerve are observed to become bulbous, the proximal being invariably larger than the peripheral bulb, and to pass through certain degenerative changes 206 INJURIES OF NERVES. W.allerian degeneration of median nerve meters. (Bertolet.) 180 dia- which have been particularly studied by "Waller and by Ranvier, and in this country by Dr. R. M. Bertolet, and which are suljsequently followed by a process of repair, the nuclei of the Fig. 102. neurilemma undergoing prolifera- tion, and the continuity of the trunk being ultimately restored by means of delicate fibres pro- jected from either segment, and by the coalescence of spindle cells in the intermediate cicatricial portion. In some cases neighbor- ing nerves appear to act vicari- ously for those trunks which are divided, thus presenting a con- dition somewhat analogous to the collateral circulation in cases of arterial obliteration. If a large portion of a nerve be excised, there is usually no reproduction, and the only chance of restoration of function is in the vicarious action above alluded to. In some cases the extremity of a divided nerve, or even an undivided nerve, becomes involved in the dense tissue of a cicatrix, or in the exuberant callus produced in the repair of. a fracture. A very painful neuralgic and paralytic condition may result from this circumstance, requiring surgical interference, which has been suc- cessfully applied in such cases by Warren, Oilier, Busch, and others. Treatment of Wounded Nerves—It has been proposed to unite the cut extremities of divided nerves by means of sutures, and several cases have been reported in which this has been done with favorable results. There is, however, no reason, according to Mitchell, who has paid particular attention to this subject, to believe that immediate union of a cut nerve can ever be obtained, though the use of a suture might hasten restoration of func- tion. If this plan should be resorted to, the ends of the nerve may be brought together with a delicate wire secured by passing its extremities through a per- forated shot or Galli's tube (as was done by -Nekton), or a fine pin or acupres- sure needle and wire loop may be used as in the hare-lip suture. Braun and Langenbeck have reported cases in which nerve-suture was resorted to long after the occurrence of the injury. There does not, I confess, appear to me to be sufficient evidence of the success of this operation to warrant its adoption, unless in exceptional cases, while its use would seem, in itself, not wholly free from risk. The pain attending nerve wounds may be alleviated by the application of warmth or cold, according to the feelings of the patient, and especially by the hypodermic use of morphia. Repeated blistering is recom- mended by Dr. Mitchell and his co-laborers, for the burning pain of nerve injuries (causalgia)—and for the muscular atrophy, faradization with the elec- tro-magnetic battery, shampooing, and the alternate use of hot and cold douches. In a case of painful spasmodic contraction of the forearm, follow- ing a gunshot injury, Niissbaum afforded relief by exposing and forcibly stretch- ing the nerves which supplied the affected part, and similar operations have been since reported by the same surgeon, and by Billroth, Gartner, Callen- der, Palmer, Petersen, T. G. Morton, Jos. Bell, and others. I have myself INJURIES OF MUSCLES AND TENDONS. 207 stretched the musculo-spiral nerve for traumatic neuralgia of the hand, but with only temporary advantage. Reflex Paralysis, resulting from injuries of nerves, is a very interest- ing subject, but belongs more to the domain of physiology than to that of practical surgery; it has been specially studied by Prof. Brown-Sequard, by Dr. Mitchell, of this city, and by Dr. Echeverria, of New York. Injuries of Muscles and Texpons. Strains and Sprains of muscular tissue are of very frequent occurrence, and vary in severity from the slightest stretching to absolute rupture of some of the muscular fibres ; the treatment consists in keeping the parts at rest, in the use of slightly stimulating embrocations, and in the internal administra- tion (in cases occurring to patients of a rheumatic tendency) of Dover's pow- der with colchicum or iodide of potassium. Corrigan's button cautery may be applied if the pain be very persistent, while the atrophy and paralysis, which sometimes result, require faradization, shampooing, etc. Subcutaneous Rupture of muscles and tendons may occur either from external violence, or from the forcible contraction of the muscle itself. Thus, the abdominal muscles are sometimes ruptured during the process of parturition, while muscular rupture is a frequent attendant upon the spasms of tetanus. Rupture of the sterno-cleido-mastoid muscle during birth, is, according to T. Smith, the cause of the so-called congenital tumor or indura- tion of that muscle. Rupture of tendons is apt to occur from sudden and unusual exertions, especially on the part of persons past the middle time of life; thus, the tendo Achillis has been known to give way in elderly gentle- men who indulge in the juvenile amusement of dancing. The line of rupture mav be through the muscle or through the tendon, though more commonly at their line of junction ; more rarely the tendon may be separated from its point of insertion. The symptoms of this accident are sufficiently evident. The patient experiences a sudden shock, attended with a sharp pain, (coup defouet), and sometimes an audible snap ; the power of using the part is lost; and usually a distinct depression or hollow can be felt at the line of rupture. If the part be the seat of varicose veins, thrombosis and milk-leg may follow, as pointed out by Verneuil. The treatment consists in placing the part in such a posi- tion as will relax the affected muscle or tendon, and allow its divided extremi- ties to be approximated as closely as possible. Repair in these cases is effected, as shown by Paget, Adams, and Demarquay, by the development of a new tissue between the divided extremities, which in the case of a tendon gradually assumes the character of the original structure, but in the case of a muscle remains permanently as a fibrous band.1 Rupture of the tendo Achillis may be conveniently treated by an apparatus consisting of a collar placed above the knee, with a cord wliich pulls up the heel of a slipper applied to the foot, so as to keep the gastrocnemius muscle thoroughly and constantly relaxed. Rupture of the extensor muscles of the thigh, or of the ligamentum patella?, should be treated by keeping the limb in an extended position and somewhat elevated; after recovery, a posterior splint should be worn for some time, to prevent sudden flexion of the knee. In a case of rupture of the biceps recorded by Dr. Samuel Ashhurst, it was found sufficient to apply com- presses and a figure of 8 bandage, and to support the arm in a sling. Para- 1 According to Demarquay, however, under favorable circumstances actual regene- ration of muscular tissue may occur. 208 INJURIES OF BURS^E AND BONES. lysis or atrophy resulting from these injuries requires the use of friction, faradization, etc., as already described. Open Wounds of tendons should be treated on general principles, care being taken to avoid gaping of the part by placing the limb in a suitable posi- tion, and by the use of sutures to approximate the cut extremities, if this seem necessary. If the proximal extremity of the cut tendon should be retracted out of reach, its distal end may be attached to a neighboring tendon, as ad- vised by Denonvilliers, Tillaux, and Duplay. Annandale has successfully pared and reunited the tendo Achillis, more than two months after its division. Luxation of a Tendon from its sheath is occasionally met with, par- ticularly in the case of the biceps, peroneus, and tibialis posticus muscles; the treatment consists in restoring the displaced tendon to its normal position by manipulation, and in endeavoring to prevent redi.splacement by the use of a compress and bandage. IXJURIES OP THE LYMPHATICS. These present, ordinarily, no features requiring special comment; in some cases, however, in wliich there is a varicose state of the lymphatic trunks (a condition usually associated with one of the varieties of Elephantiasis Arabum), wounds of the affected part are followed by a copious and sometimes troublesome flow of a milky fluid, constituting a, traumatic form of what is known as lymphorrhcea. Such wounds are difficult to heal, and sometimes degenerate into obstinate fistulse. Carefully applied pressure, and the use of caustic, or even of the hot iron, would seem, in such a case, more promising than any other remedy. Injuries of Burs^e. These are chiefly of interest from the possibility of their being mistaken for injuries of adjoining articulations. "Wounds of bursas heal with oblitera- tion of the sac. Should suppuration occur in a bursa, without external wound, the part should be freely opened, and treated as an ordinary abscess. Injuries of bursas sometimes result in chronic structural changes which will be described in another part of the volume. Injuries of Bones. Beside fractures, which will be considered in a separate chapter, bones may be subjected to contusion and to alteration of shape (bending), without solution of continuity. Contusion of bone has already been referred to in the chapter on gun- shot wounds, as a consequence of wliich injuries it is not unfrequently met with. It may also occur, however, as the result of accidents met with in civil life, and is frequently productive of very serious effects as regards the limb, or even the life of the patient. The various inflammatory conditions of bone, which will be hereafter discussed, such as periostitis, necrosis, and osteo-myelitis, may all result from contusion, while in special localities, as in the skull, serious visceral complications may secondarily ensue. In the aged, shortening and atrophy may result from bone contusion, as is often seen in the neck of the femur; this condition may be mistaken for fracture. The primary treatment of contusion of bone is to be conducted in accordance with the principles which guide the surgeon in the management of contusion of INJURIES OF JOINTS. 209 other parts. The operative measures which may be required by the after consequences of this form of injury will be referred to in another place. Bending of Bone, apart from fracture, can only be met with in very early life, or under the influence of some morbid condition which diminishes the proportion of the earthy constituents of bone, as in cases of rickets or of osteo-malacia. The treatment consists in attempting to remove the deformity by the use of suitable splints and bandages. The splint may be applied to either the concave or the convex side of the limb, but in either case care must be taken to prevent sloughing at the points of greatest pressure. Injuries of Joints. Injuries of joints, apart from dislocations, which will be considered here- after, may be classed as contusions, sprains, and wounds. Contusions of joints are of frequent occurrence as consequences of falls, blows, etc., and if not very severe, and in healthy persons, are usually readily recovered from ; in other circumstances, however, the results of these injuries maybe very serious. Hip disease is not unfrequently traced to a fall or blow upon the hip, as its exciting cause, and I have known a simple fall upon the ice, in a boy of strumous constitution, to be followed by osteo-myelitis of the humerus, with suppurative disorganization of both elbow and shoulder-joints, requiring eventually amputation at the latter articulation. The treatment of contused joints should consist in keeping the part at complete rest, and in applying cold, with leeches, if necessary; and, in the later stages, in affording y support by means of an elastic bandage, and in the use of methodical friction j and of the cold douche. Sprains—A joint is said to be sprained, when, as the result of a twist J or other external violence, its ligaments are forcibly stretched or torn, with- out the occurrence of either fracture1 or dislocation. This accident may occur in any joint, though it is most frequent in the wrist, ankle, and smaller t.Joints of the foot. The condition may commonly be easily recognized. The position assumed spontaneously by the part, is that in which there is least i tension, the hand being slightly flexed and inclined to the ulnar side in the ~A case of the wrist, and the foot being extended (" pointed toe") in the case of ? the ankle. The joint presents the usual evidences of inflammation, the r swelling and heat being particularly marked, while the part, if not painful, $ is exquisitely sensitive to the touch. These symptoms may be developed in t the course of from a few minutes to half an hour, though a patient with a sprained ankle may sometimes continue to go about for several hours, not being indeed conscious of the severity of his injury till he comes to remove his boot at night. The prognosis in the large majority of cases is favorable, though, in old persons, the joint may remain stiff and painful for many weeks or even months after the subsidence of acute symptoms. The articulation sometimes becomes the seat of chronic rheumatism, while more rarely, if the patient be strumous, suppurative disorganization of the part may ensue. The treatment in the acute stage consists in keeping the joint at entire rest, and in making cold or warm applications, as most agreeable to the patient. I have often, by the use of warm spirituous fomentations, such as the tincture 1 Under the name of sprain-fracture, Callender describes an injury consisting in the separation of a tendon from its point of insertion, with detachment of a thin shell of bone ; such a case should, of course, be treated as an ordinary fracture in the same locality. 14 210 INJURIES OF JOINTS. of opium or tincture of arnica, succeeded in dispersing the swelling, and relieving the other symptoms of inflammation—stimulating them down, as it were—more quickly than by the use of evaporating lotions, as usually recom- mended. In the later stages the part must be well supported with a soap plaster and bandage, or an elastic stocking, and subjected to methodical kneading and friction (massage), and the use of the cold douche. 3/assage has been recommended in the acute stage, and is said by Dr. Graham, of Boston, to shorten the period of treatment very materially, but I confess that I should hesitate to employ it in a case of recent sprain. When a patient with sprained ankle is unable, from the nature of his avocations, to stay at home and keep the part at rest, it may advantageously be supported with a plaster of Paris bandage, which will allow of a certain amount of exercise without injury to the joint. Should the surgeon have the opportunity of seeing the case at an early period, before the occurrence of inflammatory symptoms, it might be proper to completely surround the joint with long and broad adhesive strips, superadding a gypsum bandage—a mode of treatment which has occasionally succeeded in preventing the occurrence of inflamma- tion and its troublesome sequelae ; if this plan be adopted, however, the case should be very carefully watched, lest injurious constriction or even sloughing should result from the pressure employed. Wounds of Joints.—These injuries can usually be recognized without difficulty, either by the exposure of the articular cavity, or, if the wound be smaller, by the escape of synovia; if, however, these evidences be not pre- sent, it is an imperative rule of surgery that no exploration with the probe or otherwise should be instituted, lest the very complication that is dreaded should be induced by these manoeuvres. The prognosis of a joint wound depends on the size and situation of the particular articulation which is affected, the nature of the wound itself, and the constitutional condition of the patient. "Wounds of the smaller joints, such as of the fingers and toes, are commonly recovered from without difficulty, although anchylosis of the articulation usually results. Small incised wounds of even large joints may terminate favorably under expectant treatment, while lacerated wounds of the same joints, especially if complicated with dislocation or fracture, almost inevitably require excision or amputation. Again, in a strumous patient, a compara- tively slight wound may give rise to such disorganization of a joint as would not ensue in the case of a perfectly healthy person. Treatment.—In the case of a simple, uncomplicated wround of even so large a joint as the knee, the surgeon should make an attempt to save the limb, if a portion of the instrument wliich has caused the injury remain in the wound (as often happens in cases of needle puncture), it should be care- fully extracted, and the wound then hermetically sealed with gauze and col- lodion, or with lint dipped in the compound tincture of benzoin. The patient should be kept in bed, with the limb at complete rest, the joint being surrounded with ice-bags. The diet should be unirritating, and opium may be freely ad- ministered. Under this treatment the wound may heal, and a useful articulation be preserved. If, however, the course of events takes a less favorable turn, as is apt to happen with patients in adult life, the whole joint may become acutely inflamed, that condition being then developed which is known as traumatic arthritis. This differs from the ordinary forms of arthritis, which constitute the "white swellings" so often met with in practice, in that, in them, the disease usually originates in the cartilage or the bone itself, while in the traumatic form of the affection the synovial membrane is first in- flamed, and the other tissues become involved secondarily. When traumatic arthritis occurs in a case of joint wound, the treatment above directed should EXCISION IN CASES OF JOINT WOUND. 211 be somewhat changed; the use of cold may be abandoned, and warm fomen- tations or cataplasms substituted, while a few leeches may be applied to the neighborhood of the joint, and calomel and opium exhibited internally. At the same time the strength of the patient must be sustained, by the adminis- tration of concentrated food, and even stimulants if necessary. Any abscesses which form around the joint should be opened as soon as they are detected, while, if suppuration occur within the joint itself, the question of excision or of amputation may again arise. Free incisions into suppurating joints, as recommended by Mr. Gay, are often of the greatest service. To be effective, they should be free—mere punctures are worse than useless—and should be so situated as to allow of perfect drainage ; it is not, however, necessary to slit up a joint from side to side, and it should not be forgotten that, as Mr. Holmes puts it, these incisions, "if they do no good, will certainly do harm." The object and the sole object of opening a suppurating joint is to secure free drainage, and this object can be better accomplished by an incision of moderate size judiciously placed, than by a larger one in another part of the joint. Drainage may be assisted, as suggested by Mr. Holmes, by the introduction of a Chassaignac's tube, a bent probe, or, which would be still better, a coil of fine wire, as recommended by Mr. Robert Ellis. Should this treatment prove successful, the inflamma- tory symptoms will gradually subside, and the suppuration lessen in amount, the patient eventually recovering with a probably stiff, but otherwise useful, limb; during convalescence the joint should be kept in such a position as will allow the limb to be of most use, should anchylosis occur. If, however, the patient's condition does not improve after opening the joint, the surgeon should not hesitate to resort at once to amputation, or, in some cases, excision; for, although the prognosis of operative interference, under such circumstances, is less favorable than in cases of chronic disease, still, as it offers the patient his only chance for life, it should be unhesitatingly resorted to. Amputation or Excision in Cases of Joint Wound__If opera- tive treatment be required, either as a primary procedure or in a subsequent stage on account of the occurrence of suppuration within the articulation, the choice between amputation and excision will depend in a great degree upon the particular joint concerned. In the upper extremity, amputation can be rarely required, except for special circumstances connected with the constitu- tional condition of the patient, and excision, either primary or secondary, should be preferred, in cases which require any operation at all. In the lower extremity the case is somewhat different; the hip-joint is so deeply seated that it is scarcely ever wounded except by gunshot injury, in which case, for reasons already given, primary excision is the mode of treatment to be adopted. Wounds of the knee-joint are among the most serious injuries met with in civil practice; if complicated with fracture or dislocation, they should, I think, be considered as cases for amputation ; although exceptional instances do undoubtedly occur in which recovery without operation follows, even under these unfavorable circumstances. Excision of the knee-joint, for traumatic causes, is not a very promising operation ; still, in a young and healthy person, if the destruction of parts were comparatively slight, it might be at least a justifiable procedure. M. Spillman, who rejects knee-joint ex- cision in military surgery, yet considers it a suitable operation as applied to cases of injury met with in civil life. Eleven such cases which he has col- lected, excluding gunshot wounds, gave six recoveries, three deaths, and two consecutive amputations (Archives Gen. de Medecine, Juin, 1868, pp. 681— 701). Five cases of total excision for compound fracture, collected by Pe- nieres, gave four deaths and but one recovery, while six operations for joint 212 FRACTURES. wound, without fracture, gave but one death and five recoveries; as jnstly observed, however, by this writer, these cases might, perhaps, equally well have recovered without operation. Culbertson's tables include 28 cases, with 17 recoveries, and 11 deaths. When an attempt has been made to save the knee-joint, but without success, amputation should be unhesitatingly per- formed, as offering the only remaining chance of preserving life. One point worthy of notice in connection with wounds of the knee, is the frequent oc- currence of suppuration above the joint, abscesses being formed which dissect up the muscles of the thigh to a considerable extent, before giving evidence of their existence. It is this deep-seated destruction of the tissues of the thigh which constitutes one of the chief dangers of wounds of the knee-joint, and which renders any operation performed under these circumstances very apt to terminate unfavorably. Wounds of the ankle are attended with less risk than those of either hip or knee, and recovery may often be obtained without operation, though in other cases excision or amputation may be re- quired either primarily or secondarily. Spillman has collected sixty-eight cases of complete or partial excision of the ankle for compound fracture or dislocation, the results having been ascertained in sixty-six. Fifty-one patients recovered with more or less useful limbs, two recovered after ampu- tation, and thirteen died (two of these having been likewise previously ampu- tated) ; the mortality of the operation is, according to these figures, about twenty per cent. Culbertson's statistics are more favorable, 154 cases giving but 19 deaths, a mortality of only 12.3 per cent. In the conservative treat- ment of these injuries it is of great importance to support the foot, so that the patient after recovery may be able to walk properly, and may not be left with an extremity anchylosed in the position of a pes equinus. I have already referred (p. 59) to the proposal to tie the main artery of a limb, as a means of preventing or curing traumatic arthritis; recovery has indeed followed ligation under these circumstances, but no sufficient evidence has been adduced to show that the good result was in any degree due to the operation, which, beside being unphilosophical in conception, evidently adds an additional risk, without any compensating prospect of benefit. I have, moreover, been assured by distinguished army surgeons, who saw the plan fairly tried during our late war, that it proved then as unsuccessful in prac- tice as it is unscientific in theory. CHAPTER XI. FRACTURES. Fracture is the most common form of injury to which, the bones are exposed, and, as such, becomes a subject of the deepest interest to every practising surgeon. Moreover, no injuries require more care and judgment in their treatment than fractures, and no cases contribute, more than these, to establishing the fame or the discredit of the surgeon. A man wlro gets well with a crooked or shortened limb, is very apt, whether rightly or wrongly, to lay the blame of it upon his doctor, and though cases do undoubtedly occur in which the most skilful and attentive surgeon may fail in obtaining a satis- factory result, there can be no question that a great many bad cures of frac- CAUSES OF FRACTURE. 213 ture are directly traceable to ignorance or neglect upon the part of the practitioner. Causes op Fracture. These may be divided into the exciting and the predisposing causes. Exciting Causes__The exciting causes of fracture are external vio- lence and muscular action. 1. External Violence may act directly or indirectly. Gunshot fractures are perhaps the best examples of fracture as the result of direct violence, while fracture of the clavicle from a fall on the shoulder, or of the radius from a fall on the hand, may be taken as illustrations of the injury as produced by indirect violence. Fracture by counter-stroke (the contre-coup of French writers) is a form of the fracture by indirect violence, in which the force is applied to one side or extremity of the bone, or system of bones, which are so united and fixed that, by the natural elasticity of the parts, the force is transmitted, and produces its effect, not at the point to which it was applied, but at a point opposite. Familiar examples of fracture by counter-stroke are those of fracture of the base of the skull, from force applied to the top of the head, of the frontal bone, from a fall upon the occiput, or of the sternum, from violence applied to the back. The subject of contre-coup or counter- stroke, has been involved in some confusion by the various meanings which different authors have given to the term; as used here, it is to be understood as denoting merely a variety of injury from indirect violence, the mechanism of which is explicable by simple and well-understood physical laws, depend- ing entirely upon the structure and connections of the bones and other parts involved. 2. Fracture by Muscular Action is not of very unfrequent occurrence, though the cases in which fracture is produced by pure divulsion, or tearing asunder the fragments, are rarer than is commonly supposed. Indeed, the only instances of the kind with which I am acquainted, are those rare cases in which fracture of the sternum has occurred during the acts of parturition, vomiting, etc. In the more commonly quoted instances of fractured olecranon and fractured patella, the mechanism is somewhat different, the bones (as justly remarked by Dr. Packard) giving way like over-bent levers, across the condyles respectively of the humerus and femur, though the fracturing force in these cases, as in those of fractured sternum, is muscular contraction. Predisposing Causes__The predisposing causes of fracture may per- tain to the bone itself, or to the general condition of the patient. Thus, the situation of a bone influences its liability to fracture; the clavicle is much oftener broken than the scapula, and the lower than the upper jaw. Again, the function of a bone may predispose it to fracture ; the bones of the lower extremity, which support the trunk, or those of the upper extremity, which are constantly engaged in the active employments of life, are more liable to fracture than the vertebras or sternum, the functions of which are different. The following table, condensed from the statistics of Lonsdale, Norris, and Malgaigne, will exhibit the relative frequency of fracture in different parts of the body, in the Middlesex Hospital, Pennsylvania Hospital, and Hotel Dieu:— 211 FRACTURES. Seat of Fracture. Skull............. Nasal bones....... Upper jaw and ma- Lower jaw.....[lar Sternum.......... Ribs and costal car- Vertebrae. .. [tilages Pelvis, sacrum, etc. Clavicle......[der) Scapula (or shoul- Among the predisposing causes which pertain to the general condition of the patient, age occupies a prominent place. There can be no question that the old are more apt to be the subjects of fracture than the young, partly on account of the greater brittleness of their bones, and partly from the general rigidity of ligaments and muscles which attends advancing age, and which renders the entire frame less elastic and yielding, and there- fore more liable to this form of injury. No age is, however, exempt from fracture, and not a few instances are on record in which this has occurred even during foetal life. The circumstance that old age predisposes to the occurrence of fracture, does not contravene the well-known fact that most of these injuries are met with in those in early adult life, for the simple reason that such persons are most engaged in active employments, and are, therefore, most exposed to all forms of injury resulting from external violence. Sex, as might be supposed, exercises an influence on the liability to fracture, men, from the nature of their occupations, being more apt to have broken bones than women ; for a similar reason the right side of the body is more exposed to fracture than the left. Certain forms of cachexia, or certain diatheses, may be considered as predisposing causes of fracture. Rickets undoubtedly exercises a powerful influence in this way, as do osteo- malacia, cancer, syphilis, scrofula, gout, locomotor ataxia, and general para- lysis of the insane. Some very remarkable cases are on record illustrating the fragility of bones under certain conditions : Gibson, Arnott, Tyrrell, Lonsdale, and H. Thomson, have described such cases, but the most remarkable of all is that published in the Journal des Savants for 1690, and which appears to be the same as one quoted by Malgaigne from Saviart, in which an apparently healthy young woman of 30, during three months' confinement to bed, sus- tained, it is said, fractures of every bone in the body. Esquirol is said to have possessed a skeleton which exhibited traces of more than two hundred fractures.1 In many of these cases union readily took place, but in one men- tioned by Stanley, and in that of H. Thomson (in which indeed the bones are described as separating rather than breaking), the fractures appear to have remained ununited. Varieties of Fracture. Fractures may be Complete or Incomplete ; these names suf- ficiently express their own meaning. The form of incomplete fracture usually 1 I have myself met with a case in which without apparent reason seventeen frac- tures had been sustained by the bones of the right lower extremity; when I saw the patient, multiple enchondromata had been developed in the foot and ankle. Mai- dale. gaigue. 6 years 10 yrs. 11 yrs. 48 46 53 13 3 12 1 3 32 19 27 2 5 1 357 46 263 8 8 11 7 6 9 273 84 225 18 10 12 Seat of Fracture. Humerus....... Radius......... Ulna........... Radius and ulna Hand, etc....... Thigh......... Patella......... Tibia .......... Fibula......... Tibia and fibula Lons-dale. Xorris. 6 years 10 yrs. 118 1 197 h 96 93 J 116 9 181 133 38 16 41 1 51 ^295 197 J Mal- gaigne. 11 yrs. 310 160 38 107 71 303 45 29 108 515 VARIETIES OF FRACTURE. 215 met with in civil life is the partial or " green-stick" fracture, in which some of the bony fibres have given way, while the rest have yielded to the force, bending but not breaking. In military practice, incom- plete fractures are occasionally produced by blows from Fig. 103. sabres, but more often by gunshot wounds, the principal varieties being the fissured fracture, the grooving fracture, in which a piece is cut out from the side of a bone, and the button-hole or perforating fracture, in which a piece is fairly punched out from the centre of a bone. These terms (complete and incomplete) are principally used in reference to the long bones ; in the case of fiat bones, as of the skull, many of the fractures met with in civil life are incomplete. The most usual and the most important division of fractures is into simple and compound. A Simple Fracture, as the term is used in this book, is a fracture in which there are but two fragments, and which does not communicate with an open wound. This definition, which seems to me to correspond with the mean- ing usually attached by surgeons to the term simple frac- ture, is essentially the same as that given by Mr. Erichsen, but differs from the definitions given by Prof. Hamilton and Prof. Gross, the former author using the term as equiva- lent to Malgaigne's single fracture, without regard to its subcutaneous character, while the latter regards merely the absence of external wound, without reference to the number of fragments. The classification adopted by Mr. Hornidge, in Holmes's System of Surgery (which would make this form the " simple, single fracture"), is perhaps the most strictly Partial fracture. correct, but is almost too complicated for common use. Compound Fractures are fractures which communicate with the ex- ternal air through a wound: this wound is usually, though not necessarily, an external or cutaneous wound ; a fracture of the jaw may be compound from a wound through the buccal mucous membrane. Comminuted Fractures are those in which there are more than two fragments, the lines of fracture, however, intercommunicating with each other and occupying the same general position as regards the bone affected. A multiple fracture, on the other hand, is one in wliich the bone is the seat of two or more distinct fractures not necessarily connected with each other ; thus the radius may be broken just below its head and again above the wrist, or the tibia through the malleolus and again just below its tuberosity. A double fracture is a multiple fracture in which the solutions of continuity are but two in number. Comminuted and multiple fractures may or may not be compound, and a multiple fracture may be compound at one seat of lesion and not at the other. When the term comminuted fracture alone is used, it is understood that there is no communication with an external wound ; if there be such communication, the injury becomes a compound comminuted fracture. Comminuted frac- ture of the patella. Complicated Fractures are fractures which are accompanied by some other serious injury of the same part. Thus a fracture may be com- 216 FRACTURES. plicated by dislocation of a neighboring joint, by rupture of an important artery, or by a severe fiesh wound which does not communicate with the seat of fracture. Some authors speak of fractures Fig. 105. being complicated (in this technical sense) by any of the various lesions to which the human frame is sub- ject, but this, it seems to me, is incorrect; thus it would be wrong to describe a fracture of the right thigh as complicated by a dislocation of the left shoulder, or a fracture of any of the extremities as complicated by a wound of the pleura or lung, though the latter lesion, if produced by the sharp fragments of a broken rib, would be a technical complication of that injury, which would then be properly called a complicated fracture of the rib. Impacted Fractures are those in which one fragment is driven into and fixed in the other. impacted fracture, through Intra-periosteal Fracture is the term ap- the trochanters of the fe- pijeci f0 a fracture unaccompanied by laceration of nmr. The upper fragment is ,, . . ^ . ,. 0 . . , ,,.,,,, the periosteum ; it is a form of miury rarely met wedged into the lower. t .' . n t 1 /• 1 with except in certain flat bones, as those of the skull, and, indeed, the creation of this subdivision seems to me to be of very little practical utility. Direction of Fracture__Fractures are also classified in accordance with the direction in which the separation of the bony fibres occurs ; thus fractures are said to be transverse, oblique, or longitudinal. A Transverse Fracture is one in which the general line of separation is transverse, or in a plane at right angles with the long axis of the bone. A perfectly transverse fracture in a long bone is very rarely met with, the line of separation being almost always more or less oblique; a variety of the transverse is the serrated fracture, in which the fragments present corre- sponding indentations which render it comparatively easy to maintain them in apposition. Transverse fractures usually result from direct violence or from muscular action. The Oblique Fracture is the form most commonly met with in the long bones. The plane of fracture may, of course, vary greatly in different cases ; thus a fracture is said to be oblique from before backwards and from without inwards, etc. Oblique fractures are commonly caused by indirect violence. Longitudinal Fractures are those in which the line of separation runs in the general direction of the long axis of the bone. This form of fracture is comparatively rare in civil life, but is frequently met with as a result of gun- shot injury, especially since the general introduction into warfare of the im- proved conoidal ball. Longitudinal fractures commonly occur in the shafts of long bones, and usually do not extend beyond the epiphyseal lines, though occasionally they pass through the epiphyses into the neighboring joints. Several other divisions are made by French writers, according to the peculiar form of the fracture, but the above are sufficient for practical purposes. Separation of Epiphyses.—This is a form of injury which may fairly be classed among fractures, the symptoms and treatment of the two sets of cases being pretty much the same. Separation of an epiphysis may take place at either end of the humerus, the femur, or the tibia, and at the lower extremity of the radius ; it is also frequently seen in the case of certain bony SYMPTOMS OF FRACTURE. 217 processes, as the acromion and olecranon ; while in certain flat bones, as the sternum and os innominatum, similar injuries are met with, consisting in a separation of the osseous structure into its original constituent parts, in the lines of cartilaginous junction. Epiphyseal separation can of course only occur before complete ossification has taken place ; hence, in the long bones it is not met with beyond the age of twenty or twenty-one, though in other situations, as in the acromion, it may occur at a much later period. The direction of an epiphyseal separation is transverse, and, from the proximity of the epiphyseal lines to the articulations, these injuries are liable to be con- founded with dislocations. The diagnosis in such cases can usually be made, by taking care, in the examination, to grasp the epiphysis itself firmly with Fig. 106. Deformity resulting from injury of radial epiphysis in childhood. (From a patient in the Episcopal Hospital.) one hand, while the other exercises the movements of flexion, rotation, etc., when, if the case be one of separated epiphysis, the lesion can readily be recognized as being above or below the line of the joint, as the case may be. Epiphyseal injuries are apt to be followed by arrested growth of the affected bone, and thus sometimes cause great deformity, as shown in Fig. 106. Symptoms of Fracture. Deformity___The most prominent, and one of the most characteristic symptoms of fracture is deformity or displacement. The Causes of Displace- ment, in cases of fracture, have been the subject of much dispute among sys- tematic writers. Without entering into a minute discussion of this matter, I may say, in general terms, that the causes of displacement are fourfold, viz., 1, the force that produces the fracture ; 2, the action of surrounding muscles; 3, the weight of the limb below the seat of fracture; and 4, the natural elas- ticity and resiliency of the ligaments and other soft tissues above the seat of fracture. 1. Deformity from the influence of the fracturing force is seen in cases of depressed fracture of the skull, in cases of partial fracture of the clavicle with inward angular deformity, and in cases of impacted fracture generally. 218 FRACTURES. 2. Muscular action is the most common cause of displacement in cases of fracture. It is seen in the shortening which accompanies almost all fractures of the extremities, and in the rotatory displacement common in fractures of the femur, radius, etc. It is probably the sole cause of displacement in cases in which the fracture itself has been caused by muscular action, as in fractures of the patella or olecranon. Beside the ordinary contraction of the muscles around the seat of fracture, there is often a spasmodic condition induced by the irritation caused by the sharp fragments of the broken bone. 3. Displacement by the weight of the limb below the seat of fracture, is seen in the dropping of the arm and shoulder, in eases of fractured acromion or fractured clavicle. It assists the action of the rotator muscles, in producing eversion of the foot, in fractures of the lower extremity. 4. Finally, the natural elasticity of the soft tissues above the seat of frac- ture, is seen as a cause of deformity in the projection of the inner fragment of a fractured clavicle, when, as pointed out by Anger, the weight of the arm being taken off by the fracture, the inner end of the clavicle is jerked upwards by the normal resiliency of its ligamentous and other attachments. Direction of Displacement___The displacement in cases of fracture may take place in various directions ; thus, there may be angular, transverse, longitudinal, or rotatory displacement. 1. Angular displacement is usually due in the first place to the action of the fracturing force, but is kept up or may be originally produced by muscular action. Thus, in fracture of the thigh there is often an angular displacement outwards and forwards, due to the fact that the most powerful of the femoral muscles are those on the back and inner side of the limb. This is the form of displacement met with in partial or " green-stick" fractures, and it may also accompany oblique or comminuted fractures, or those in which there is impaction. 2. Transverse displacement is comparatively rare ; it occurs principally in cases of serrated fracture of the long bones, in which the separation has not been sufficient to allow overlapping from muscular contraction. It is also met with in fractures connected with joints, as in splitting fractures of the con- dyles of the humerus or femur. 3. Longitudinal displacement is displacement in the direction of the long axis of the bone at the point of fracture. It may consist in shortening, or in lengthening. Shortening occurs principally in oblique fractures of the long bones, and is due to muscular action, often assisted by the nature of the frac- ture, which allows one fragment to slide upon the other as upon an inclined plane. When the shortening is so great that the upper end of the distal frag- ment is drawn above the lower end of the proximal fragment, there is said to be overlapping, and the more prominent fragment is said to ride the other. The overlapping often amounts, in fracture of the thigh, to several inches. Another form of shortening is due to impaction ; this is often seen in fracture of the cervix femoris, the shortening being principally in the direction of the axis of the neck of the bone, not of its shaft; hence the deformity in such a case is comparatively slight. The form of longitudinal displacement wliich consists in lengthening, is chiefly seen in cases of fractured patella, fractured olecranon, fractured calcaneum, etc., in which the fragments are often widely separated by muscular action ; it is, however, as pointed out by Malgaigne, occasionally met with in fractures of the articular extremities of the long bones, as of the fibula, when it is a secondary condition dependent on ante- cedent rotatory displacement. 4. Rotatory displacement consists in one of the fragments being twisted upon its own axis ; this form of displacement may be due to muscular action, or to the weight of the limb below the seat of fracture. This displacement is SYMPTOMS OF FRACTURE. 219 constantly seen in fracture of the upper part of the femur, when the lower fragment is rotated outwards by the powerful external rotator muscles of the thigh ; in fracture of the bones of the leg, by the action of the same muscles, the upper fragments, moving with the femur, are subjected to rotatory dis- placement. So in fracture of the radius, particularly if above the insertion of the pronator radii teres, the upper fragment is usually rotated outwards by the biceps and supinator brevis. Displacement in cases of fracture may be confused with deformity from other causes ; thus a periosteal node or an exostosis may closely simulate angular displacement; shortening may result from old joint disease or from contracted tendons ; the position which a joint assumes when the seat of sprain, may be mistaken for rotatory displacement; while the transverse, or, indeed, any of the varieties of displacement may be due to dislocation and not to fracture. Hence, the surgeon, in making his diagnosis, must not rely upon the appearances presented to the eye, or even upon mere tactual exami- nation. The limb involved should be carefully and repeatedly measured be- tween known fixed points, and compared with the corresponding unaffected limb ; and in cases of doubt, not only the injured limb, but the bone itself should be accurately measured and compared with its fellow of the opposite side. Mobility is often a striking and easily recognized symptom of fracture ; the part wliich gives support to the limb is broken, and the limb can be bent in any direction. In fractures, however, of the leg or forearm, when but one > of the two bones is broken, the other acts as a splint, and hinders the develop- j ment of this symptom ; again, in serrated, and especially in impacted frac- I tures, there will often be no undue mobility ; or the swelling of the soft parts may be so great as to render the mobility of a fracture, especially if near a joint, difficult of recognition. On the other hand, dislocation, which is usually characterized by immobility of the affected joint, may, if there be much destruction of the articular ligaments, be accompanied by positive increase of mobility, and thus simulate fracture. But in the continuity of a bone, at a distance from its articular extremities, mobility, when present, is a sign of the greatest value, and may, indeed, be considered as almost pathognomonic. Crepitus is another symptom of great importance, and when existing in connection with undue mobility, may be looked upon as establishing the pre- sence of fracture. Crepitus or crepitation is the grating sensation produced by rubbing together the rough ends of the fragments. It is felt as well as heard, and is usually recognized without difficulty; it must not be mistaken for the grating produced by moving diseased joints, nor for the crackling due to effusion in the tendinous sheaths, nor yet for the crepitation of traumatic emphysema; each of which conditions may, under certain circumstances, closely simulate the true crepitus of fracture. The diagnosis might, perhaps, be aided in such cases, as suggested by Lisfranc, and more recently by Laughlin, of Indiana, by the use of the stethoscope. The non-existence of crepitus is no evidence that a bone is not broken, and its absence may be due to several causes : thus, the fragments may overlap to such a degree that their rough ends are not in contact—a condition often met with in fracture of the thio-h, when it is necessary for an assistant to make extension before the frag- ments can be brought together and crepitus produced ; or the fragments may be widely separated—as in cases of fractured patella ; or a portion of mus- cular tissue may be caught between the fragments, and prevent crepitus. In partial fracture, there is no crepitus; nor in impacted fracture, as long as the impaction continues. 220 FRACTURES. Pain and Tenderness are symptoms of fracture, but may be equally due to so many other causes, that they cannot be considered as diagnostic. In some cases, however, persistent, localized tenderness is a sign of some value, especially in cases of partial or impacted fracture, in which the more characteristic symptoms are absent. LOSS of Function used to be considered an important symptom of frac- ture. A'elpeau, however, showed that a fractured clavicle interfered with raising the arm to the head, merely by the pain caused by the act; and Gouget, a French army surgeon, has shown the same thing, as regards the power of walking, after fracture of the patella (Rec. de Mem. de Mid. de Chir. et de Phar. Mil., Mai, 18(io, p. 394). I have myself known a man with fracture of both bones of the leg, to walk about the ward, when under the influence of mania-a-potu, using his fracture-box as a boot, and apparently not feeling any inconvenience from his injury. Muscular Spasm is a not unfrequent accompaniment of fracture, though, of course, in no degree a diagnostic symptom : it is produced by a reflex condition, due to the irritation produced by the sharp extremities of the fragments. Numbness is occasionally met with in cases of fracture, and is pro- duced by simultaneous injury, or subsequent compression, of neighboring ner\ es. Extravasation and Ecchymosis, to a greater or less extent, occur in almost every case of fracture : the degree of ecchymosis is often much greater after a few days, than when the injury is first received, and may then (especially if accompanied by much vesication, as it is apt to be if the soft parts have been much bruised) be mistaken by a hasty observer for incipient gangrene. When extravasation proceeds from a ruptured artery, giving rise to a traumatic aneurism, it constitutes a very serious complication of fracture. Diagnosis of Fracture. The diagnosis of fracture can usually be made without much difficulty by attending to the symptoms above enumerated, the first three of which, when coexisting, may indeed be considered as pathognomonic. In cases of partial and of impacted fracture, the surgeon has not the evidence furnished by crepitus and mobility, and must rely upon the other signs of fracture, espe- cially deformity and localized tenderness. Again, in cases where but one of several bones is broken, asln the hand or foot, the diagnosis is more obscure, especially if there be much swelling of the soft parts. In such a case, the surgeon carefully explores the surface, by making firm but gentle pressure upon each part in succession, and is thus enabled to detect any abnormal prominence, and often to elicit crepitus, which could not otherwise be obtained. If the metacarpus or metatarsus be involved, each bone should be successively grasped by its extremities, and so manipulated as to render evident any frac- ture which may be present. As it is of great importance in any case of sus- pected fracture that the surgeon should arrive at a correct diagnosis, his examination should always be made deliberately and systematically. The deformity, mobility, impairment of function, pain, etc., should be successively noted, before proceeding to the manual examination which is to determine the existence or non-existence of crepitus. In this final part of the investi- PROCESS OF UNION IN FRACTURED BONES. 221 gation, preliminary extension being made by an assistant, if necessary, the surgeon grasps the limb above and below the suspected seat of fracture firmly—so that he controls the bone as well as the flesh, and gently moves his hands in various directions, so that if there be a fracture, the ends of the fragments must rub against each other. It is scarcely necessary to say that, in this examination, all rough and needless manipulation is to be positively interdicted. If true bony crepitus be once elicited, it is sufficient, in con- nection with the other symptoms, to establish the diagnosis ; and nothing can be more reprehensible than for a surgeon to persist, in spite of the pain thereby caused, in endeavoring again and again to renew this evidence, thus appearing more anxious to make a clinical demonstration for himself or for the bystanders, than to relieve the sufferings of his patient. The detection of crepitus may, as already mentioned, sometimes be facilitated by having recourse to auscultation. The examination of a case of suspected fracture should be made as soon as possible after the time of reception of the injury, as the diagnosis is then more easy than if oedema and inflammatory swelling have already occurred. If, however, the surgeon do not see the case in an early stage, it is often judicious to defer any minute examination, treating the case as one of frac- ture until the swelling has subsided, when, if there be really no bone broken, at least no harm will have been done by the delay. Or, if for any reason it were important to ascertain the nature of the case at once, the plan recom- mended by Rizet, a French army surgeon, might be tried. This plan con- sists in endeavoring to disperse the swelling by systematic friction and knead- ing ^massage), in the course of which proceeding, the fracture, if there be one, will become evident. Under certain circumstances, the use of an anaes- thetic would be justifiable, in order to facilitate the diagnosis (see page 72). In any case of doubt, it is safe to presume that the worst has occurred, and treat the case as one of fracture. It is remarkable what severe injuries of bone may exist, and yet, for a time at least, escape attention; Mr. Erichsen gives a remarkable case of compound comminuted fracture of the humerus, which, though carefully examined by himself and others, was not detected until the eighth day, and I can myself recall a case in the Pennsyl- vania Hospital, in which the swelling of the part prevented the recognition of anything further than that the patient had a fracture of both tibia and fibula, and yet in which (death taking place soon after from mania-a-potu) an autopsy showed that the bones were broken into at least a dozen fragments. Process of Union in Fractured Bones. In order to understand the process of repair after fractures, it will be neces- sary to pause for a few moments to consider the natural process of growth and maintenance of bone in its normal condition. This subject has been recently most fully and carefully studied by Oilier, of Lyons, to whose elabo- rate and admirable Treatise on the Regeneration of Bones I would respect- fully refer the reader for a detailed exposition of the whole subject of bone pathology. Bone grows in length by the development of bone cells from the epiphyseal cartilages, or cartilages of conjunction, and in thickness by the development of bone cells from the inner or osteo-genetic layer of the perios- teum ; while this peripheral thickening is going on, there is a simultaneous conversion of the innermost layers of bone into medulla or marrow, and hence the medullary cavity enlarges as the bone grows. Tiyning now to consider the effects of any traumatic irritation upon the constituents of bone, 222 FRACTURES. we find the various nutritive and formative changes which were described as parts of the inflammatory process (see Chap. I.), taking place in the perios- teum, the bone tissue proper, and the medulla. Direct irritation of either periosteum or medulla is apt to result in giving rise to what was described as the second formative change of inflammation, the formation of pus, or suppu- ration : indirect irritation, however, whether propagated from the bone or from the external soft parts, gives rise (usually) only to the earlier changes, viz., temporary hypertrophy, and the formation of lymph. In the case of the periosteum, the effect of propagated traumatic irritation is to cause a hyperplasia of the deep or osteo-genetic layer, manifested by swelling, and ultimately resulting in an increased production of new bone ; in the marrow, the irritation, if not excessive, results in induration and a local retrograde metamorphosis into bone. Finally the bone tissue itself responds to the stimulus, and becomes medullized (assuming the character of granulations), proliferation of its cells takes place, and hypertrophy, temporary or permanent, results, with (if the irritation continue) the various changes which will be hereafter considered under the head of osteitis. These are not mere theo- retical views, but have been adopted by Oilier after numerous carefully con- ducted and often repeated experiments upon the lower animals, as well as after extended clinical observation.1 Taking now the simplest case of fracture—an intra-periosteal fracture, so called—the process of repair can be seen at a glance. The traumatic irrita- tion propagated from the broken bone causes swelling of the periosteum, active proliferation, and formation of a sheath of new bone around the seat of fracture ; this is the " ensheathing" or " ring callus" of surgical writers. At the same time the medulla feels the effect of the irritation, becomes hardened and partially ossified; this constitutes the "interior" or "pin callus." Lastly, the osseous tissue itself undergoes cell proliferation, and union of the fragments takes place, mutatis mutandis, precisely by the same process that we have already studied in considering wounds of the soft tissues. The new material which is thus developed between the fragments themselves, constitutes what Dupuytren called the intermediate, permanent, or definitive callus, in contradistinction to the ensheathing and interior forms of callus, wliich are temporary or provisional. This explanation is applicable to the process of repair as seen in every va- riety of fracture. The new formations from the periosteum and medulla gradually disappear, the ensheathing callus is partly absorbed and partly in- corporated in the bone, in the process of its normal maintenance, while the ossified medulla, or interior callus, undergoes rarefaction and medullization, so that in time the continuity of the marrow cavity is again restored, and the whole bone resumes its pristine appearance. In the case of fracture unac- companied by displacement, the periosteal and medullary new formations may be so small in amount and so temporary in duration, as to escape obser- vation ; this is seen in certain serrated, impacted, and partial fractures, and 1 It is but right to say that a different explanation is given by Billroth ; according to this distinguished surgeon and pathologist, the periosteum possesses no peculiar osteo-genetic power, and the formation of callus is due not to proliferation of pre- viously existing cells, but to an accumulation of wandering cells, which, following Cohnheim, he looks upon as white blood corpuscles escaped from the vessels. The same difference of opinion, in fact, prevails with regard to the pathology of inflamma- tion and repair in the osseous tissues, that has already been noted with regard to those processes in the soft structures of the body. According to Feltz, bone, perios- teum, and medulla, are all restored by means of an " embryo-plastic" tissue, which differs from the connective and medullary tissues, but is of an embryonic character analogous to that met with in foetal life, and probably results from a " direct gene- sis." (Robin, Journ. del'Anat., etc., Juillet-Aout, 1876.) TREATMENT OF FRACTURES. 223 is often spoken of as union by intermediate callus alone. On the other hand' the fragments themselves sometimes fail to unite, the sole bond of union being the provisional (though in these cases not temporary) callus, resulting from the action of the periosteum or medulla. In cases in which there is great dis- placement, especially in neglected fractures of the thigh, very large and thick bands of callus are often seen, stretching across and uniting the fragments which are themselves widely separated. The time occupied by the process of repair varies, of course, according to the size of the fractured bone and other extraneous circumstances. For the first few days, no apparent change occurs in the neighborhood of the fracture, nature being apparently engaged in repairing the injury of the soft parts, causing the absorption of effused blood, etc. The formation of the provisional callus usually begins during the second week, and by the end of the third or fourth week this new structure has commonly attained sufficient bulk and strength to prevent displacement by any moderate degree of force. The definitive union of the fragments is not completed until a later period—sometimes many months subsequently. In certain situations, or under certain circumstances which will be considered hereafter, bony union does not take place, and the fragments are connected by fibrous tissue only. In cases of compound fracture, the process of union, though the same, is much slower in its progress, being delayed by the occur- rence of granulation, of suppuration, and often of necrosis, and presenting similar differences to those wliich are observed in the healing of open, as compared with that of subcutaneous, wounds. Cartilage is occasionally met with in callus; it is, however, but a temporary constituent, due to excess of irritation. Separated epiphyses unite as fractured bones : the part usually remains permanently thickened, while, from the injury to the cartilage of conjunction, the growth of the bone in length is permanently interfered with (See Fig. 106). For further information on the interesting subject of the repair of bones after fracture, I would respectfully refer the reader to the writings of Dupuytren, Malgaigne, Stanley, and Paget, but especially to the work of Oilier, already referred to. i Treatment of Fractures. The general indications to be met, in the treatment of all fractures, may be said to be—1, to reduce or set the fracture as soon as possible ; 2, to pre- vent a recurrence of displacement; and 3, to see to the well doing of the part affected, and to look after the constitutional condition of the patient. I shall first consider the general principles which should guide the surgeon in the treatment of simple fractures, then the modifications of treatment re- quired by the principal complications of simple fracture, and finally the treatment of compound fractures. Treatment of Simple Fractures__Fractures are often met with at a distance from home, and in localities where no surgical appliances are at hand, and where no treatment can be satisfactorily carried out. Under such circumstances, it becomes necessary for the surgeon to attend, in the first place, to the transportation of his patient. If the fracture be in the upper extremity, it may be sufficient to support the injured limb in a broad sling made from handkerchiefs, when the patient can ride or even walk a short distance without much inconvenience ; if the fracture be in the lower extremity, it will be necessary for the patient to be carried upon a sofa, or litter extemporized from boards, a window-shutter, etc. If a mattress cannot be obtained, the patient's head and the broken limb may be supported on any old cloths that can be procured, or upon straw. Temporary splints may 224 FRACTURES. sometimes be formed from the bark of trees, or made by laying together three or four thicknesses of folded straw or rushes. The limb should be laid in as easy a position as possible, and the litter borne deliberately, but with a firm step ; it is usually recommended that the bearers should be instructed to step off with alternate feet, as it is said that thus less vibration is communicated to the litter. Before the patient is removed from the litter, the surgeon should see that a suitable bed has been prepared. Various fracture-beds have been invented by surgeons, amongst the most ingenious being those of Daniels, Burges, Coates, and Hewson, but, for practical purposes, I know of nothing better than a simple perforated hard mattress, with a pad accurately fitting the perforation, and a pan which slides in a frame-work beneath a corresponding opening in the bedstead; the latter should be provided with strong wooden or metallic slats, so as to furnish an even surface and secure firmness and rigidity to the whole arrangement. The lower sheet must, of course, be also perforated, and should be secured to the mattress so as not to form ridges under the patient's body. If a fracture-bed cannot be procured, an ordinary bedstead with a hard mattress may be used, in which case a bed- pan must be employed to receive the fecal evacuations. These preliminary matters having been attended to, and the patient being in bed (if the fracture be in the lower extremity), the surgeon removes the clothing as gently as possible, and exposes the injured part and the corres- ponding part of the opposite side. He then, by a careful and methodical examination, proceeds to satisfy himself as to the nature and extent of the injury, and then, replacing the limb in an easy position, prepares his splints and bandages before attempting to reduce the fracture. 1. Reduction, or Setting the Fracture, consists in replacing the fragments by manipulation as nearly as possible in their normal position, as regards each other. I say advisedly, " as nearly as possible," for I believe with Prof. Hamilton, that it is only in exceptional cases that the displacement of frac- ture can be entirely overcome. Reduction should be effected as soon as pos- sible, for the reason that it is much easier to the surgeon, and much less painful to the patient, if done before the development of inflammation ; if, however, the patient is not seen until a later period, or if displacement should, from any cause, have recurred, the surgeon need not hesitate at any stage of the case to effect as perfect reduction as he can, for the slight addi- tional irritation thus produced will be of much less consequence than the evils which would result from continued displacement. Reduction should be effected by the hands alone; no mechanical contrivance should be used to give increased force, lest serious mischief to the already lacerated tissues should be produced. In the immense majority of cases, little or no force will be required, it being sufficient to place the limb in such a position as to relax the displacing muscles, when the bones will fall into position of them- selves. Even in fracture of the femur, in which extension is commonly necessary to effect reduction, it is a good rule that no more force should be used than can be applied with the hands alone. In cases in which one or both fragments are embedded in the muscular tissue, or in which, from any other cause, there is great muscular resistance, it may be justifiable to employ aiuesthesia as an aid to reduction. 2. To Prevent the Recurrence of Displacement, the surgeon makes use of various forms of apparatus, splints, bandages, etc. It is often very difficult to maintain reduction during the first few days, on account of the spasmodic action of the muscles constantly reproducing the deformity; but the tend- ency to spasm gradually passes off, so that by constant attention and care- ful dressing during the early stage of the treatment, it is almost always possible to obtain such accurate apposition of the fragments, as will secure a TREATMENT OF SIMPLE FRACTURES. 225 well-shaped and useful limb, though probably not one absolutely free from deformity. The different forms of bandage used by surgeons, and their modes of application, were considered in the chapter on Minor Surgery ; the splints and special apparatus employed, will be described in discussing frac- tures of the several bones. Suffice it to say here, that the surgeon should . aim to use as simple apparatus as possible ; plain and light splints of wood, - pasteboard, wires,1 or thin metal, such as can be made by any carpenter or blacksmith, are, I think, in every way preferable to the elaborate and com- plicated appliances which have been, from time to time, recommended for the treatment of fractures. Straight and angular splints, made of smooth half- inch boards, for the upper extremity, straight splints and plain fracture-boxes with soft pillows for the lower extremity, a roll of cotton wadding or of tow for padding splints, or bags filled with bran or sand for the same purpose, a n few pieces of binders' board, a half dozen or a dozen roller bandages, a few yards of adhesive plaster, and two or three bricks for use in making " weight extension," constitute an armamentarium sufficient for the treatment of al- most all cases of fracture. The general principles to be observed in the use of splints and other apparatus may be stated as follows:— (1.) They are to be used as means of retention only, not of reduction or extension; these are effected by the surgeon's hands, and splints and band- ages are merely to prevent the recurrence of displacement. (2.) All splints, etc., should he firmly and evenly padded, so as not to exert injurious pressure on the bony prominences with which they come in contact, while at the same time the padding must not be so bulky as to render the splints clumsy or unmanageable. (3.) Circular conpression is to be carefully avoided, as swelling is inevi- table after a fracture, and the risk of gangrene from this cause is by no means only theoretical. Hence, as a rule, in the early stages of fracture, no bandage should be applied beneath the splints. (4.) In treating fractures of the shaft of a bone, the nearest joints above and below should, if practicable, be fixed by the splints used ; if the fracture involve an articulation, the shafts of the bones which form the joint should themselves be so fixed. (5.) When a fracture is properly " put up," unless the patient suffer so much pain as to render it probable that displacement has recurred, or that the splints are pressing unevenly, the dressing should not be disturbed more than absolutely necessary. It is a good rule to leave the fingers or toes ex- posed, so that the surgeon can by them judge of the condition of the circula- tion in the injured limb ; and if they appear unduly congested or swollen, the dressings should be at once removed, and reapplied with additional precau- tions against gangrene. If a case do well, every other day is quite often enough to renew the bandages during the first fortnight, the interval between the dressings being gradually lengthened after that time to half a week, and finally, to a week. At the same time, while in no class of cases is meddle- some surgery to be more reprobated than in this, fractures should be inva- riably looked upon as cases requiring careful and continual watching, and a patient with a broken bone should receive from his surgeon at least daily visits, until after the subsidence of all inflammatory symptoms. 3. The third indication for treatment (see p. 223) brings up the considera- tion of the various accidents which may arise during the management of a case of fracture. Muscular spasm and extravasation are such constant accompaniments of fracture, as to entitle them to be considered as symptoms, 1 Surgeon-Major Porter, of the Medical School at Netley, suggests that, in military practice, splints might be readily made from abandoned telegraph wire. 1-3 226 FRACTURES. under which head they have been referred to. Spasm is best controlled by the free use of opium ; moderate compression with a firm bandage is often recommended, but is a somewhat hazardous remedy, and should be used with great caution. Tenotomy has been also proposed for this purpose; but I can scarcely conceive of a case in which its use would be justifiable. Extrava- sation, if moderate, may be disregarded ; if there be much contusion and vesication, the limb should be simply laid on a pillow, protected by oil-cloth, while evaporating lotions are applied until the subsidence of inflammation; if large vesicles or bulla? form, they should be opened with the point of a lancet. If the extravasation proceed from the rupture of a large artery, the case will require special treatment, which will be considered under the head of com- plications. Embolism by particles of fat is an occasional complication of sim- ple fracture, which has been already referred to at page 137. Gangrene is the most serious accident which can be met with in the treat- ment of a simple fracture, and may be due either to arterial obstruction at a point above the seat of fracture, to venous obstruction due to swelling of the part or to tight bandaging, or to a combination of these causes. With regard to tight bandaging, it is to be remembered that a bandage may seem suffi- ciently loose when applied, and yet in a few hours may become the cause of great constriction from subsequent swelling of the limb; hence the importance of not applying a bandage beneath the splints; it is, as remarked by Mr. Erichsen, almost invariably to a neglect of this rule that the occurrence of gangrene from the pressure of a bandage is due. Especially is this true in the case of the forearm, in fracture of wdiich part this accident most often occurs. It should not be forgotten, however, that this accident may be partly or entirely due to arterial obstruction, which is of course an unavoidable occurrence ; hence we should not be too hasty in accusing a fellow-practi- tioner of mal-practice on account of such an accident, for it may be really due, at least in some measure, to causes entirely beyond control. The treat- ment of gangrene occurring under such circumstances must vary according to its nature and extent; if it be due to constriction, and the surgeon fortunately discover it in time, he must instantly remove the bandages, when possibly Fig. 107. Gangrene from tight bandaging. (Bell.) the patient may escape with superficial sloughing. If complete gangrene have occurred, amputation of course becomes necessary ; if the disease show a disposition to self-limitation, the surgeon may await the formation of the lines of demarcation and separation, but if the gangrene be of the rapidly spreading traumatic variety (p. 147), immediate removal of the limb must be practised at a point above the furthest limits of the disease. In the former TREATMENT OF COMPLICATED FRACTURES. 227 case a favorable result may be anticipated, but under the latter circumstances the patient is apt to sink after the operation, as happened in a case in which some years since I amputated at the shoulder-joint, for spreading gangrene following a badly treated fracture of the forearm. The other accidents which occur during the treatment of fractures, cannot be considered as peculiar to these injuries. Thus there may be excessive inflammation, followed by abscess or sloughing, surgical fever, traumatic delirium, tetanus, erysipelas, or pyamiia. In old persons the confinement to bed required in the ordinary treatment of fractures may produce pulmonary or cerebral congestion; hence the advantage in such cases of using the plaster of Paris bandage or other immovable apparatus, which may enable the patient to get about as soon as possible. In renewing the dressings of a fracture, the limb should be firmly and care- fully held by an assistant, so as to prevent any recurrence of displacement while the splints are off; it is well at each dressing to gently rub the affected limb with soap liniment or dilute alcohol (carefully drying the part after- wards), so as to keep the skin in a healthy state. The patient's general condition should be attended to, and any disorder of the bowels or chest remedied by appropriate measures. The use of the catheter is very often required for a tew days, when the patient is confined to bed, especially if the fracture be situated in the pelvis or femur. Passive Motion is effected by the surgeon flexing and extending the joints of the injured limb, while firmly holding the parts above and below. There is a difference of opinion as to the time at which passive motion (which is designed to prevent anchylosis) should be begun ; my own conviction is very clear, that it should not be practised until firm union has occurred between the fragments—usually, therefore, not before the third or fourth week after the accident, and that it should even then be used with moderation and with gentleness. The patient may, indeed, often be safely left to regain mobility of the joints by the ordinary physiological exercise of the limb, assisted by methodical friction, and the use of the cold douche. In the case of the upper , extremity, the patient may, after recovery, be advantageously directed to swing a flat-iron or put up a dumb-bell with the affected member, several times a day, continuing the exercise on each occasion until slight fatigue is experienced. Treatment of Complicated Fractures.—Fractures may be com- plicated by various conditions which will require special modifications of the general course of treatment above described. Thus the extravasation, al- though proceeding from vessels of moderate size, may produce so much swelling as to give rise to great congestion or even strangulation of the tissues, and consequent gangrene, demanding amputation ; or the contusion and subse- quent inflammation may be so great as to cause suppuration and sloughing, resulting in the conversion of the case from one of simple, into one of com- pound fracture. Rupture of the Main Artery of a limb is a very serious complication of fracture. This accident is principally met with in connection with fracture about the knee-joint, and the injured vessel may be either the posterior tibial or the popliteal. In either case, a rapidly increasing, obscurely pulsating tumor—a diffuse traumatic aneurism in fact—forms in the ham; and, unless promptly treated, will inevitably cause gangrene. If the posterior tibial be the wounded artery, at least partial warmth will be restored to the leg and foot, and pulsation will return in the anterior tibial: under these favorable circumstances, an effort should be made to save the limb by resorting to com- pression or ligation of the superficial femoral, in Scarpa's space. The reason 228 FRACTURES. for not treating the case as one of ordinary wounded artery is, that by so doing, even if the opening in the vessel could be found, which would be doubt- ful, the injury would be converted into a compound fracture of the worst kind, which would almost inevitably require amputation ; while there would be a chance, though not a very brilliant one, that, by the use of the proximal ligature, the arterial wound might heal, and allow the preservation of the limb. If, however, the temperature of the leg and foot continue to sink, and no pulsation can be detected in the anterior tibial, gangrene appearing immi- nent, it becomes almost certain that the popliteal artery is ruptured; and, under such circumstances, amputation should be at once performed. So, also, if after an attempt to save the limb gangrene should occur, amputation would be necessary. In any case of doubt, I think the safety of the patient would be consulted rather by removing the limb, while he was yet in good general condition, and when the operation could be done immediately above the knee, than by running the risk of being compelled to amputate at a higher point, with the patient under the depressing influence of gangrene. Dr. Laurent, a French surgeon, has collected 27 cases of this form of injury, occurring in various parts of the body, nine, or one-third of the cases, having terminated fatally. More favorable results were obtained by compression and ligation according to the Hunterian method, than by other modes of treatment. Rupture or other Serious Injury of an Important Nerve, as the musculo- spiral or median, is a very troublesome and annoying complication of fracture, causing loss of power or permanent impairment of the nutrition of the limb, as in a number of cases collected by Callender. This accident may not be apparent at the time of reception of the injury, and I have even known a surgeon to treat a broken arm until complete union of the fracture had oc- curred, not discovering the existence of paralysis until the splints were finally removed, when the limb dropped helplessly by the patient's side. The treat- ment of such a case is very unsatisfactory; it should be conducted on the principles laid down in the last chapter, in discussing injuries of the nerves in general. A very Severe Flesh Wound, even if not communicating with the seat of fracture and thus rendering it compound, may seriously complicate the pro- gress of the case, and may occasionally necessitate amputation. Unless, how- ever, the injury to the soft tissues were, in such a case, in itself sufficient to condemn the limb, a fair trial should always be given to conservative treat- ment before resorting to amputation. The Implication of a Joint in the line of fracture, will very often give rise to a certain amount of stiffness if not to absolute anchylosis, after recovery ; or, in a strumous constitution, may cause disorganization of the articulation, and thus eventually render amputation imperative. In every case of fracture involving a joint, the treatment should be conducted with great caution, and the prognosis should be extremely guarded. Dislocation of an Adjoining Articulation is a not unfrequent complication of fracture. In such a contingency the fracture should be temporarily put up with wooden splints and firm bandages, so that the limb may be used as a lever in effecting reduction of the dislocation, the patient being of course etherized. The fracture is then to be treated in the ordinary manner. If the dislocation be not recognized until a later period of the case, the sur- geon must wait until firm union of the fracture has occurred, and then, ap- plying splints, make an effort to reduce the dislocation, a feat which, under these circumstances, may be very difficult to accomplish. A fracture in a limb wliich is the seat of an old Unreduced Dislocation, or of a Previously Anchylosed Joint, presents no "peculiar difficulties of treat- TREATMENT OF COMPOUND FRACTURES. 229 ment, though it may require a modification in the form of the splints used, to adapt them to the existing deformity of the part. Fracture of the bone in a Stump, or into the site of a Previously Excised Joint, is occasionally met with, but requires no special treatment beyond the necessary modification of apparatus. Chorea, affecting a limb which is the seat of fracture, is a very serious complication : in a case of simple fracture of the humerus complicated with chorea, reported by Dr. Wm. Hunt, of this city, it was found impossible to keep the parts at rest, and the patient died exhausted on the tenth day. A fracture occurring in a Previously Paralyzed Limb, commonly unites without particular difficulty. There is, of course, no risk of recurring dis- placement from muscular action, but special care must be taken to avoid undue pressure, which might readily induce sloughing. Treatment of Compound Fractures.—The first question to be determined with regard to any case of compound fracture, is whether or not amputation is to be performed ; if the operation is to be done at all, it should be done as soon as possible, for the reasons already given in Chapter V. If amputation have not been done before the setting in of the intermediate or inflammatory stage, it must be, if possible, further postponed until suppura- tion is freely established. Amputation for Compound Fracture___Xo universal rules can be laid down, as to what cases of compound fracture should be submitted to primary ampu- tation, but each individual case must be treated on its own merits, according to the judgment of the surgeon. It may, however, be said that the circum- stances which usually call for amputation in these cases are the following:— 1. Extensive and severe laceration of the muscular and other soft tissues. —A compound fracture, in which the wound is made by the fracturing force, is a more serious injury than one in which the wound is made by the frag- ments perforating the skin, for the reason that in the latter case the soft tis- sues are comparatively little injured, while in the former they are apt to be greatly torn and bruised, or perhaps completely pulpefied. Hence compound fractures from railway and machinery accidents, especially in the lower ex- tremity, are almost invariably cases for amputation ; in the upper extremity it is often possible to save the limb, even in these unfavorable circumstances, and if the age and general condition of the patient should justify the attempt, it should certainly be made. It is in such cases that irrigation is found to be of special service in moderating the consecutive inflammation. 2. A compound fracture accompanied with a wound of a large artery will often require amputation. If the bleeding vessel can be readily found and tied in the wound, or can be controlled by position, pressure, etc., this should be done, when, if other circumstances are favorable, an attempt may be made to save the limb. If, however, the wounded vessel cannot easily be secured, and if the part injured be the lower extremity, immediate amputa- tion should be unhesitatingly resorted to. In the upper extremity such ex- treme measures may not be required, and if the bleeding vessel can neither be controlled by pressure, etc., nor secured in the wound, a ligature may be applied to the brachial artery, which has been several times successfully tied under such circumstances. 3. Great comminution of the bones themselves may be a cause for amputa- tion in cases of compound fracture. In the upper extremity much may be done in the way of conservatism, by removing splinters, and then placing the bones in such a position as to favor union. In the lower extremity, if the comminution be so extensive that removal of the primary and secondary sequestra will leave a gap in the continuity of the bone, the resulting limb, 230 FRACTURES. even if it could be preserved, would scarcely have sufficient firmness to be useful, and hence in such cases primary amputation is to be recommended. An exception should, perhaps, be made in cases of compound fracture in the upper third of the thigh, in which position primary amputation is so fatal an operation that the surgeon is loath to resort to it under any circumstances; but, indeed, these injuries are very apt to terminate in death under any mode of treatment. 4. Compound fractures into large joints often require amputation. In the case of the shoulder or elbow, provided that the extent of bone lesion, or of lac- eration of the soft tissues, be not too great, excision should be practised in preference to removal of the limb. The hip-joint is so deeply seated that it is seldom involved in a compound fracture, unless from gunshot wound, or from some crushing injury which necessarily proves fatal from visceral complica- tion ; when the accident does occur, however, primary excision is, I think, the correct mode of treatment, and has been successfully employed, under these circumstances, by P. A. Harris, of New Jersey. Compound fractures of the wrist, ankle, and knee joints are usually cases for amputation. Espe- cially should this rule be considered imperative as regards the knee-joint; much as I admire the operation of excision, and strenuously as I would advo- cate the practice of conservative surgery, I cannot but believe that in the immense majority of instances the best interests of the patient will be pro- moted by primary amputation in cases of compound fracture of the knee- joint. 5. A compound fracture, which would of itself require amputation, may be complicated by the existence of a simple fracture in the same limb, but at a higher point. In such a case, should the amputation be done at the seat of the upper fracture, or below? In my own experience, such cases, when an attempt has been made to save the limb, have invariably terminated fatally ; hence, I should be disposed (unless the upper fracture were situated high up in the thigh) to recommend primary amputation, at or above the seat of highest lesion. Still, if it were certain that the soft parts between the two fractures were healthy, and quite free from injury, it might be right to remove only the part that was irretrievably hurt, ami to make an attempt to save the rest of the limb ; as it happens, however, these cases are usually such as result from accident by railway or other vehicles, or by machinery, and are apt to be attended with much greater destruction of soft parts than is at first appa- rent ; so that, in most instances, amputation at the highest point of injury will be found the safest mode of treatment. The complication of compound fracture with dislocation at a higher point of the same limb, is of less consequence. In such a case the broken bones should be temporarily put up, and the dislocation reduced, the compound fracture being afterwards treated on its own merits. Compound epiphyseal separation is sometimes met with in young persons, and may be mistaken for compound fracture involving an articulation, from which lesion it can, however, always be distinguished by careful examination. If, as sometimes happens, the diaphysis project tlirough the wound, reduction is very difficult, and can usually be accomplished only by resecting the pro- jecting portion, an operation which may be best performed with Butcher's or a chain saw. The after-treatment does not differ from that of ordinary com- pound fracture; the resulting limb, though shortened, is not materially im- paired in utility, even in the case of the lower extremity. Treatment of Compound Fractures which do not require Amputation___ Many ingenious forms of special apparatus have been invented for the treat- ment of compound fractures, but I am not aware that they present any advan- tages over the ordinary splints and boxes habitually used in the management TREATMENT OF COMPOUND FRACTURES. 231 of simple fractures. The only special precaution to be observed is, to so arrange the splints and bandages that free drainage may be secured from the wound, and that the latter may be readily accessible without removing the entire apparatus. The points to be particularly attended to in the treatment of these injuries are : 1. Reduction of the fracture. 2. Extraction of splinters. 3. Closure of the wound ; and 4. Management of the consecutive inflammation. 1. Reduction is to be effected, as in the case of simple fracture, by relaxing the neighboring muscles, and by gentle manipulation. If a fragment project through the skin, the difficulty of reduction is much increased, and in such cases it may be necessary to enlarge the external wound, or even to resect the projecting end of bone. This measure should, however, be resorted to with extreme hesitation, especially in the lower extremity, for the loss of any considerable portion of the continuity of a long bone will be apt to result in the formation of a false joint, requiring subsequent amputation. This, in- deed, has been the invariable result in cases in which I have seen this opera- tion performed. 2. In the management of splinters or sequestra, the rules which were given in the chapter on Gunshot Wounds, founded on Dupuytren's division of splinters into primary, secondary, and tertiary, are to be observed. Those fragments wliich are loose or but slightly connected are to be removed, while those wliich are more firmly attached are to be pushed into place, that they may give solidity to the callus, and assist in the repair of the injury. In case of doubt, it is better to err on the side of allowing fragments to remain, as, if they afterwards become necrosed, they will be spontaneously loosened, when they can usually be removed without much difficulty, though in some cases a dead splinter may become surrounded by callus, requiring division of the latter before the sequestrum can be extracted. 3. If the external wound be small, and unaccompanied with much contu- sion, an attempt should be made to close it, and thus convert the case into one of simple fracture. I have occasionally succeeded in doing this ; and the effort should always be made when the nature of the case will permit it. For this purpose the wound is to be washed and freed from blood, and then her- metically sealed with gauze and collodion, styptic colloid, Paresi's antiseptic preparation (page 146), or the compound tincture of benzoin; or, in the absence of these agents, simply with a piece of lint dipped in blood, as recommended by Sir Astley Cooper. If, however, the wound be a large one, or if it be accompanied with much contusion and laceration, it will be useless to attempt its closure, and it should then be dressed lightly, and in such a way as to allow of free drainage. Even if an attempt have been made to close the wound, the parts should be frequently examined, and if it appear that pus is accumulating underneath the dressing, the latter should be imme- diately removed, and free vent given to the accumulated discharges. 4. The management of the inevitable consecutive inflammation which attends compound fractures, is to be conducted in accordance with the principles enunci- ated and the rules laid down in the chapters on the Treatment of Inflammation, and on Wounds in General. Ice, water-dressing, irrigation, laudanum fomen- tations, poultices, astringent washes, antiseptic applications, etc., may each and all be appropriately used in different cases and under different circumstances. The splints employed should be protected by oiled silk from being soiled by the discharges ; and while the fracture should not be unnecessarily disturbed, the utmost care must be taken to keep the parts clean, and to preserve the neighboring integument in a healthy condition. In compound fractures of the lower extremity, the bran dressing, introduced by Dr. J. Rhea Barton, 232 FRACTURES. of this city, will be found most serviceable. It affords equal pressure and support to the injured member, restrains hemorrhage, absorbs discharges, and can be daily renewed, as far as necessary, without material disturbance of the limb. Its mode of application will be described in the next chapter. The patient's general condition must also receive attention. The action of the bowels must be regulated, and traumatic fever moderated by the administra- tion of suitable remedies. When suppuration is fairly established, tonics, especially iron, quinia, and cod-liver oil, may be freely exhibited. The diet should be nutritious, but unirritating; and in the later stages, or perhaps from the first, free stimulation may be required. The connection which has now been so often traced as to make it appear causal, between prolonged sup- puration and the peculiar form of visceral degeneration known as albuminous or amyloid, clearly indicates the paramount importance, in these cases, of maintaining the patient's strength and supporting his system in every pos- sible manner. The time required for the cure of a compound fracture may be estimated at from two to three times as long as would be needed in the case of a simple fracture of the same part. Secondary amputation may be required in the treatment of compound fractures, on account of traumatic gangrene, sloughing following erysipelas, osteo-myelitis, extensive necrosis, general exhaustion of the patient, hectic, etc. The proper period for amputation in cases of traumatic gangrene has already been pointed out in preceding chapters. In the case of the other complications which have been mentioned, the surgeon must choose his time as best he can, operating at some period when there is a momentary sub- sidence of constitutional disturbance, and while not hastily condemning a limb without fair trial of conservative measures, yet not delaying interference until the patient has sunk so low that interference will be of no avail. The only general rule that can be given with regard to these cases, is, to avoid, if possible, operating during the intermediate stage, wliich usually ranges from the second to the tenth or twelfth day. After suppuration has been fairly established, the case becomes somewhat assimilated to one of chronic disease, and amputation can then be performed with comparatively fair prospects of success. Treatment of Fractures -with "Immovable Apparatus."— In the later stages of the treatment of fractures, advantage may often be derived from the use of a plaster of Paris bandage, or one of the other forms of immovable dressing described in Chapter IV. It is right to add that several excellent surgeons, both at home and abroad, recommend the use of these dressings even in the early stages of fractures, and believe that by their employment as good, if not better, results may be obtained than by the ordi- nary methods. For my own part, I cannot but regard any form of immovable dressing as unsafe, when employed before the swelling wliich always follows a fracture has entirely subsided, and I am not in the habit of applying the plaster bandage until the union o£ the broken bones has become tolerably firm—usually in the course of the third or fourth week. I would invite those who are interested in the further consideration of this subject to refer to Prof. Hamilton's excellent treatise, where the comparative advantages of these different modes of treatment are fully, and—as far as I am able to judge—very fairly, set forth. There are two principal ways in which the plaster of Paris bandage may be applied ; one, and that which I think upon the whole the best, consists in the application of the wetted gypsum roller over a dry roller, in the way described on page 82, care being taken to keep the limb well extended TREATMENT OF BADLY UNITED FRACTURES. 233 while the plaster is setting; and the Fig. 10S. other, or " Bavarian plan," in which two pieces of flannel, stitched together at their middle by a straight seam, are laid beneath the limb, the inner layer being then folded evenly around the part and secured with pins or stitches, when the liquid plaster is spread OVer it, and the OUter layer Bavarian immovable splint. (Bryant.) finally brought up and secured in the same manner as the first; after the plaster has become hard, the pins or stitches are removed, when the splint may be opened and taken off, the seam at the back serving as a hinge. Treatment of Badly United Fractures__From various causes, over some of wliich the surgeon may have no control, a fracture may unite with so much deformity as to disfigure the limb, if not to render it useless. If the deformity be in a longitudinal direction, depending on overlapping of the fragments, the case is, I believe, hopeless, for the surrounding muscles will have probably become permanently contracted and shortened, and attempts at extension after union has once occurred will prove fruitless. Transverse deformity will be gradually lessened by the processes of nature, superfluous callus being absorbed, and projecting bony prominences rounded off. Angular deformity, if very slight, may be left to nature, in the hope that it will be gradually removed by the physiological action of the muscles. If at all marked, however, it will require treatment, and this, if the bony union be comparatively soft, can usually be satisfactorily carried out by care- ful bandaging and the judicious use of pads and compresses—or the surgeon may by gentle but firm pressure bend the newly-formed callus, so as to restore the limb to its proper shape. If the union of the fracture be further advanced, more force may be required, and the surgeon may break the bone over again, with a view to resetting it in a better position. This may be done with the hands, or at a later period with a screw clamp, such as those devised for the purpose by Rizzoli, Von Bruns, Butcher, and C. F. Taylor, of New York. A remarkable case has been reported by Mr. Switzer, an English army sur- geon, in which a large amount of deformed callus disappeared under inunc- tion with compound iodine ointment, and it would certainly be proper to try the sorbefacient effects of this remedy before resorting to the severer measures which will next be described. When the callus is so firm as to resist the application of such an amount of force as the surgeon deems justifiable, he may adopt measures to weaken the bond of union, by operative interference. Perhaps the best plan in such a case is that suggested by Brainard, of Chicago,, which consists in subcutaneously drilling through the uniting medium in various directions, and then rupturing the remainder; or the bone may be partially divided with a saw (Langenbeck) or chisel (Niissbaum, O'Grady), or, as done by Warren and Heath, a wedge-shaped piece may be removed from the apex of the bony angle, the rest of the bond of union being, in either case, broken through as in Brainard's method; or the deformed callus might be entirely exsected—an operation, however, which,, in addition to its inherent risks, would expose the patient to the chance of recovering with a false joint; or, finally, in an aggravated case, it might be necessary to resort to amputation. For further information on this subject,, the reader is respectfully referred to Dr. G. W. Norris's excellent paper, in his well- known Contributions to Practical Surgery. 234 FRACTURES. Reduction of Deformity in Partial, and in Impacted Fractures—In con- nection with the subject of Badly United Fractures, I may refer to the question which often arises as to whether or no reduction should be attempted in cases of partial and of partially impacted fractures. The answer to this question may be said to depend upon the position of the fractured bone ; thus, while it would be manifestly improper to attempt reduction of an impacted fracture of the neck of the femur, it is, I think, right to reduce a partial fracture of the clavicle or of the forearm, even at the risk of converting the case into one of complete fracture. In the forearm (and in the clavicle, if the angular projection be outwards), the deformity would be so great as to be very objectionable, while inward angular displacement of the clavicle might endanger the integrity of the important underlying structures by irritation from bony spiculas. Tardy or Delayed Union of Bones is occasionally met with, and is, probably, more often dependent on constitutional than on local causes. Sometimes it appears to result from mere debility and depression, without the existence of any positive cachexia; under such circumstances it may be sufficient to get the patient out of bed, with his limb supported in a plaster of Paris bandage, letting him recover his health by means of out-door exer- cise. In some cases the process of union may be assisted by the use of tonics, especially cod-liver oil and the phosphates (which, however, have not been found as practically useful as was anticipated), and by giving an extra allowance of ale or porter. If a syphilitic taint be suspected, iodide of potas- sium or mercury may be cautiously administered. Ununited Fracture axd False Joint. Occasionally a broken bone does not unite at all, or unites only through the medium of fibrous or ligamentous bands, or, having been united, becomes again separated by the absorption and softening of the callus. In some bones, indeed, as in the patella, bony union almost never occurs, but in such cases the want of union cannot be considered abnormal. The terms ununited frac- ture and false joint are applied only to fractures in those situations in which bony union is habitually met with, as in the various long bones, or the lower jaw. The proportion of cases in which non-union occurs is estimated by Hamilton at 1 in 500 ; it is, therefore, a rare accident. Ur. Norris, of this city, whose monograph on this subject is the best that has yet been published, has described four distinct forms under which non- union of fracture may occur. rVhe first is that which has already been re- ferred to under the name of delayed union; here callus is formed, but does not undergo complete ossification, and, hence, the union is imperfect. " In the second class of cases, there is entire want of union of any sort between the fragments, the ends of which seem to be diminished in size, and are ex- tremely movable beneath the integuments. The limb in these cases is found greatly shrunken, and hangs perfectly useless."1 In the third and most usual form, the ends of bone are rounded off and tapering, and "are con- nected together by strong ligamentous or fibro-ligamentous bands," passing between the fractured extremities ; there may be but one band, or several; " in either case the newly-formed substance is firmly adherent to the bones, and, if of any length, is in a high degree pliable." In the fourth variety, to which the name of pseudarthrosis or false joint is properly given, " a 1 Dr. C. B. Porter, of Boston, reports a case in which after ununited fracture the humerus was absorbed, and entirely disappeared without exfoliation. CAUSES OF NON-UNION AFTER FRACTURE. 235 dense capsule without opening of any sort, containing a fluid similar to syno- via, and resembling closely the complete capsular ligaments, is found. In these cases the points of the bony fragments corresponding to each other are rounded, smooth, and polished, in some instances are eburnated, and in others are covered with points or even thin plates of cartilage, and a membrane closely resembling the synovial of the natural articulations. It is in this kind of cases that the member affected may still be of some utility to the patient, the fragments being so firmly held together as to be displaced only upon the application of considerable force." The diagnosis of ununited fracture is usually sufficiently easy: I have, however, known great relaxation of the ligaments of the wrist-joint to be mistaken for ununited fracture of the extremity of the ulna. Causes of Non-union after Fracture__These may be either con- stitutional or local. Among the former may be enumerated general impair- ment of health, and various cachectic conditions and diatheses, such as scurvy, phthisis, rickets, syphilis, or cancer. With regard to the influence of cancer in preventing union after fractures, Dr. Norris says that when the accident depends upon the presence of a cancerous tumor at the seat of fracture, union will not occur, but when it depends on mere brittleness, re- sulting from what Mr. Curling has called eccentric atrophy, the bones unite readily enough. So with regard to syphilis and rickets ; though cases are recorded in which these appear to have acted as causes of non-union, other cases are frequently met with in which the disease is well marked, and yet union readily occurs. Pregnancy is often regarded as a cause of non-union in fractures, but it is probably thus effective in those cases only in which the pregnant state is accompanied by great debility, as from sympathetic vomit- ing. The same remark applies to the supposed efficiency of lactation as a cause of ununited fracture. Age does not appear to exert any particular in- fluence, fractures in the very young and the very old often uniting quite as well as in those of middle life, and more than one-third of the whole number of cases of ununited fracture occurring in those between twenty and thirty. Among the more prominent local causes, may be mentioned deficient vascu- lar or nervous supply, mobility or want of proper apposition of the fragments, the intervention between the fragments of a shred of muscle or other soft tissue, or of a foreign body, necrosis or other disease of the ends of the frag- ments themselves, injudicious treatment (especially tight bandaging and pro- longed use of cooling applications), and too early use of the fractured limb. The frequency with which ununited fracture occurs in different parts, is shown in the following table taken from Dr. Xorris's paper. Locality. Number of cases. Cured. No benefit. Died. Result unknown. Thigh ...*... Leg....... 48 33 48 19 2 31 32 31 17 2 9 1 14 1 6 3 1 2 Total . . . 150 113 25 10 2 Ununited fracture is also occasionally met with in the clavicle, scapula, ribs, and spine. 226 FRACTURES. Treatment___The treatment of ununited fracture, and of false joint, consists in removing, as far as possible, by constitutional, hygienic, and local measures, any cause which may seem to hinder the process of union between the broken bones, and in endeavoring to excite in the periosteum, in the medulla, and in the fragments themselves, such activity as will induce those changes which we have seen to be necessary in the natural process of repair after fracture. For this purpose, those remedies should be employed which were spoken of in treating of delayed union, the fragments being accurately adjusted, and rendered perfectly immovable by the use of suitable splints and bandages. Firm and accurately fitting splints of metal, leather, or paste- board may be employed, or the plaster of Paris bandage,1 or (in the case of the lower extremity) the ingenious and elegant contrivances of Prof. Smith, of this city, or of Dr. Hudson, of New York. In order to excite renewed activity in the periosteum and other bone-producing tissues, various plans, such as blistering, cauterizing, or galvanizing the skin, have been employed, and when the beneficial effect of transmitted periosteal and medullary irrita- tion is remembered, it can readily be understood that these methods should occasionally have proved successful. Other plans which have sometimes succeeded, consist in rubbing together the ends of the fragments themselves, and in "percussing" the injured limb with a rubber-protected mallet (Thomas). In the event of these simple remedies failing, severer measures may be employed: of these the most important are the establishment of a seton between the fragments, as recommended by Dr. Physick, or on either side of the ununited fracture, as suggested by Oppenheim ; the introduction of stimulating injections, as practised by Dr. Hulse and M. Bourguet; acu- puncture, as suggested by Malgaigne; the introduction of ivory pegs (Dief- fenbach and Hill); electro-puncture (Lente); subcutaneous scarification (Miller); drilling the fragments themselves (Detmold and Brainard) ; scrap- ing or cauterizing the fragments; holding the fragments together by means of sutures or pins (Severinus, Rodgers, Gaillard, and F. Mason); resection (White, Roux, Jordan, and Bigelow); transplantation of a fragment split off from a neighboring bone (Niissbaum) ; and finally amputation. Of all these, the most promising methods are, I think, those of Physick, Brainard, Gail- lard, and Bigelow. Before resorting to any of them, the suggestion of Oilier may be adopted, to rejuvenate, as it were, the periosteum by the milder forms of irritation, that it may afterwards more readily respond to the severer operation. Physick introduced a piece of silk or tape, by means of a long seton needle, directly between the fragments, and allowed the foreign body to remain four or five months. Norris has, however, shown that the seton is equally efficient and more safe when removed at an earlier period, and sur- geons now seldom allow it to remain longer than a fortnight; it is rarely used in the case of the thigh, where other means are more successful. Brainard's plan consists in drilling the fragments subcutaneously with a metallic per- forator or bone drill. His manner of using the instrument, as quoted by Hamilton, is as follows : " In case of an oblique fracture, or one with over- lapping, the skin is perforated with the instrument at such a point as to 1 Guenther, a Danish surgeon, and Nillien, of Illinois, have observed that the growth of the nails is arrested during the early stages of a fracture, to be resumed as the process of repair goes on, and they suggest this as a means of testing the progress of cure, without disturbing the dressings, in cases of delayed union, or of false joint. It would appear, however, that the growth of the nails may be checked by any cause which interferes with the nutrition of the part, and hence this test might not be uni- versally applicable ; Mitchell has noticed an arrest of nail growth in cases of cerebral paralysis, and Gay has observed the same phenomenon as a result of compression of the subclavian artery. TREATMENT OF UNUNITED FRACTURE, ETC. 231 enable it to be carried through the ends of the fragments, to wound their surfaces, and to transfix whatever tissue maybe placed between them. After having transfixed them in one direction, it is withdrawn from the bone, but not from the skin, its direction changed, and another perforation made, and this operation is repeated as often as may be desired." Prof. Gaillard's method consists in pinning together the fragments by means of a gimlet-like Fig. 109. Improved bone-drill. instrument, provided with a movable silver sheath, a handle, and a brass nut (Fig. 110): the sheath is introduced through an incision, and held against the bone, while the shaft is passed through and made to transfix both frag- ments ; the nut is then screwed down firmly on the sheath, the whole instru- ment being allowed to remain in situ till union is obtained. This plan affords Fig. 110. I ■ 3 f)J) Gaillard's instrument for ununited fracture. more secure apposition than merely wiring together the fragments, as prac- tised by Rodgers, Flaubert, N. R. Smith, and others. The operation em- ployed by Prof. Bigelow, of Boston, is almost identical with that independently suggested by Oilier, of Lyons, and is probably the surest method of treating ununited fracture : it consists in making a subperiosteal resection of the ends of the fragments, the freshened extremities being then held together by a wire suture. Dr. Bigelow has thus treated eleven cases, with but one failure, and that from disease of the bone, which subsequently required amputation. This plan has also been successfully adopted by other surgeons, including Byrd, of Illinois, Annandale, Packard, and myself. Whatever method be employed, the after-treatment must be carefully con- ducted by the use of proper splints, and by the administration of tonics and good food. The phosphate of lime is recommended by Bigelow and Dolbeau, the latter of whom finds that the action of the drug is manifested by the occurrence of formication in the injured limb. In some cases, when the inconvenience resulting from the ununited fracture is not very great, it might be advisable to decline any operation, and employ the apparatus of Prof. Smith, already referred to, or some similar contrivance. 238 SPECIAL fractures. CHAPTER XII. special fractures. I have gone so fully, in the last chapter, into the consideration of the causes and symptoms of fractures in general, and of the principles by which the surgeon should be guided in undertaking their treatment, that it will not be necessary to repeat what has been said, with regard to each several bone ; hence, in the present chapter, I purpose merely to point out the peculiar symptoms and diagnostic marks of the special fractures, and to indicate very briefiy the most convenient and satisfactory modes of treatment, referring the reader, for more detailed information upon this subject, to the excellent treatises of Hamilton, Malgaigne, Cooper, Smith, of Dublin, Lonsdale, etc., and to the chapter on Fractures in Dr. Wales's valuable work on "Mechanical Therapeutics," which contains a very good account of the different forms of apparatus devised for the treatment of broken bones. Fractures of the skull, and of the vertebras, are principally interesting on account of their involving respectively the brain and spinal cord; hence their consideration will be post- poned till we come to speak of injuries of those parts of the body. Fractures of the Face. Any of the facial bones may be broken by direct violence, and especially by gunshot wound ; the nature of the injury is usually recognized with fa- cility, and the treatment should be particularly directed to the lesion of the soft tissues. Nasal Bones—These are not unfrequently broken, and the injury may escape detection from the rapid swelling of the soft parts. The treatment consists in removing the displacement (if there be any), by inserting a broad director or a pair of polypus forceps into the nostrils, and moulding the bones into their proper places ; the parts may then be supported by means of a com- press on either side, and a few strips of adhesive plaster. If the septum be broken, it should be restored to its proper place in the same way, the shape of the nose being preserved by plugging the nostrils, if necessary. Occasion- ally the whole nose is split off, as it were, from the face, hanging by the alas in front of the mouth. In such a case, in which the injury was produced by a blow from an iron pan, I kept the nose in place by numerous sutures, the patient making a good recovery. Sometimes the whole nose is driven in- wards, fracturing the ethmoid bone, and involving the brain. Under such circumstances, the nose should be gently drawn forwards with forceps, and the case treated as one of fracture at the base of the skull. Profuse hemor- rhage may require plugging of the narcs. AW Adams has devised special apparatus for forcibly straightening the nose when deformity has ensued, and for subsequently keeping the parts in position. An ingenious nasal splint has also been devised by Gamgee, of Birmingham. Fracture of the Lachrymal Bone may cause obstruction of the nasal duct, and consequent epiphora; or emphysema of the subcutaneous tis- sue may follow whenever the patient blows his nose. FRACTURE OF THE LOWER MAXILLA. 239 Fracture of the Malar Bone is to be treated by keeping the parts in place by compresses, adhesive strips, and bandages. Fracture of the Zygoma, if comminuted, may interfere with masti- cation, by the impaction of splinters in the temporal muscle ; in such a case, the surgeon should cut down and remove the offending fragments. Upper Maxilla—Fractures of the upper jaw are sometimes attended with such profuse hemorrhage as to require plugging the antrum, or even ligation of the external carotid. If the malar bone be thrust in upon the an- trum, it should be drawn out with a tire-fond or screw elevator (Fig. 77), aided by pressure from within the mouth. If the upper jaw be broken through the alveolus, the teeth may be held together by means of wire. The vascular supply is so free in this part, that necrosis rarely follows, even in cases of gunshot injury ; the fetid discharge is, however, a source not only of annoyance, but of constitutional depression, and hence free use should be made in such cases of detergent and disinfectant washes. Sometimes all the bones of the face are crushed and separated from their attachments by explo- sions, violent blows, or falls. Such cases are attended with great shock, and usually prove fatal from hemorrhage or cerebral complication. Lower Maxilla—The lower jaw is more frequently broken than any other bone in the face. The fracture, which is usually caused by direct vio- lence, may be in any part of the bone, the most usual seats being, however, near the symphysis, and about the position of the mental foramen. The lower jaw is often broken in two or more places at once, and its fractures are frequently rendered compound by laceration of the mucous membrane. Frac- tures near the symphysis are more or less transverse, while those further back are almost invariably oblique from before backwards, allowing considerable displacement, which is evidenced by shortening of the alveolar border, and depression of the chin. In fractures near the angle of the bone, the dental nerve is occasionally involved, an accident which causes temporary paralysis, or more rarely convulsions. The displacement, mobility, and crepitus, which accompany fracture of the jaw, render its diagnosis usually easy : in cases of fracture below the condyle, there is, besides, embarrassment in the motions of the jaw, and pain, felt especially on opening or shutting the mouth. Frac- tures of the lower jaw commonly unite without much difficulty, and with lit- tle deformity. Treatment___For the treatment of an ordinary case of broken jaw, nothing' is required except a compress to support the chin, and a roller bandage. Velpeau, indeed, during Yig. 111. the last years of his life, is said to have abandoned all forms of apparatus, in the treatment of these in- juries, believing that sufficient rest was insured to the fragments by the inevitable occurrence of pain upon any attempt at motion made by the patient. I am in the habit of treating these fractures in the manner recommended by Dr. J. Rhea Barton, of this city, with the superaddition of a few occipitofrontal turns of the roller, as in Gibson's bandage. The following description of Barton's bandage is taken from Sargent's minor surgery :—" Composition : A roller five yards long, and two inches wide ; suitable compresses. Application: Place the initial extremity of the Bartou,s baadage for fractm.ed roller upon the occiput, just below its protube- jaw. 240 SPECIAL FRACTURES. ranee, and conduct the cylinder obliquely over the centre of the left parietal bone, to the top of the head ; thence descend across the right temple and zygomatic arch, and pass beneath the chin," which should be supported by a compress, " to the side of the face; mount over the left zygoma and temple to the summit of the cranium, and rejoin the starting-point at the occiput, by traversing obliquely the right parietal bone; next, wind around the base of the lower jaw on the left side to the chin, and thence return to the occiput along the right side of the maxilla;" to these three turns, I add a fourth, around the head just above the ears, making an occipito-frontal turn, which being pinned at its intersection with the others, serves to prevent slipping. The same course is to be continued until the roller is exhausted, and additional security may be furnished by sealing the bandage (as it were) with a few strips of adhesive plaster. Gibson's bandage consists of a com- press beneath the chin, with turns of a roller passing from that part to the top of the head, from the occiput to the forehead, and from the nape of the neck to above the mental protuberance, the whole being held in place by a short strip passing from the forehead, backwards to the nape along the median line of the head. Many surgeons prefer to treat fractures of the jaw with an external splint, moulded from pasteboard or gutta-percha, and held in place by a simple sling of four tails, two of which are tied on the top of the head and two behind the neck (Fig. 15), or with an ingenious apparatus composed of a leathern sling, with strong linen webbing straps, devised for the treatment of these cases by Prof. Hamilton ; wiring together the teeth on either side of the fracture is often recommended, but I confess to have seen very little advantage from the practice : a better plan is the application of clasps of ivory, silver, steel, or other material, as practised by Lonsdale, Mutter, N. R. Smith, Nicole, Wales, Bullock, and others, or of interdental splints of gutta-perch or vulcan- ized India-rubber, as ingeniously applied by Dr. Gunning, of New York, and Dr. Beans, of Atlanta, Ga. In a case of fracture of both rami of the jaw, Annandale succeeded in obtaining a good result by cutting down externally, on each side, and securing the fragments by means of the wire suture. A similar plan, in cases of single fracture, had been previously employed by Buck and Hamilton, of New York, and by Kinloch,of Charleston. Whatever mode of treatment be adopted, care must be taken not to pro- duce uneven or undue pressure. Neglect of this precaution will cause great irritation, and probably the formation of abscess, a very troublesome and painful complication of fractured jaw, and one that may give rise to necrosis and to consequent non-union, which accident is, in this position, I believe, more apt to result from tight bandaging than from the bandage being too loose. Gunshot fracture of the lower jaw is sometimes attended with so much splin- tering as to require partial resection of the bone. The period required for the cure of a simple fracture of the jaw is usually from three to six weeks. Fracture of the Hyoid Bone is a very rare accident. Hamilton has collected ten cases, of which three were caused by hanging, three by grasping the throat between the thumb and fingers, three by direct blows or falls, and one by muscular action. The accident is attended with great pain, sometimes with hemorrhage, and with difficulty in opening the mouth, in swallowing, and in speaking. The diagnosis can be made by observing the mobility of the fragments, and the inward angular displacement, with or with- out crepitus. The treatment consists in reducing the deformity, by pressure from within the mouth, and in keeping the parts at rest by use of a paste- board or leather collar, with the enforcement of quiet, and the hypodermic administration of opium. Of thirteen cases collected by Dr. Gibb, two proved fatal. FRACTURES OF THE TRUNK. 241 Fractures op the Trunk. Ribs___The ribs are more frequently broken than any of the other bones of the trunk: these injuries may be produced by direct violence, as from the kick of a horse, or by indirect violence, the front and back of the chest being pressed together, and the ribs giving way like an over-bent bow, at the weak- est part. The ribs are occasionally broken by muscular action (as in partu- rition), or, according to Malgaigne, even by the impulse of the heart. The middle ribs, from the fourth to the tenth, are those most exposed to fracture, and the usual seats of injury are near the junction of the costal cartilages, and in the neighborhood of the angles. The direction of the fracture is com- monly transverse or slightly oblique; occasionally a rib is comminuted, or broken in more than one place. These fractures are rarely compound, except as the result of gunshot wounds. The displacement in cases of fractured rib is usually slight; if the result of a direct blow, there will probably be some inward angular deformity, while if from indirect violence, the projection will be outwards; if a number of ribs on the same side be broken, there may be a slight tendency to overlapping. The diagnostic signs are deformity, mo- bility, and crepitus, which is sometimes readily perceived, but at other times can only be elicited by careful and prolonged manipulation, by compressing the chest from before backwards, or by auscultation. There are, besides, pain and localized tenderness, with a sharp stitch, if the pleura be wounded, and, possibly, haemoptysis, pneumothorax, or emphysema, if the lung be in- volved. The pain is much increased by movements of the chest wall, and the breathing is therefore shallow, and to a great extent diaphragmatic. The prognosis is favorable ; except in cases complicated with thoracic or other severe injury, it is very rare for death to follow fracture of the ribs. Union commonly takes place in from three to five weeks, with very little deformity, and by means of a well-marked ensheathing callus. False-joint is occasion- ally met with in this situation, while, on the other hand, the production of new bone is sometimes excessive, causing coalescence between adjacent ribs. Treatment—In the treatment of fractured ribs, the surgeon may disregard any existing deformity, which will usually spontaneously disappear by the expansion of the chest in the respiratory movements ; even if it should not, it would be preferable to allow the displacement to remain, rather than to at- tempt its removal, as has been proposed, by the use of sharp hooks or screw elevators. The chief indication in any case of fractured rib, is to put the affected part in a state of complete rest, and this may best be done by surround- ing the side of the chest which is involved, with numerous overlapping broad strips of adhesive plaster, each reaching a little beyond the median line, both behind and before. This mode of treatment, which appears to have origi- nated with Dr. Hannay, of England, is, according to my experience, much superior to any other which has been proposed. The strips, which should be about two inches wide, are laid on in circular layers, beginning from below, each strip overlapping its predecessor by about one-third of its width. As the dressing becomes loosened, other layers of strips are to be tightly applied immediately over the first, so that the chest is kept constantly fixed by a stiff and firm splint of adhesive plaster. The patient will usually be most at ease in a sitting posture for the first day or two. Thoracic complications must be met by appropriate treatment, and in any case opium may be freely admin- istered. The dressing maybe removed at the end of three weeks, when union is commonly sufficiently firm to enable the surgeon to discontinue his attend- ance. If, in any case of injury of the chest, it is uncertain whether a rib be broken or not, the dressing above described should be applied, as it will afford great comfort, even in cases of contusion without fracture. 16 242 SPECIAL FRACTURES. The emphysema which sometimes accompanies fracture of the ribs requires no special treatment, usually disappearing spontaneously in the course of a few days or weeks. Rupture or laceration of an intercostal artery, which proved fatal in a case recorded by Amcsbury, could scarcely be recognized unless the fracture were compound. Under such circumstances an effort should be made to secure the bleeding vessel, for which purpose, if necessary, a portion of the adjacent rib might be excised. In cases of gunshot fracture, all spicule should be carefully removed, and the after-treatment conducted with reference to the condition of the thoracic viscera, on the principles which will be laid down in the chapter on Injuries of the Chest. The Costal Cartilages are occasionally broken, either at their junction with the ribs or through their middle. The causes are the same as in the case of fractured ribs ; but, as the violence required is greater, there is more apt to be serious visceral complication. The symptoms are the same as those of fractured ribs, except that crepitus is rarely perceptible. The direction of the fracture is commonly transverse, the anterior fragment usually projecting in front of the posterior. Union takes place by the production of bone, not of cartilage, the callus being chiefly developed on the pleural side of the frac- ture ; non-union has been observed in one case by Hamilton. The treat- ment consists in the application of adhesive strips, as for fractured ribs.1 Sternum___True fracture of the sternum is a very rare accident. Dias- tasis of the first from the second bone is more often met with, and is a less serious affair. These injuries may result from direct violence, from counter- stroke (the force being applied to the back), or from muscular action, as in parturition, or in the act of vomiting. The line of separation is usually transverse, though it may be bevelled as regards the thickness of the bone. Malgaigne, Kramer, and Meyer have each observed longitudinal fractures of the sternum. The most usual seat of injury is at the junction of the manu- brium and gladiolus, and in this situation the lesion is, as already observed, commonly a diastasis, or, according to Maisonneuve, Brinton, and Rivington (who have repeatedly observed a true joint in this position), a dislocation. It is a matter of some importance, as regards the prognosis, to be able to say in any individual case whether the lesion be a true fracture or a diastasis, for in the latter cast?, the posterior ligament being intact, the patient usually es- capes visceral complication. In true fracture, the lung or even the heart may be torn, and, even if these dangers be avoided, there is considerable risk of the subsequent formation of abscess in the mediastinal space. The following may be looked upon as evidences of true fracture, viz., the presence of crepi- tus, the injury being below the junction of the first and second bones, or the fact of the upper fragment projecting in front of the lower. In diastasis the lower rises in front of the upper fragment. Direct violence exerted upon the manubrium has never been known to produce true fracture, while when exerted upon the gladiolus it almost never produces diastasis. In cases of injury from indirect violence, if the marks of fracture above given be not present, the diagnosis must be made by noting the presence or absence of haemoptysis, emphysema, etc. The ensiform cartilage is rarely the seat of fracture or dislocation, though well-marked cases have been observed by Hamilton, Martin, Billard, Mau- riceau, Gallez, and Polaillon. In making the diagnosis of fractured sternum, the possibility of a con- genital deformity being mistaken for the result of violence, must not be over- 1 See interesting papers by Dr. E. H. Bennett, in the Dublin Journal of Medical Science for March, 1876, and October, 1877. FRACTURE OF THE PELVIS. 243 looked. The detection of crepitus and mobility may be facilitated, as sug- gested by Despres, by placing a cushion beneath the back, so as to render the front wall of the thorax prominent. The diagnosis in cases of fracture from counterstroke may, according to Hewett, be aided by noting the occur- rence of ecchymosis some days after the reception of the injury. The prog- nosis of diastasis, or of uncomplicated fracture, is favorable ; union usually takes place in from three to four weeks. The treatment consists in keeping the parts at rest, by the application of a broad compress, held in position with adhesive strips or bandages. If there be much displacement, attempts at reduction may be made, by straightening the spine and drawing the shoulders backwards. Opium will usually be required, and any thoracic complications must be met by suitable remedies. Mediastinal abscesses should be opened at the side of the sternum, when pointing occurs; they have been evacuated by Gibson and others by the use of the trephine, but the results of the operation do not warrant its repetition. Pelvis—Fractures of the pelvis are chiefly interesting on account of the liability to implication of the adjacent viscera. One of the Ossa Innominata may be broken, the injury being sometimes limited to a separation of the crista ilii, or of one of the spinous processes, and at other times passing tlirough the rami of the pubis or ischium, or in the neighborhood of the sacro-iliac symphysis. The ilium, pubis, and ischium may separate in their lines of conjunction, the acetabulum being thus split into three portions ; or dia- stasis may occur at the pubic or sacro-iliac symphyses. Fractures of the pubis and ischium assume a somewhat oblique direction, while those about the sacro- iliac junction correspond pretty generally to the line of the symphysis. The diagnosis of fractured pelvis can usually be made without much difficulty. There is great pain, aggravated by motion, and especially by any attempt to walk or stand; there is abnormal mobility; and crepitus can be elicited by grasping the ilia in ether hand and moving them in opposite directions. The displacement in fractures of the pubis and ischium is often considerable, and can usually be readily detected. These injuries are commonly caused by great violence of a crushing nature, such as the fall of a bank of earth. In one case, which was under my care, the crest of the ilium was knocked off by a sharp blow resulting from the fall of a stove-pipe. The pubis has some- times been fractured as the result of muscular contraction, as in a remarkable case recorded by M. Letenneur, while diastasis of the pubic, and occasionally of the sacro-iliac, symphysis may occur in the process of parturition. Frac- ture of the Acetabulum is an accident that is often spoken of as complicating dislocation of the hip. I believe, however, with Prof. Bigelow, that this fracture is much rarer than is generally supposed, and that its existence should never be assumed unless crepitus can be detected at the seat of supposed lesion, while even in such a case the injury (as pointed out by Birkett) may really consist in a luxation, complicated with fracture of the head of the femur. Fracture of the acetabulum may consist merely in a separation of its posterior lip, or in a destruction of its floor, attended some- times with impaction of the head of the femur in the pelvic cavity. The latter form of injury is commonly attended with such severe visceral lesions as to prove fatal. Separation of the lip of the acetabulum is marked by the signs of dislocation, the displacement being readily reduced with crepitus, but as readily reproduced when extension is discontinued. The great danger in cases of fracture of the pelvis is from rupture or lace- ration of the bladder or urethra. Hence the surgeon's first step should be to pass a catheter, with a view of ascertaining the condition of those organs ; if they are found to have been injured, prompt treatment must be employed, 244 SPECIAL FRACTURES. according to the principles which will be laid down in speaking of Injuries of the Pelvic Aiscera. The treatment of fractured pelvis consists in the first place in restoring the displaced fragments to their proper position, if this can be done without vio- lence : in the case of a woman, reduction maybe assisted by introducing one or more fingers into the vagina. The entire pelvis should be surrounded by a padded belt, or firm and broad roller, so as to keep the parts at perfect rest, while the hip-joint of the affected side is fixed by means of a pasteboard splint or a sand-bag, as in cases of fractured thigh. The patient should lie on his back, on a hard mattress, with the knees slightly flexed, and supported by pillows. Compound fractures of the pelvis are usually fatal accidents, though I have seen recovery after perforating gunshot fracture of the ilium. In the treatment of such a case, all splinters should be carefully removed, and means adopted to secure free drainage through the external wound. Sacrum and Coccyx___Fractures of these parts usually result from direct violence, the fracture being transverse, and the lower fragment pressed inwards upon the rectum. Richerand gives one case of longitudinal fracture of the sacrum. These injuries are rarely met with except in connection with other severe pelvic lesions, and are then apt to prove fatal; the treatment would consist in endeavoring to effect reduction by pressure from within the rectum, and in the application of a padded belt. Bernard, a French sur- geon, plugged the rectum with a lithotomy tube, in order to maintain reduc- tion, but I should prefer, with Hamilton, to dispense with such an instrument and rely upon keeping the parts at rest and administering opium. Fracture of the coccyx sometimes results in the development of a very painful neu- ralgic condition of the part, constituting a form of the affection described by Dr. Nott and Sir J. Y. Simpson, and known as coccygodynia; the treatment recommended by those gentlemen consists in subcutaneous division of the liga- mentous attachments of the part, or, if that fail, in excision of the bone itself, an operation wliich has been successfully resorted to by Dr. Burnham, Dr. Mursick, and other surgeons. Fractures of the Upper Extremity. Clavicle—The clavicle is peculiarly liable to fracture, not only from its exposed position, but from the fact of its being the sole bond of osseous con- nection between the trunk and the upper extremity. It may be broken by direct violence in any part of its length, but is much oftener fractured by indirect violence (such as a fall or blow on the shoulder), and then usually gives way near the outer end of its middle third, where the bone is weakest. Partial fracture from indirect violence is usually situated towards the inner end of the middle third, and is characterized by slight angular projection. Partial fracture from direct violence is commonly situated more externally, and is marked by angular depression. Muscular action is an occasional cause of fractured clavicle, particularly, according to Delens, of fractures of the inner third of the bone ; the immediate mechanism of the accident in some cases may be, as suggested by Dr. Packard, the bending of the clavicle over the first rib, which acts as a fulcrum. Fractures from direct violence are commonly transverse, and may occasionally be comminuted; fractures from indirect violence are almost invariably oblique, the bevelling being from before backwards, and from without inwards. Fracture of the sternal end of the clavicle, within the fibres of the costoclavicular ligament, is usually attended with but little displacement, though, according to R. AW Smith, the FRACTURE OF THE CLAVICLE. 245 outer fragment is in these cases displaced forwards, or forwards and slightly downwards; similarly, there is little displacement in fracture of the outer third, within the limits of the coraco-clavicular ligament, but if the fracture be outside of the trapezoid branch of that ligament, the displacement, accord- ing to the same surgeon, is quite marked. According to A. Gordon, how- ever, even the existence of the last-named variety of fracture is doubtful. Fractures of the middle of the clavicle, especially such as are produced by Fig. 112. Attachments of outer end of clavicle ; showing branches of coraco-clavicular ligament. (Gray.) indirect violence, are accompanied with great and very constant, displacement. This consists in a tilting upwards of the inner fragment, and a dropping of the outer fragment, which is also rocked inwards and somewhat backwards by the action of the powerful muscles attached to the scapula, particularly the rhomboidei, trapezius, levator anguli scapulas, pectoralis minor, and some fibres of the serratus magnus. The diagnosis of fractured clavicle can usually be made without difficulty: if the middle of the bone be involved, the displacement is in itself sufficiently characteristic, while crepitus can readily be elicited in any position of the fracture, on account of the subcutaneous character of the bone in its whole length. In cases of partial or partially impacted fracture from direct violence, an accident of not unfrequent occurrence among quite young children, per- sistent tenderness over the point of injury will be found a valuable diagnostic 246 SPECIAL FRACTURES. sign. The attitude of the patient, in cases of complete fracture, is peculiar, and often significant of the nature of the injury; the head is bent towards the affected side, so as to relax the Fig. 113. muscles, while the elbow and forearm are supported in the opposite hand, so as to diminish the dragging sensa- tion produced by the weight of the limb. The prognosis, as regards the life of the patient and the utility of the limb, is very favorable; I believe, however, that a, perfect cure—that is, without deformity—is very rarely ob- tained, at least in oblique fractures of the middle of the bone. Comminuted fracture of the clavicle is sometimes a serious injury, from concomitant laceration of the subclavian vein or plexus of nerves. Compound frac- ture of this bone is rare, except as the result of gunshot injury, when it is apt to prove fatal from thoracic complications; I had, however, under my care, some years ago, a case of multiple fracture of the clavicle from direct violence, which became second- arily compound by the occurrence of suppuration ; slight necrosis followed, „,.,,. , „ , . , ., but the patient eventually made a Complete ohlique fracture of clavicle near its r j middle. (Gray.) good recovery. hracture of both clavicles is an accident of rare occur- rence, but presents no peculiarities, except that of course it requires some modification of the apparatus used in treatment. Treatment of Fractured Clavicle___The treatment of fractured clavicle may be conducted by position alone, or by position aided by various forms of appa- ratus. The deformity, as we have seen, depends (1) on the tilting up of the inner fragment, by the resiliency of its ligamentous attachments and the action of the sterno-cleido-mastoid muscle ; (2) on the falling of the shoulder with the outer fragment, due to the weight of the arm ; but (3) chiefly on the rocking inwards and backwards of the outer fragment, by the action of the powerful muscles attached to the scapula. Hence the indications for treat- ment are, (1) to relax the sterno-cleido-mastoid muscle, (2) to prevent the weight of the arm from dragging down the outer fragment, and (3) by fixing the scapula, to carry the attached external fragment outwards and forwards, and thus restore the shape of what has been not inaptly called the " shoulder girdle." These indications may all be met by position alone. For this pur- pose the patient should lie flat on his back, on a firm, hard mattress, with the head slightly elevated, and the arm flexed and carried across the chest, so that the hand rests on the sound shoulder—the position commonly known as the "Velpeau position," from its having been employed by that distinguished surgeon in the treatment of these and other injuries (see Fig. 115). The elevation of the head (by means of a single pillow, which must not touch the shoulders) relaxes the sterno-cleido-mastoid muscle, and thus obviates the tendency to upward tilting of the inner fragment; the position of the arm across the chest makes the weight of the limb act, if at all, in an upward direction, and thus effectually prevents any downward displacement; while FRACTURE OF THE CLAVICLE. 247 the weight of the chest, together with the firm and even counter-pressure of the mattress, serve to fix the scapula, and thus prevent that rocking of the bone around the chest, which causes the inward and backward displacement of the outer fragment. By this simple mode of treatment the deformity can, at least in the immense majority of cases, be completely reduced, and could the patient be trusted to remain quiet for a sufficient length of time (three to four weeks), nothing further would be required. In practice, however, very few patients can help shifting their posture in sleep, if not while awake, and hence retentive apparatus is usually necessary. If the patient can remain in bed, the scapula may be fixed by a broad and long wedge-shaped pad, applied as a compress on the lower blade of the bone, and held in place by several broad strips of adhesive plaster, while the arm is fastened in the "Velpeau position" by a few strips of the same material. If the patient cannot remain in bed, the same appliances may be used, with the addition of a compress upon the projecting end of the inner fragment, and a broad roller bandage used as what is known as the "third roller of Desault,"1 with additional cir- cular turns to fix the arm in the required position. The same indications may be met by using Fox's apparatus (to be presently described), or any of its modifications, taking care to apply the pad—not as an axillary fulcrum, but simply as a scapular compress. The posterior figure of 8 bandage, recom- mended by some authors, is defective in that its force is exerted on the acro- mial part of the scapula only, and not on the entire bone ; the same objection applies to most of the back splints devised for these cases, though a back splint, such as that devised by Dr. Staples, of Minnesota, broad enough to fix both scapuke, might be made a useful adjuvant to the compresses already described. Vacher, of Birkenhead, has modified the figure of 8 bandage by applying metallic caps to both shoulders, and drawing them backwards by means of a posterior strap and buckle. The apparatus introduced by Dr. George Fox, of this city, is thus described by Sargent: " The apparatus con- sists of a firmly stuffed pad of a wedge shape, and about half as long as the humerus, having a band attached to each extremity of its upper or thickest margin ; a sling to suspend the elbow and forearm, made of strong muslin, with a cord attached to the humeral extremity, and another to each end of the carpal portion ; and a ring made of muslin stuffed with cotton to encircle the sound shoulder, and serve as means of acting upon and securing the sling." Fox's apparatus has undoubtedly produced a great many excellent cures ; it has done so, however, I believe, by fixing the scapula more or less perfectly, and not by affording leverage to the humerus as it was originally intended to do. Indeed, the wedge-shaped pad, if used as a fulcrum, produces so much pain that few patients can endure it for any length of time ; so that in prac- tice surgeons generally apply it far back—where it acts merely as a scapular compress__or else reduce its thickness to such a degree that its action as a fulcrum is entirely defeated. Fox's apparatus has been ingeniously modified by Dr. Levis, Prof. Hamilton, and others, and any of these forms of the sling and pad dressing may be used with good results, provided that they are accurately 1 The application of the third roller of Desault is thus described by Wales : Place the initial extremity of the roller " under the axilla of the sound side, then conduct the cylinder over the broken clavicle, upon which a compress must be placed, down the posterior surface of the arm under the elbow, and over the forearm to the point of departure; thence across the back obliquely over the injured shoulder, down the front of the arm and under the elbow, to pass obliquely across the chest to the axilla of the sound side." These turns are repeated until the roller is exhausted, thus forming two triangles, one in front and the other behind the chest; the firmness ot the bandage may be much increased by making additional circular turns as reconi mended in the text. 248 SPECIAL FRACTURES. Sayre's dressing for fractured cla vicle. (Hamilton.) Fig. 114. adjusted and carefully watched by the surgeon.1 Moore, of Rochester, and Say re, of New York, believe that the point of most importance is to render tense the clavicular fibres of the pecto- ralis major muscle, and thus draw the inner fragment downwards ; the former surgeon ac- complishes this purpose by forcing the entire arm backwards, and fixing it with a shawl or strip of muslin folded as a cravat and made to describe figures of 8 around the sound shoulder and the elbow of the affected side; while Prof. Sayre employs two broad adhesive strips, one of which fixes the arm and acts as a fulcrum, while the other forces the shoulder backwards by drawing the elbow forwards, at the same time supporting the forearm, as shown in Fig. 114. Union of a fractured clavicle usually occurs within three weeks, but the dressings should be retained, as a matter of safety, at least a couple of weeks longer. Scapula___The scapula may be broken through its body, through its neck, through the glenoid cavity, or through the acromion or coracoid processes. Fracture of the Body of the Scapula is a rare accident, and is usually due to direct violence, though it is said in one case (Ileylen's) to have been pro- duced by muscular action. If the spine of the scapula be involved, the line of fracture can commonly be detected with facility by palpation, and in other cases crepitus can generally be elicited by pressing firmly on the scapula with one hand, while the other moves the shoulder in various directions. The treatment consists in attempting to reduce the deformity, if there be any, by manipulation, and in then fixing the arm to the side by circular turns of a roller bandage or by adhesive strips, the forearm and elbow being supported in a suitable sling. If the lower angle have been separated from the rest of the bone, it may be secured, as advised by Boyer, by the additional applica- tion of a firm compress. Fracture of the Neck of the Scapula (in the anatomist's sense of the term) is an accident the possibility of wliich has never been established by dissec- tion, and which, if it have ever occurred, except when complicated with comminution of the glenoid cavity, must certainly be very rare. The term "fracture of the neck of the scapula," as used by Sir Astley Cooper, how- ever, means fracture through the supra-scapular notch, and in this position the lesion has unquestionably been met with, though very rarely. I have myself seen one example, in a child five years old. The amount of displace- ment depends on the degree of integrity of the various ligaments of the part, especially the coraco-clavicular and coraco-acromial. If these be ruptured the glenoid cavity and head of the humerus fall into the axilla (where the latter may be sometimes felt), causing a depression beneath the acromion as in dislocations of the shoulder, though not so deep ; crepitus is elicited by laying one hand on the shoulder so as to touch the coracoid process, and with 1 See a full and able discussion of the principles of treatment of fractured clavicle, and the comparative merits of different forms of apparatus, by Dr. Edward Harts- horne, of this city, in the 2d volume of the Pennsylvania Hospital Reports, pp. 108-142. FRACTURE OF THE SCAPULA. 249 Fig. 115. the other hand moving the arm in various directions. In a child the part may be grasped by placing the fingers on the shoulder and thrusting the thumb deeply into the axilla. The deformity can readily be reduced, but instantly recurs when support is removed, and the coracoid process can be felt moving with the humerus, instead of with the acromion. The treatment consists in fixing the scapula by placing a thin pad or folded towel in the axilla, fastening the arm to the side by circular turns of a roller or adhesive strips, and supporting the forearm and elbow in a sling. The same dressing would be applicable in a case of comminution of the glenoid cavity. Fracture of the Acromion is probably a rarer accident than epiphyseal separation of that process. AThen the line of fracture is through or behind the acromio-clavicular articulation, the shoulder drops forwards, inwards, and downwards, as in cases of fractured clavicle : if, however, the fracture be in front of the acromio-clavicular articulation, there will be little or no dis- placement, and the diagnosis must be made by the detection of mobility and crepitus. Union occurs with- out much deformity, though rarely, according to Cooper, except by fibrous tissue. The treatment consists in fixing the arm and scapula by an axillary pad and bandage, and in supporting the elbow with a sling. This, as well as frac- ture of the body or neck of the scapula, may be also effi- ciently treated with the ban- dage known as A'elpeau's, the application of which can be seen from the accompanying illustration. Fracture of the Coracoid Process occasionally though rarely occurs, as the result of direct violence. There is sel- dom any displacement, and no treatment is required beyond the use of a sling, with per- haps a few turns of a roller around the arm and shoulder. Two or more of these va- rious forms of scapular frac- ture may coexist in the same case, or any one of them may be complicated by fracture or dislocation of the humerus or clavicle ; for the treatment of such injuries no general rules can be laid down, but each case must be managed with refer- ence to its own peculiar exigencies. The ingenuity of the surgeon will often be much taxed in endeavoring to meet the different indications presented, and he will often be disappointed by the persistence of deformity, which, however, fortunately seldom proves much of an impediment to the usefulness of the arm. The time required for treatment, in cases of fractured scapula, is usually from three to four weeks. Fractures of the Humerus.—Fractures of the humerus are divided by Hamilton into eleven classes, of which four are fractures of the upper ex- Velpeau's bandage. 250 SPECIAL FRACTURES. tremity (head, neck, and tubercles), one of the shaft, and six of the lower extremity. 1. Fractures of the Upper Extremity of the Humerus — (1.) The fracture may pass through the Head and Anatomical Neck of the bone, being chiefly intra-capsular, and may or may not be impacted, accord- ing to circumstances. If the fracture be entirely intra-capsular, bony union cannot well occur, and the detached head of the humerus is apt to become carious or necrosed, requiring an operation for its removal. Fracture of the anatomical neck is attended with but little deformity, nor does it much inter- fere with the motions of the part. There may be slight shortening, and crepitus can usually be elicited by pressing the head of the bone into its socket and making rotation ; the shoulder is the seat of severe pain. This injury results from direct violence, and is principally met with in old persons. (2.) Fracture through the Tubercles of the humerus differs from the pre- ceding variety merely in being completely extra-capsular. Bony union takes place in these cases, but the motion of the joint is apt to be impaired by the irregular masses of callus which are formed. Crepitus may be detected by grasping the tubercles with one hand, and rotating the arm with the other; there is rarely much displacement, though, if the fracture be impacted, there may be slight shortening. The signs of this injury are very obscure, and in many cases the diagnosis cannot be positively made during life. Fig. 116. Fig. 117. Separation of upper epiphysis of humerus. (From a Fracture of the surgical neck of the patient in the Episcopal Hospital.) humerus. (Gray.) (3.) Longitudinal Fracture of the Head and Neck, or Splitting off of the Greater Tubercle, produces a marked increase in the antero-posterior diameter of the upper end of the humerus, and while there is some depression under the acromion, a smooth, bony prominence can be felt under the coracoid pro- cess ; crepitus can be usually elicited by pressing together the tubercles and FRACTURES OF UPPER EXTREMITY OF HUMERUS. 251 rotating the arm, while the mobility of the limb is unimpaired. Union takes place by bone, or by fibrous tissue, according to the amount of separation be- tween the fragments. (4.) Fracture of the Surgical Neck of the humerus, under which head may be included separation of the upper epiphysis, is the most frequent form of injury met with in this region. The surgical neck is that part of the hume- rus which extends from the line of epiphyseal junction to the place of inser- tion of the latissimus dorsi and pectoralis major muscles. Fracture of this part usually results from direct violence, and is often accompanied with great contusion and swelling of the soft parts. Separation of the epiphysis (Fig. 110) is an accident of early life, but true fracture, though met with in chil- dren, is more frequent among adults. Crepitus can be readily elicited, unless either impaction or overlapping have occurred; in the latter case the diagnosis can be easily made from the deformity, which is characteristic, and which corsists in the upper end of the lower fragment being drawn upwards, inwards, and forwards, while the upper fragment is rotated outwards. Reduction is often difficult and sometimes impossible in these cases, in spite of which, union commonly occurs without material impairment of the usefulness of the limb. Treatment of Fractures of the Upper Extremity of the Humerus__Com- pound fractures of these parts, especially if resulting from gunshot injury, usually require either excision or amputation. The treatment of simple fractures of the upper end of the humerus may be conducted satisfactorily in the following way. A roller should be in the first place applied smoothly and evenly to the injured arm, from the tips of the fingers to, but not above, the seat of fracture. This bandage should be applied while the elbow is in a flexed position. A thin pad, compress, or folded towel is then to be placed in the axilla, so as to fill up the hollow of that part and afford a firm basis of support to the humerus. This pad may be held in place by a bandage or by adhesive strips. The arm is then to be brought to the side, with the elbow a little forwards, so as to obviate the anterior angular projection, and sufficient extension made to reduce the frac- ture. The arm is to be securely fastened to the chest with circular turns of a roller or adhesive strips, and the forearm secured across the chest, somewhat as in the " Vel- peau position," or merely supported by a sling, as may be found most convenient. After a few days, when swelling has subsided, a moulded pasteboard or gutta-percha cap may be applied to the shoulder and upper half of the humerus, and will give additional security and firmness to the dressing. This simple mode of treatment, wliich is very similar to that recommended by Fergusson (Fig. 11*), will, I think, be found quite as efficient and a great deal less annoying to the patient than the angular splint, short splints, and axillary pad often used for the purpose. Erichsen uses a pad, a leather shoulder cap, and a sling, while Hamilton employs a simple outside splint of gutta-percha without any pad. Welch's shoulder splint may be also used in the treatment of those injuries. Fiar. 118. Dressing for fracture of the surgica neck of the humerus. (Fergusson.) 2. Fracture of the Shaft of the Humerus is an accident of fre- quent occurrence, and may result from either direct or indirect violence. The 252 SPECIAL FRACTURES. seat of the fracture is more often below than above the middle of the bone, and its line usually somewhat oblique, from above downwards and outwards. The displacement consists in the drawing upwards and inwards of the lower fragment, with some eversion of the upper fragment, and an anterior angular projection, due to the weight of the forearm. The diagnosis is easy, the in- creased mobility and crepitus rendering the nature of the injury almost unmis- takable. The treatment consists in the application of a bandage up to, but not above, the seat of fracture (until after the subsidence of swelling), and the use of an internal angular splint, with an outside splint moulded from paste- board or gutta-percha. If the anterior angular deformity give any trouble, the internal may be replaced by an anterior angular splint, or a short ante- rior splint may be used with the moulded pasteboard splint, while the forearm is laid across the chest, and fixed by a broad bandage, or merely supported by a short sling around the wrist. Various plans of making permanent extension have been proposed, but are all of questionable utility, sufficient extension being afforded by the weight of the elbow, which for this purpose should be unsupported, or at least not pressed upwards. If the internal angular splint be used, care should be taken that it do not press on the axillary vein ; the angle of the splint may be varied at different dressings, so as to avoid stiff- ness of the elbow. 3. Fractures of the Lower Extremity of the Humerus__ (1.) Of these the first to be considered is the Fracture at the Base of the Condyles not implicating the Fig. 119. joint, under wliich head may be properly included separa- tion of the lower epiphysis of the humerus. This form of fracture usually results from indirect violence exerted upon the extremity of the elbow, and its line is gene- rally oblique, upwards and backwards. This injury is frequently confused with dis- location of the elbow back- wards, but the diagnosis can be made by observing that in fracture there is increased mobility, crepitus, shortening of the humerus, but no change in the relative position of the olecranon and condyles, and that the deformity, while easily reduced, instantly recurs on the removal of extension. In dislocation, on the other hand, there is immobility, no crepitus, no shortening, but an obvious projection of the olecranon behind the line of the condyles, and the displace- ment when reduced does not return. (2.) Fracture at the Base of the Condyles, complicated by a Splitting Fracture between them, is a somewhat rare accident; it is marked by the same symptoms as the preceding variety, with the addition of increased breadth of the lower end of the humerus, and of crepitus between the con- dyles, developed by pressing them together. Besides the above varieties there may be separate fractures, of (3) the Inner Condyle (trochlea), (4) the Inner Epicondyle (epitrochlea), (o) the Outer Condyle, and possibly (6) the Outer Epicondyle, though I am not aware that the existence of this lesion has ever been demonstrated by dissec- Fracture at the base of the condyles. (Gray.) FRACTURES OF LOWER EXTREMITY OF HUMERUS. 253 Fracture at the base of, and between the condyles. (Erichsen.) tion. The diagnosis of these varieties of fracture Fig. 120. can usually be made by the detection of mobility and crepitus, elicited by grasping the arm firmly with one hand, and moving either condyle succes- sively in various directions, or by pressing and rub- bing the condyles together. There is commonly not much displacement, except in the case of fracture of the inner epicondyle, when the separated fragment is often displaced downwards in the direction of the hand. These injuries generally result from direct violence, and after recovery the elbow is often left stiff, if not absolutely anchylosed. Treatment of Fractures of the Lower Extremity of the Humerus—Any of these fractures may be conveniently and efficiently treated by means of a simple internal rectangular splint (Fig. 121), the forearm being in a semi-prone position with the thumb pointing upwards, or by means of an anterior angular splint, the fore- arm being supine. The splints should be well padded, and no bandage should be applied beneath the splint, until after the subsidence of inflammatory swell- ing. Indeed, the soft parts are often so much involved in these cases, that the use of evaporating lotions may be required for a few days, the limb being bandaged to the splint above and below, while the joint itself is left exposed. Several forms of apparatus have been devised for the treatment of these in- juries, among the most ingenious of which may be specially mentioned Fig. 121. the splints of Sir A. Cooper, Hamil- ton, Bond, AVelch, and Mayo. I am not aware, however, that they present any advantages over the simple form of dressing above recom- mended ; whatever plan be adopted, great care must be taken to avoid undue or uneven pressure, which might produce excoriation or even gangrene. Great difficulty is some- times experienced in maintaining reduction, from the action of the powerful muscles at the back of the arm ; by careful bandaging, however, and the judicious use of compresses, this difficulty can usually be overcome.1 As already mentioned, if the elbow- joint be involved in the fracture, there will always be great risk of anchylosis ; hence, it may be proper to resort to passive motion at a comparatively early period in these cases, as soon sometimes as the end of the third or fourth week ; or the patient may be directed to swing a flat-iron, as recommended in the last chapter. Compound fracture of the elbow-joint is a very serious injury, and usually requires excision or amputation. The time required for the treatment of a fractured humerus is commonly from five to eight weeks, according to the age of the patient, and other modi- fying: circumstances. Physick's elbow splints. 1 Dr. T. Blanch Smith reports a case in which, other means failing, reduction was maintained by extending the forearm upon the arm, and applying a long straight splint. 254 SPECIAL FRACTURES. Fracture of the Olecranon is usually produced by direct violence, such as a fall on the point of the elbow. It may also be caused by indirect violence—a fall on the hand, etc. ; or even by muscular action, through the powerful contraction of the triceps extensor muscle. In the latter case, the mechanism of the injury probably consists in the olecranon process being broken as an overbent lever, across the condyles of the humerus, which act as a fulcrum. The symptoms of the accident are sufficiently obvious. If the ligamentous expansion of the triceps be extensively ruptured, the detached process will be drawn a considerable distance up the arm, giving rise to marked displacement. In the majority of instances, however (at least accord- ing to my own experience), there is little or no separation, and the diagnosis must then be made by noting the existence of abnormal mobility and of crepitus. Crepitus can commonly be elicited simply by seizing the olecranon and rubbing it laterally against the extremity of the shaft of the ulna, or, if there be any displacement, by grasping the forearm just below the elbow, so that the forefinger rests upon the point of the olecranon, which it draws down in contact with the shaft, when crepitus may be brought out by flexing and extending the forearm with the other hand. Union occasionally takes place by bony deposit, but is more often ligamentous merely. The utility of the arm may, however, be preserved even with considerable retraction of the upper fragment. The treatment consists in fixing the olecranon in apposition with the shaft (which may be. conveniently effected by means of a compress and adhesive strips), and keeping the joint at rest in an extended position for four or five weeks, or until union has occurred. Surgeons are divided as to the comparative advantages of complete or of partial extension, many agreeing with Sir Astley Cooper, and Prof. Hamilton, in recommending the former, while the majority of French surgeons, Mr. Erichsen, and others, prefer the latter. I am myself in the habit of using a simple obtuse-angled splint, well padded, and applied to the inside of the arm and to the palmar surface of the forearm, wliich is kept in a semi-prone position. Figure of 8 turns around the elbow assist in fixing the olecranon. This position—one of slight flexion—is less irksome to the patient, and is at least as effective in obviating deformity as that of complete extension, which sometimes causes an angular depression at the seat of fracture. In cases of compound fracture of the olecranon, or of any compound fracture about the elbow-joint, in which an attempt is made to preserve the limb, the arm should be flexed to an angle of from 100° to 120°, which will be found the most useful position should anchylosis ensue. Fracture of the Coronoid Process of the Ulna has been sup- posed to be a frequent complication of backward dislocation of the elbow-joint. I have, however, been unable to refer to more than twenty cases in which this lesion has been diagnosticated during life (and in none of them does the diagnosis seem to have been confirmed by dissection), while only three of nine specimens described by authors appear to give satisfactory evidence as to the existence of fracture. Hence, though the possibility of the accident must be admitted, it must be considered very rare. The cause of such an injury would probably be indirect violence, and its diagnosis would have to be established principally by exclusion. The treatment would consist in fixing the elbow on a rectangular splint, and in practising passive motion after three or four weeks. Fractures of the Forearm__Both bones of the forearm are frequently broken through their shafts, either by direct, or more frequently by indirect, violence, while by direct violence either the radius or the ulna may be frac- FRACTURE OF LOWER EXTREMITY OF RADIUS. 255 tured separately. If only one bone be broken, the other acts as a splint, and prevents the occurrence of much displacement, in spite of the obliquity of the fracture ; but if both bones have given way, there is marked shortening, wliich, with the mobility and crepitus, render the nature of the case evident. The treatment consists in reducing the deformity by extension and manipula- tion, and in fixing the limb so that the line of the bones is preserved, and the interosseous space not encroached upon, while the motions of pronation and supination are preserved. For this purpose the supine position, advised by Lonsdale, is preferable to that of semi-pronation ordinarily recommended. The reason is that in any fracture of the radius, particularly in one above the insertion of the pronator radii teres, the upper fragment is supinated by the action of the supinator brevis and biceps muscles, and therefore, unless the lower fragment be also supinated by the surgeon, union with rotatory de- formity will almost inevitably ensue. Two straight splints are required, which should be just wide enough to prevent the encircling bandage from pressing the bones together, and thus diminishing the interosseous space. The palmar splint should reach from the bend of the elbow to beyond the fingers ; the dorsal from just below the olecranon to just above the styloid process of the ulna. They should be well and evenly padded, the object being not to thrust the bones apart as by a wedge, but to fix them in the position which they have assumed under the surgeon's manipulations. No bandage should be used underneath the sjitints, and the dressing should be renewed at least every other day during the first fortnight. For fracture of both bones, the splints should be retained for from five to seven weeks, but for fracture of the shaft of either bone alone, four weeks will usually suffice. A perfect cure of a fracture of both bones of the forearm is perhaps rarely obtained ; but I believe that the surgeon will secure better results by this mode of treatment than by any other. Fracture of the Head of the Radius is a rare form of injury which does not appear to have been recognized during life, though the possi- bility of its occurrence has been demonstrated by dissection. Fracture of the Neck of the Radius is rarely met with except when complicated with other lesions. The diagnostic signs are slight ante- rior displacement, with localized pain, mobility, and crepitus. The treatment consists in the application of a well-padded internal rectangular splint, the separated fragment being kept in place by means of a firm compress. Fracture of the Lower Extremity of the Radius is an acci- dent of very frequent occurrence. Its nature and pathology have been made the subject of special study by Colles, R. AV. Smith, Erichsen, Goyrand, Aroillemier, Nekton, Barton, Gordon, Moore, and Pilcher, of New York. There are two varieties of this form of fracture, which are known generally in this country as Colles's and Barton's fractures. Colles's fracture, which is by far the most common, is a transverse or slightly oblique fracture, situated at from a quarter of an inch to an inch and a half above the articular extremity of the radius. Barton's fracture is a very oblique fracture, extending from the articulation upwards and backwards, separating and displacing the whole or a portion of the posterior margin of the articulating surface. It is a very rare accident, constituting probably not more than one or two per cent, of the whole number of fractures in this locality. The cause of these injuries is almost invariably a fall upon the palm of the hand, the position of over-exten- sion causing the bone to give way, as pointed out by Gordon, by what mechanicians call a " cross-breaking strain ;" the displacement is very con- 256 SPECIAL FRACTURES. stant, the lower fragment being drawn somewhat upwards and backwards, while the upper fragment projects downwards and forwards ; the hand at the same time inclines somewhat to the radial side, though if, as sometimes hap- pens, there be also a fracture of the styloid process of the ulna, this symptom may not be present. In some cases, according to Moore, of Rochester, the styloid process is dislocated and caught beneath the annular ligament, from which position it must be released before reduction can be accomplished. The so-called " silver fork" deformity, which usually characterizes this injury, is well seen in the accompanying illustration (Fig. 122). The diagnosis of this Fig. 122. Fracture of the radius near its lower end. (Liston.) fracture is generally easy. Beside the peculiar displacement, there is pain, greatly increased by motion and especially by attempts to rotate the wrist, while crepitus can be readily elicited by drawing down the hand and rubbing together the fragments. In some rare cases the fracture is completely im- pacted, when crepitus will be absent, and reduction very difficult, if not impos- sible. The treatment consists in effecting reduction by means of extension and manipulation, and in fixing the limb by the use of splints and compresses. Two compresses are required, one over the dorsal projection (lower fragment), and one over the palmar prominence (upper fragment). Two straight splints may be applied over these compresses (as recommended by Dr. Barton), or, which I prefer, the well-known splint of Dr. Bond (Fig. 123) may be used, Fig. 123. Bond's splint. or one of the ingenious modifications of Drs. Hays, Hamilton, and others. To any of these a short dorsal splint may be sometimes advantageously added. Bond's splint consists of a piece of wood, of the shape indicated in the figure, with a carved block to support the hand and fingers, and side strips of leather or pasteboard. It is prepared for use by placing in it a layer of cotton wad- ding or folded lint, and adjusting upon this the palmar compress in such a position that, when the splint is applied, it will press accurately upon the lower end of the upper fragment. The splint is laid on the fractured limb, so that the hand folds lightly over the block (which should fit the hollow of the palm), and the dorsal compress is then adjusted to the lower fragment so as to main- tain the reduction which has hitherto been kept up by the surgeon's hands. The dressing is completed by the application of a roller bandage, firmly, but FRACTURES OF THE LOWER EXTREMITY. 257 not tightly, for fear of gangrene. Another efficient, but, as it seems to me, unnecessarily complicated apparatus, is that employed by Dr. A. Gordon, of Belfast, which, like the splint devised by Dr. Carr, of New Hampshire, em- ploys a curved instead of a plane surface for the support of the broken bone. The semi-prone position is that usually recommended for the treatment of this injury, but I myself prefer the position of supination, which I have Fig. 124. Gordon's splint for fracture of the lower end of the radius. already advised for fractures of both bones of the forearm. AYhen Colles's fracture is complicated with Fracture of the Styloid Process of the Ulna, the case should be treated with two straight splints, as an ordinary fracture of the forearm, with the addition of compresses to combat the "silver-fork" deformity, if required. Five to seven weeks are usually necessary for the treatment of these cases. Fractures of the Hand__Fracture of the carpus or metacarpus should be treated on a broad palmar splint, which is so padded as to fill up the hollow of the hand, and afford firm support to the injured member; frac- tures of the phalanges commonly require, in addition, a small pasteboard splint, applied immediately to the injured finger. The use of apparatus may be dispensed with after two or three weeks. In the treatment of all fractures of the upper extremity, the limb should (unless fastened to the chest) be supported in a sling, which may, within rea- sonable limits, be lengthened or shortened according to the patient's prefer- ence or fancy. Fractures of the Lower Extremity. Femur__Fractures of the thigh-bone may be divided into—1, those of its upper extremity ; 2, those of its shaft; and 3, those of its condyles. 1. Fractures of the Upper Extremity of the Femur are usually classified as fractures (1) of the neck within the capsule, (2) of the neck without the capsule, (3) of the neck, partly intra- and partly extra- capsular, (4) through the trochanter major and base of the neck, and (5) of the epiphysis of the trochanter major. The terms intra- and extracap- sular have, however, as justly remarked by Prof. Bigelow, not much practical significance, for the reason that the attachment of the capsule varies in dif- ferent individuals, so that, apart from the difficulty of diagnosis during life, it is often impossible, in looking at a specimen wliich shows bony union, to say whether the fracture was originally inside or outside of the capsular liga- 17 258 SPECIAL FRACTURES. Fie. 125. ment. Hence, this distinguished surgeon divides these injuries merely into the impacted and non-impacted varieties of fracture. The old classification, however, is at least unobjectionable, and may properly be retained, as being more familiar than any other. 1. Intra-capsular Fracture of the Neck of the Thigh-bone is an accident of frequent occurrence, being met with principally in those of advanced life, and in women oftener than in men. It is predisposed to, by the ordinary senile change in the structure and shape of the cervix femoris, which is, in old age, often less obliquely attached to the shaft than in earlier life. This form of fracture results, usually, from indirect violence of an apparently trivial nature, such as slipping from a curbstone, tripping over a loose piece of carpet, or even turning in bed. The symptoms are alteration in the shape of the hip, pain, crepitus, inability to stand or walk, shortening, and eversion of the foot. Alteration in the shape of the hip is evidenced by flattening of the tro- chanter, which may also be observed to rotate in an arc of abnormally small radius, the reason being that its centre of motion is changed from the ace- tabulum to the seat of fracture. Dr. Allis has observed that, in the erect posture, the fascia lata is relaxed upon the injured side. Pain is markedly increased by any motion of, or pressure on, the joint, and is sometimes so intense as to render the use of anaes- thesia necessary as an aid to diagnosis. Crepitus may sometimes be detected by simply rotating the limb, but is usually not elicited until, by means of extension, the separated fragments are brought into contact. Inability to stand or walk is usually present from the first, though instances are not wanting in which patients have walked a short distance after the acci- dent before falling, probably from the fracture being at first incomplete, or partially impacted. The atti- tude of the limb, as shown in the accompanying illus- tration (Fig. 125), is often characteristic, and some- times almost diagnostic. The shortening, in these cases (as ascertained by measuring both limbs from the anterior iliac spines to the tips of the inner malleoli), is commonly not very marked at first—probably not exceeding half an inch to an inch ; it subsequently, and often suddenly, in- creases, by the giving way of ligamentous attachments, by rupture or stretching of the capsule, or by unlock- ing of fragments, and not unfrequently amounts, under these circumstances, to two inches or even more.1 Eversion of the limb almost always accompanies these cases, and is probably due to a combination of causes, some mechanical—as the weight of the foot, and others physiological—as the action of the external rotator muscles upon the lower fragment. In a few cases inversion has been observed, and is Fracture of the neck of the femur. (Fergusson.) 1 To determine whether or not the shortening is, in any particular case, in the cervix femoris, Mr. Bryant measures the distance on either side from the trochanter major to a line drawn from the anterior-superior spine of the ilium at right angles to the plane of the body. Dr. Cleemann, of this city, has pointed out that from the shortening of the limb, in these cases, a fold or wrinkle is formed over the ligamentum patellae, and can be "smoothed out" by making extension. FRACTURES OF UPPER EXTREMITY OF FEMUR. 259 attributed by Mr. Erichsen to paralysis of the external rotator muscles from concomitant injury. In cases of impacted fracture, these symptoms are all much less marked, and the eversion may be so slight that, as justly remarked by Bigelow, it may be " best indicated by a comparison of the extent to which the two limbs can be inverted." The diagnosis between intra- and extra-capsular fracture will be con- sidered when we come to speak of the latter form of injury. The prognosis of unimpacted intra-capsular fracture must always be guarded. Bony union very rarely takes place in these cases, chiefly on account of the deficient vascular supply to the pelvic fragment, and the diffi- culty, often amounting to impossibility, of keeping the fragments in apposi- tion. Many surgeons, indeed, have doubted whether bony union ever occurs under these circumstances, and those specimens which have been produced as instances of osseous union are all open to the objection that the line of frac- ture may have been at least partly extra-capsular. In cases of impacted intra-capsular fracture, however, bony union may undoubtedly occur. As these injuries are commonly met with in those of advanced age, the shock and general constitutional disturbance are often considerable; old per- sons, too, bear confinement badly, and, in such, these injuries not unfrequently prove fatal, through the occurrence of congestion or inflammation of internal organs, the formation of bed-sores, etc. Under more favorable circumstances the patient may recover, union taking place, if at all, by means of fibrous bands, and the limb remaining permanently shortened and lame. 2. Extra-capsular Fracture of the Cervix Femoris is a less common in- jury than the intra-capsular variety. It is, like the latter, usually, though less exclusively, met with in advanced life, and is generally produced by direct, though occasionally by indirect violence, such as a fall on the feet or knees. The line of fracture commonly corresponds with the anterior and posterior inter-trochanteric lines, and the inner almost invariably penetrates the outer fragment, in such a way as to split and comminute it into several portions. Either trochanter may be completely detached, and the fracture may involve the summit of the shaft itself. Occasionally the fracture is completely im- pacted. The symptoms are much the same as those of the intra-capsular form of injury, the chief differences being that the trochanter moves in an arc of still shorter radius, that the pain is acuter and more superficial, and that the crepitus is more distinct, the fragments being sometimes felt loose under the skin ; the shortening (unless in cases of impaction) is greater at first, but does not undergo much subsequent change, while eversion is not so invariably present. As this form of fracture usually results from direct vio- lence, it is commonly attended with great contusion and swelling of the soft parts. The differential diagnosis between intra- and extra-capsular fracture may in many cases be made by attention to the above-mentioned peculiarities, taken in connection with the history of the case, the age of the patient, etc. In cases of impacted fracture, the diagnosis is much more difficult, and in such cases the surgeon must be very cautious in his examination, lest he in- advertently remove the impaction, and thus seriously complicate the condition of the patient: for in any fracture about the neck of the femur, impaction is a most desirable circumstance, limiting the amount of shortening, and favor- ing the occurrence of bony union. Severe contusion of the hip may cause temporary eversion and immobility, and thus simulate fracture ; if the joint be also the seat of rheumatoid arthritis, there will be superadded shortening and false crepitus. The diagnosis, under such circumstances, must be made 260 SPECIAL FRACTURES. by careful inquiry into the history of the case and the previous condition of the patient. The prognosis of extra-capsular fracture, unless the patient die from shock or general constitutional disturbance, or from some concomitant injury, is usually favorable. Bony union readily occurs in these cases, the amount of callus, on account of the comminution of the fracture, being very large, form- ing stakctitic projections or osteophytes, which are most abundant along the posterior inter-trochanteric line. 3. The neck of the thigh-bone may be broken Partly Within and Partly Without the capsule; the symptoms would, of course, be essentially those of the previously described varieties, and the chances of bony union proportional to the degree in which the fracture was extra-capsular. 4. Fracture through the Trochanter Major and Base of the Neck—The line of fracture in this injury, which is sufficiently described by its name, separates the femur into two segments, the upper of which embraces the head, neck, and trochanter major. The signs of the injury are crepitus, eversion, and shortening of about three-fourths of an inch; bony union readily occurs. 5. Fracture of the Epiphysis of the Trochanter Major must be an ex- tremely rare accident, there being, according to Hamilton, but one authentic case on record. The diagnosis, I should suppose, could only be made during life by observing displacement of the epiphysis, without the ordinary signs of fractured femur. Treatment of Fractures of the Upper Extremity of the Femur—I have no hesitation in expressing my preference for the treatment of these injuries by means of the straight position with moderate extension, whenever that mode of treatment is applicable. In cases of impacted fracture, extension is (for reasons already indicated) undesirable, and such cases maybe treated by posi- tion alone, the joint being fixed by means of the long splint, in any of its varieties, or simply supported by means of heavy sand-bags placed on either side of the injured member. If the 'fracture be unimpacted, the same treat- ment should be employed, with the addition of moderate extension. For this purpose, Liston's splint, or that of Desault (as modified by Physick and others), may be conveniently used; or the surgeon may employ Hagedorn's apparatus, as modified by Gibson, or the less cumbrous contrivances of Gross, Hartshorne, or Horner. The simplest mode of treatment, however, and that which I much prefer, is the old-fashioned weight extension, first popularized in this country by Prof. Gurdon Buck, of New York, with the addition of sand-bags to either side of the limb. Weight extension is thus applied: A strip of adhesive plaster (cut lengthwise and well stretched) is prepared, 21- to 3 inches wide, and 3^- to 4 feet long. On the middle of this is placed a block of wood, of the same width as the adhesive strip, but four inches long, and half an inch thick; over this, again, is placed another adhesive strip of the same width, and 1^ to 2 feet in length ; the block which is sometimes called the stirrup is thus secured in the centre of a long band, of which the upper twelve inches at either end are adhesive. This band is then applied to the leg on which extension is to be practised, so that it adheres on either side from just below the knee to just above the malleolus, the stirrup remaining as a loop about four inches below the sole of the foot (Fig. 126). The appa- ratus is fixed by two or three broad strips passed circularly around the limb, which is finally surrounded with an ordinary spiral bandage. The malleoli should be protected by a layer of cotton, to prevent excoriation. It is well to allow a short time to elapse before applying the extending force, so that the strips may become firmly adherent. To the stirrup is fixed a cord, which plays over a pulley fixed at the foot of the bed, and which carries the extend- FRACTURE OF SHAFT OF FEMUR. 261 ing weight, wliich, for fractures of the neck of the femur, need not usually exceed ten or twelve pounds. Counter-extension maybe made by means of a perineal band, or broad adhesive strips applied to the lower part of the trunk and fastened to the head of the bed, or, which is usually sufficient, simply by elevating the foot of the bed, thus utilizing the weight of the body itself as the counter-extending force. The sand-bags are merely long bags, like the Fig. 126. Adhesive-plaster stirrup for making extension in cases of fracture of the lower extremity, etc. "junks" used with Physick's splint, except that they are filled with clean sand instead of bran : the outer should reach from the axilla to the sole of the foot, and the inner from the perineum to the internal malleolus. AYhile I have recommended this mode of treatment for every case to which it is applicable, it is but right to say that there are certain cases, especially of intra-capsular fracture in old persons, in which no apparatus can be borne, and in which even confinement to bed is fraught with dangerous consequences; under such circumstances, the injured limb should be simply laid across pillows, as recommended by Sir Astley Cooper, until the pain and inflammation which attend the injury have subsided, the patient being then allowed to get up in a chair or on crutches ; bony union, under such circumstances, cannot be hoped for, and the general rather than the local condition of the patient should be the object of attention. In some of these cases, a moulded leather or paste- board splint, or a plaster of Paris bandage, may be used with advantage. Colles, of Dublin, employs a modification of Sayre's apparatus for hip- disease. 2. Fracture of the Shaft of the Femur__This injury may be met with at any age, and in any part of the bone ; it is most frequent, how- ever, in the middle third. The accident commonly results from direct vio- lence, and the direction of the fracture is almost invariably oblique. The fracture is marked by mobility, shortening, eversion, and crepitus, which are so manifest that the nature of the injury can scarcely be mistaken. AArith regard to the prognosis of fracture through the shaft of the femur, I have no hesitation in saying that I have never seen a, perfect cure, either in my own practice or in that of others ; by this, I mean that I have never seen a cure without shortening. AVithout entering upon a discussion as to the possibility of such a result (for a full and candid consideration of which question I would respectfully refer the reader to Prof. Hamilton's excellent treatise), I will merely say that I have never seen less shortening than a quarter of an inch, after fracture of the thigh, even in children ; and that I consider a shortening of from half an inch to an inch, a satisfactory result in adults. The treat- ment of fractures of the shaft of the thigh is most conveniently conducted 262 SPECIAL FRACTURES. with the weight extension apparatus already described, substituting, however, for the sand-bags, long splints (either padded or provided with bran junks), which have the effect of fixing both the hip and the knee joints, a very import- ant consideration in the management of these injuries (Fig. 127). The chest Fig. 127. Weight extension with long splints for treatment of fractured thigh; counter-extension made by raising foot of bed. and pelvis should both be secured to the external splint by broad and firm bands, while the splints themselves should be kept in position by similar bands, passing at intervals across the affected limb. In fractures of the upper part of the shaft, there is frequently seen an anterior angular projection, wliich is generally attributed, and is probably usually due, to the tilting forwards of the lower end of the upper fragment; though that it is occasionally due to the projection of the lower fragment is shown by several specimens described by Mr. Butcher. Whatever be the cause of the projection, it may require the application of a third, anterior splint, which should reach from the groin to Fig. 128. N. R. Smith's anterior splint, applied for a fracture of the thigh. above the knee, and should be well padded to prevent excoriation. After several weeks, when union is pretty well advanced, short moulded pasteboard splints may be applied immediately around the seat of fracture, the long splints and weight extension being continued as before, or, instead of the pasteboards, FRACTURE OF CONDYLES OF FEMUR. 263 the plaster of Paris bandage may be substituted. This is the mode of treat- ment which I am in the habit of employing in cases of fractured thigh, and I have found it to be as efficient as it is simple. Excellent cures may, how- ever, doubtless be obtained by the use of other means, such as the various forms of apparatus already mentioned (page 2(50), or the " suspension splints," of Prof. N. K. Smith, of Maryland (Fig. 128), and Prof. J. T. Hodgen, of St. Louis. Compound Fractures of the Thigh may be conveniently treated with the weight extension apparatus, with the bracketed long splint (Fig. 129), with a simple long fracture-box (particularly useful when the bran Fig. 129. Compound fracture of shaft of thigh-bone ; treatment by bracketed long splint. (Erichsen.) dressing is to be employed), or, in some rare eases, with the old-fashioned double-inclined plane, which was so popular at the end of the last and the beginning of this century.1 3. Fracture of the Condyles of the Femur__Either condyle may be broken off separately, or there may be a splitting fracture between them, complicated with a more or less transverse fracture through their base. The symptoms are mobility, crepitus—elicited by rubbing the condyles together—and, if the fracture extend through their base, shortening; there is also an increase in the breadth of the limb around the condyles, which per- sists after recovery. These accidents may result from direct violence, or from falls on the knee (the patella, as remarked by AYillett, acting as a wedge in splitting the condyles asunder), and are often followed by secondary in- flammation of the knee-joint, which may run on to suppurative disorganiza- tion, endangering either the limb or life of the patient. The treatment con- sists in placing the limb at rest in a straight or almost straight position, in a long fracture-box with a firm but soft pillow, and in making moderate exten- sion if there be much shortening; recovery will usually be attended with more or less anchylosis. Separation of the Lower Epiphysis of the Femur would require the same treatment as fracture of the condyles. Compound Fracture of the Femur, involving the Knee-joint, should, almost invariably, be con- sidered a case for amputation. The time required for the treatment of a fractured thigh may be said to be from eight to ten weeks ; even if union appear firm before that time, the pa- tient should not be allowed to bear any weight on the limb, for fear of con- secutive shortening, wliich I have known to occur after apparently complete recovery. 1 I will merely mention, without in any degree commending, the plan proposed by Dr. Hennequin, in an essay which received the Barbier prize, that "in fractures of the thigh the limb should be placed in a horizontal plane, in moderate abduction and outward rotation, with the leg flexed at a right angle, and the trunk elevated ;" a position which would require the patient to sit on the side of the bed, with his leg hanging over the edge (Arc/tires Ge'ne'rales de Me'deciue, Dec. 1868, pp. G57-662). 264 SPECIAL FRACTURES. Patella___Fractures of the patella are usually met with in male adults, and are commonly produced by muscular action, the patella being broken as an over-bent lever across the condyles of the femur; under such circumstances, the line of fracture is transverse, and the upper fragment may be drawn some distance upwards by the powerful muscles of the thigh. The patella is occasionally broken by direct violence, when ;, the fracture may be comminuted or longitudi- !i nal. The diagnosis is easily made : in trans- ' verse fracture there is almost always some dis- placement, which is increased by flexing the knee ;: while in comminuted or longitudinal fractures, the nature of the case is rendered evident by the mobility and crepitus, which, Fracture of patella; fragments under such circumstances, are very distinct. separated by flexing the knee. Inability to walk Or Stand, which is often spoken of as a sign of fractured patella, is, as remarked by Gouget, more apparent than real, the patient being able, though not willing, to walk, on account of the pain which attends the effort. The prognosis is favorable ; though bony union is rarely obtained, especially in the case of transverse fracture, the utility of the limb is not materially im- paired, and instances are on record in which patients, after recovery, have engaged in duties requiring great activity and strength of limb, although with a separation of several inches between the fragments of the patella. The treatment consists in placing the limb in a straight position, with the leg somewhat elevated, so as to relax the fibres of the quadriceps femoris muscle.2 The upper fragment of the patella, being drawn downwards, is held in place by means of a firm compress, which is secured by strips of adhesive plaster fastened to a broad posterior splint, provided for the purpose with notches or cross-pieces. The whole limb and splint are then surrounded with a roller, which, by figure of 8 turns around the knee, gives additional security and firmness to the part. The limb should be raised, simply by pillows or by an inclined plane, the relaxation of the quadriceps femoris muscle being further assisted, as recommended by Hamilton, by elevating the patient's trunk. Care must be taken, as with all fractures of the lower extremity, to keep the foot strictly at right angles with the leg, so as to avoid the "pointed toe" deformity which is otherwise apt to ensue. This simple mode of treatment, which is essentially the same as that recommended by Hamilton, is quite as efficient as the more complicated plans devised by Lonsdale, Amesbury, Cooper, Burge, Callender, Beach, and others. Malgaigne's hooks, while doubtless efficient, and probably less dangerous than is usually supposed, are at least unnecessary, and, from their formidable appearance, undesirable. A 1 T. Curtis Smith, of Ohio, has, however, recorded a case in which the only dis- placement was a slight anterior projection of the upper fragment, which could not be brought into place except by flexing the knee ; in this instance, doubtless, the ex- pansion of the quadriceps femoris tendon, which covers the anterior surface of the patella, remained intact. 2 According to Hutchinson, this precaution is unnecessary ; the separation of the fragments is due, in his opinion, not to the action of the quadriceps femoris, wliich he believes to be entirely passive, but to fluid pressure from within the joint. (See an able paper in ired.-Chir. Trans., vol. lii. pp. 327-340.) Schede recommends, in these cases, that the joint should be tapped with antiseptic precautions. Lister, Uhde. and H. Smith, reviving a plan adopted many years ago by Rhea Barton, of this city, wire the fragments together (antiseptically), and have thus obtained good results. FRACTURES OF THE BONES OF THE LEG. 265 better mode of treatment, which has been revived by Gibson of Missouri, Eve of Tennessee, and Blackman of Ohio, consists in holding the fragments in apposition by means of an iron ring. Dr. Blackman thus twice succeeded in obtaining bony union. Many authors advise that no dressing should be em- ployed until the swelling which follows the accident has subsided ; but this delay exposes the patient to the risk of permanent shortening of the rectus femoris, and I, therefore, think it better to apply the apparatus at once, though, of course, not too tightly, watching it carefully, and being prepared to loosen it, should the exigencies of the case so require. After recovery, a pasteboard or leather cap should be worn around the joint for some time, until the ligamentous bands which unite the fragments have attained the necessary degree of firmness, to resist any ordinary force to which they may be subjected. The duration of treatment, in cases of fractured patella, should be about six weeks, the joint being still longer protected with a suitable cap, as already directed. In any case in which confinement would be inconvenient, a plaster of Paris bandage might be used after the first week or two, the patient being then allowed to go about. Compound Fracture of the Patella, involving, as it usually does, the knee- joint, is commonly considered a case for amputation. The elaborate statistics of Air. Poland show, however, that this extreme measure is in reality seldom called for; thus, of G^ cases treated without operation, 56 recovered and only 12 died (17.65 per cent.), while of 7 in which amputation was performed, 5 recovered and 2 died (28.57 per cent.), and of 10 treated by excision, only 4 recovered and 6 died (60 per cent.). Of the whole 85 cases, therefore, 65 recovered and 20 died. Suppuration of the joint occurred in 43 of those cases which terminated favorably, and in all of those which proved fatal.1 Fractures of the Bones of the Leg__Either the tibia or fibula, or both, may be broken, the cause of these injuries being usually direct, though occasionally indirect violence, and the line of fracture generally oblique, except in the upper part of the tibia, where it is commonly transverse. If only one bone be broken, there will not be much displacement, the other acting as a splint, except in fractures just above the ankle, when the foot inclines to the injured side. Fracture of both bones, in the middle or lower third, is often attended with considerable displacement, the line of fracture being oblique (from above downwards, forwards, and inwards), and the lower being drawn up behind the upper fragments by the powerful muscles of the calf. The existence of this displacement, together with undue mobility and crepitus, renders the diagnosis easy; and even wdien one bone only is broken, the nature of the case can be readily ascertained by careful examination. A " V-shaped" fracture, occurring at the junction of the middle and lower thirds of the tibia, is described by Gosselin, Hodges, and other writers. Separation of the Upper Epiphysis of the Tibia is a very rare accident, there being, indeed, as far as I know, but three instances of it on record; one is mentioned by Mad. Lachappelle, the case being that of a new-born infant, and the injury having been produced during delivery; the second is figured in the last edition of Holmes's System of Surgery, from a specimen in the museum of St. George's Hospital; and the third occurred in my own practice, in a boy eleven years old, who was caught between the bumpers of railway cars ; the laceration of the soft parts was so great as to require amputation, and the nature of the accident was thus ascertained by dissection ; the speci- men from which the accompanying illustrations are taken, is now in the 1 Med.-Chir. Trans., vol. liii. p. 49. 266 SPECIAL FRACTURES. museum of the Episcopal Hospital. Dr. Yoss, of New York, has recorded a case of separation of the lower epiphysis, in which, in spite of the occurrence of necrosis, recovery with a useful limb was ultimately obtained. Fig. 131. 132 \mXh Fig. 133. Separation of upper epiphysis of tibia. (From a specimen in the museum of the Episcopal Hospital.) Treatment___For the treatment of the great majority of fractures of the leg, whether one or both bones be involved, I know of no apparatus which presents so many advantages as the old-fashioned fracture-box with movable sides (Fig. 133), containing a soft but firm pillow ; the fracture having been reduced, the limb is gently laid in the box, the sole of the foot being adjusted to the foot-board, with the heel well brought down, and raised on a pad of cotton or tow placed beneath the tendo Achillis. The foot is then secured by a turn of bandage, and the sides of the box brought up so as to make firm and equa- ble pressure upon the fractured limb. Care must be taken to keep the foot at a right angle with the leg, to prevent eversion of the knee by frequent adjust- ment,1 to prevent excoriation of the heel by the use of the pad under the tendo Achillis, and of the malleoli by pads above and below those promi- nences, and to counteract any tendency to lateral displacement by the use of suitable compresses. By strict attention to these points, I do not hesitate to say that, in the immense majority of cases, as good a cure can be obtained / l A convenient practical rule is to see at each visit that the ball of the great toe, the, liwner malleolus, and the inner condyle of the femur are all in the same vertical plane. ii!i'^ii!:j':l!:ll.^^;ii :..i'i! ii"1 ■ii^llii:.....l:i';!'T .iil^lil .ili,!;1;1;; Fracture-box, with movable sides. FRACTURES OF THE BONES OF THE LEG. 267 with the simple fracture-box, as with any of the complicated contrivances which the ingenuity of surgeons has suggested. In fact, the chief difficulty with the fracture-box is that it is so simple, that surgeons are apt to think that nothing is required beyond placing the limb in it, and there letting it stay for the requisite number of weeks ; and it is, I believe, to the neglect of the surgeon, rather than to any fault of the apparatus, that are to be attributed the bad results on which many modern writers, in objecting to the use of the fracture-box, lay such stress. If in cases of very oblique fracture it be desired to make extension, this can readily be done by means of the ordinary adhesive-plaster stirrup, pulley, and weight, the extending bands (which, of course, must not be attached above the seat of fracture) being brought through slits in the foot-board of the fracture-box. Certain cases of oblique fracture1 may be best treated in the flexed position, and a very good apparatus for this purpose is the anterior splint of Prof. N. K. Smith, of Maryland (Fig. 128). The comfort of the patient may often be promoted by suspending the fractured limb from a yoke attached to the sides of the bedstead, for wliich purpose either the ordinary fracture-box, or Salter's swing cradle (Fig. 134), or the " anterior splint," may be conveniently employed. Fig. 134. Salter's cradle. After three or four weeks, when union is pretty well advanced, the limb may be advantageously surrounded with moulded and well-padded paste- board splints, being then replaced in the fracture-box; or the plaster of Paris bandage may be now safely applied. The treatment of a broken leg usually occupies from six to eight weeks. It is in cases of compound fracture of the leg, that the bran dressing, introduced by Dr. J. Rhea Barton, of this city, is particularly useful. It is thus applied : inside of an ordinary fracture-box, of suitable size, is placed a sheet of oil-cloth, or India-rubber cloth, and on this a layer of fine and clean bran about two inches deep : the fracture being reduced, the limb is laid in 1 For the treatment of these oblique fractures, Malgaigne recommends an apparatus, provided with a sharp screw to hold the fragments in place ; while Laugier, and more recently Mr. Bloxam, recommend division of the tendo Achillis. I have no personal experience with either of these modes of treatment, which, however, I cannot but think unnecessarily severe. 268 SPECIAL FRACTURES. the box, with a pad of cotton beneath the tendo Achillis and around either malleolus, and a layer of the same material around the limb just below the knee ; the sides of the box are then brought up and secured, and more bran is dusted and packed around and over the leg till the box is filled, the frac- tured limb being thus firmly and evenly supported on all sides. The same precautions as to position are to be observed as in the management of a simple fracture, the daily dressing consisting in letting down one or both sides of the box, and, without disturbing the iimb, removing the soiled bran with a spatula, and replacing it with fresh material. The great advantages of the bran dressing are its simplicity and cleanliness, the bran readily absorbing all discharges as they are formed, and affording a sure protection against flies; in recent cases, the uniform pressure of the bran has been, moreover, found very efficient in checking hemorrhage. Fracture of the Head of the Tibia into the knee-joint is apt to be complicated with injury of the popliteal vessels (see page 227). For its treatment, a fracture-box, long enough to fit the joint, is employed, such as was recommended for fracture of the condyles of the femur. This injury is often followed by anchylosis. Fractures about the Ankle are, perhaps, more troublesome than any other fractures of the leg. The fibula alone may be broken, usually giving way about three inches above the joint, or the tip of the inner mal- leolus may be torn off as well (Pott's fracture), or either malleolus may be longitudinally splintered into the ankle-joint (an accident commonly followed by anchylosis), or, finally, the inner malleolus alone Fig. 135. may be broken, the fibula escaping. Any of these forms of injury may be safely and conveniently treated with the fracture-box, the deformity being obviated by frequent and careful adjustment and the judicious use of compresses. I have never had occasion to use Dupuytren's splint for fractured fibula, though I doubt not that when carefully ap- Wire rack for fracture of the leg. plied it is an efficient apparatus. In the manage- ment of fractures of the leg, or in fact of any part of the lower extremity, the injured limb should be protected from the weight of the bedclothes by means of a suitable framework of bamboo, wood, or wire, as shown in Fig. 135. In cases of fractured leg occurring in very young children, or in adults suffering from mania a potu, when no restraint can be borne, it is a good plan to surround the broken limb with a soft pillow, which is held in place by means of firm bandages; the part can then be tossed about without risk of further injury. Fractures of the Bones of the Foot__The only tarsal bones, the fractures of which require special notice, are the calcaneum and astra- galus. The Calcaneum may be broken by direct violence, or by muscular action ; the line of fracture may assume any direction, and, when the injury results from direct violence, the fracture may be comminuted or impacted. If the tuberosity of the bone only be separated, the fragment may be drawn upwards for a considerable distance by the action of the gastrocnemius mus- cle, whereas, if the fracture be through the body of the bone, there can be little or no displacement, the fragments being held in place by the lateral DISLOCATIONS. 269 ligaments. The treatment, if there be no displacement, consists merely in placing the limb in a fracture-box or on a pillow, and combating inflamma- tion by evaporating lotions, etc., applying subsequently splints or a gypsum bandage. AA'hen the posterior fragment is drawn upwards, the foot should be kept in an extended position, so as to relax the gastrocnemius, by means of a well-padded anterior splint, or the apparatus already recommended for rupture of the tendo Achillis (page 207). The Astragalus is almost invariably broken by the patient falling from a height, alighting on his feet. Simple fracture of this bone is rarely at- tended with displacement; in fact there are, as far as I know, but two cases of the kind on record, one reported by Dr. Norris, and one by myself.1 In the former, the displacement was downwards and forwards ; in the latter, downwards, outwards, and backwards. The treatment consists in reduction (if practicable), the limb being then placed in a fracture-box, and subse- quently dressed with pasteboard splints or a starched bandage. If reduction were impracticable, in a case of simple fracture, I should be disposed to tem- porize, reserving excision (which is usually recommended under such circum- stances) as a secondary operation, to be employed should sloughing or ne- crosis ensue : in Dr. Norris's case, the displaced fragment was excised by Barton, but amputation was subsequently required, and the patient ulti- mately died, a year and a half after the occurrence of the accident. Even in fractures unattended with displacement, necrosis may ensue, when secon- dary excision of the affected portion will be required; in a case of this kind under my care at the Episcopal Hospital, I removed the greater part of the astragalus nearly three months after it was broken, with the happiest results. In a Compound Fracture of the astragalus, if reduction were impractica- ble, I should advise complete excision, which Rognetta (whose paper on this subject is classical) considers preferable to excision of the displaced fragment only. AArhen, however, such an injury is attended with much comminution, or is complicated with fracture of the malleoli or other tarsal bones, amputa- tion will often be required as a primary operation. Fractures of the Metatarsal Bones or Toes are usually pro- duced by direct violence, and, if attended with much laceration, commonly require amputation. In cases of simple fracture, it would be sufficient, after effecting reduction, to apply a plantar splint, and to place the limb in a frac- ture-box, the dressing being changed, after a time, for pasteboard splints or a plaster of Paris bandage. CHAPTER XIII. DISLOCATIONS. A dislocation or luxation is a displacement, as regards their relative position, of the bones which enter into the formation of a joint. Dislocations are variously classified: thus they are said to be traumatic, pathological or spontaneous, and congenital. Traumatic dislocations are such as result from the sudden application of force ; pathological or spontaneous luxations are such as occur from an alteration in a joint as the result of disease (as in the ' Amer. Journal of Med. Sciences, April, 1862, pp. 335-340. 270 DISLOCATIONS. dislocation of the femur in hip-disease), or simply from a paralyzed condition of the muscles around the joint, without any evidence of disease of the articu- lation itself; while congenital dislocations are, as the name implies, such as exist at the moment of birth, being usually due to original malformation of the parts concerned. AYhen the term dislocation or luxation is used alone, it is generally understood to mean one of the traumatic, or, as Hamilton calls it, accidental variety. AYhen dislocation occurs in the form of joint desig- nated by anatomists as " amphi arthrosis" or " mixed articulation," it is sometimes called diastasis, as in the separations between the first and second bones of the sternum, between the vertebrae, or at the pubic or sacro-iliac symphysis. Dislocations are further classified as complete or partial; as simple, com- pound, or complicated; as recent or old; and as primitive or consecutive. In a complete dislocation, the bones which enter into the formation of the joint are entirely separated from each other ; in a partial or incomplete lux- ation (also called a subluxation), the articulating surfaces remain in contact, through a portion of their extent. The terms simple, compound, and com- plicated, bear the same relative meanings as when applied to fractures. Compound luxations may be made so directly by the luxating force, or may become so through rupture of the overstretched soft parts wliich surround the dislocated joint. Among the most serious complications of a luxation may be mentioned fracture of either of the articulating surfaces of the injured joint, and rupture of the main artery of the limb, as of the popliteal in back- ward dislocation of the knee. A recent dislocation is one in which time has not been afforded for the production of inflammatory changes in the articu- lating surfaces and surrounding tissues, or at least not to such a degree as seriously to impede reduction ; an old dislocation being, of course, one in which sufficient time has elapsed to permit such changes to occur. A primi- tive luxation is one in which the displaced bone remains in the position into which it was first thrown by the luxating force. A consecutive dislocation is one in which the displaced bone has secondarily changed its position, either under a continuance of the influence of the luxating force, or as the result of subsequent muscular contraction, or of the surgeon's manipulations in an at- tempt to effect reduction. Causes of Dislocation__Age and Sex are Predisposing Causes of dislocation, only so far as they influence the exposure of the individual to external violence ; thus these accidents are rare in infancy and in old age, being usually met with in those in active adult life, and much more frequently in men than in women. More important predisposing causes are the ana- tomical relations of the joint, and the condition of the neighboring muscles and ligaments; thus the ball-and-socket joints are more liable to luxation than the ginglymoid, while persons of vigorous, muscular frame are less exposed to these injuries than those whose tissues are relaxed and feeble. The fol- lowing table, compiled from Malgaigne's statistics, shows the relative fre- quency with which various parts are dislocated :— Cases. Jaw . . . . 7 Elbow Vertebrae . . . 4 Radius Pelvis . . . . 1 Wrist Clavicle . . 42 Thumb Humerus . . • 370 Fingers lases. Cases. 45 Femur . . . . 40 7 Patella . . . . 2 16 . 9 20 Ankle . . . 31 7 Metatarsus . . . 2 Atrophy and paralysis of a limb predispose it to dislocation, as do likewise stretching and relaxation of ligaments from articular effusion, or from pre- vious dislocation, ulceration, etc. ARTICULAR CHANGES PRODUCED BY DISLOCATION. 271 The Exciting Causes of dislocation are external violence, direct or indirect, and muscular action. The latter is the more usual agent in the production of pathological dislocations, when it acts slowly and gradually; traumatic luxations are also, however, traceable to the effect of muscular action, espe- cially when the joint lias been previously weakened by any of the causes above mentioned ; thus cases are recorded by Cooper, Haynes, Bigelow, and others, in wliich patients possessed the power of producing dislocation by a voluntary effort, and I have myself seen such a case in the person of an epi- leptic woman, who was in the habit of dislocating her hip in the public streets, as a means of exciting sympathy. Symptoms and Diagnosis of Dislocation__The usual signs of dislocation are: (1) a change in the shape of the joint and in the relative position of the articulating surfaces, the extremity of the displaced bone being often felt in an abnormal position ; (2) an alteration in the length of the limb, either shortening or elongation; and (3) unnatural immobility of the affected joint. The first is the only symptom which can be considered essen- tial, for in partial luxations (as of the elbow) there may be neither lengthen- ing nor shortening, and if the articular ligaments be extensively lacerated, there may be a positive increase instead of diminution of mobility. From a fracture in the neighborhood of a joint, a dislocation may usually be distin- guished, by observing the immobility (when that is present), the absence of crepitus, and the fact that the displacement when removed by reduction does not return. True crepitus does not exist in a case of pure dislocation; there is, however, a rasping or crackling sound, due to effusion or inflammatory changes in the articular structures, which is commonly developed in the course of two or three days, and which may readily be mistaken for the crep- itus of a fracture in which the process of repair has already begun. Again, while displacement does not always recur in cases of fracture, it may recur in a case of dislocation, if there be much laceration of the ligamentous tis- sues, or if the articular surfaces themselves have undergone structural change from inflammatory action ; thus in old luxations of the hip it is often easier to effect than to maintain reduction. Hence no one of these symptoms can be considered as in itself pathognomonic, and it is found in practice that the most experienced surgeon is occasionally liable to err in the diagnosis between luxation and articular fracture. Dislocation, like fracture, is commonly accompanied by pain, swelling, and ecchymosis; wide-spread extravasation may occur from rupture of vessels, and paralysis (temporary or permanent), or neuralgia, from compression or laceration of neighboring nerves. Articular Changes produced by Dislocation—The immediate effects of a dislocation consist of a rupture more or less extensive of the cap- sular ligament, with or without laceration of the other ligaments of the joint, and of neighboring tendons, muscles, vessels, and nerves; in cases of dislo- cation from muscular action, however, the capsular ligament may be merely stretched, without rupture. If the luxation be promptly reduced, the lace- rated structures are gradually restored to their normal condition, though the joint is often left permanently weakened, and paralysis or neuralgia may con- tinue for an indefinite period. If reduction be not effected, the articular sur- faces themselves undergo changes. In a ball-and-socket joint, the old cavity becomes filled up, and its margins absorbed and flattened, while a new socket is commonly formed around the head of the dislocated bone, which changes its shape, and becomes gradually accommodated to its new position; if, how 272 DISLOCATIONS. ever, the head of the bone rests upon muscle, instead of a new socket being formed, the soft tissues undergo condensation, forming a cup-shaped cavity of fibrous structure, which becomes attached by its margins to the displaced bone, and is lubricated by a synovia-like fluid. In the hinge-joints similar changes occur, the osseous prominences being rounded off, and the displaced bones gradually accommodating themselves more or less perfectly to their new positions. These changes, which occur with comparative rapidity in childhood, take place very slowly in adult life, often occupying several years in their completion. At the same time, the surrounding muscles and tendons become shortened and atrophied, and abnormal adhesions often form between the displaced bones and neighboring nervous and vascular trunks—a circum- stance which has several times been the cause of fatal hemorrhage in attempts to reduce old dislocations. Prognosis___In some cases, beyond a temporary stiffness and weakness of the part, a dislocation appears to entail no unpleasant consequences; but in the majority of instances, a limb which has been the seat of luxation will not be completely restored for months or even years, or occasionally during the whole lifetime of the patient. An unreduced dislocation of course causes permanent disability, and yet it is surprising to what an extent the displaced parts accommodate themselves to their new positions, the utility of a limb after dislocation being often much greater than would be thought probable in view of its evident deformity ; so that it is sometimes a question, in cases of old dislocation, whether reduction Avould be desirable, if even it could be ac- complished. Treatment.—The indications for treatment in any case of dislocation may be said to be to effect reduction, to put the joint in such a condition that the natural process of repair may take place without undue inflammation, and to encourage the restoration of the functions of the part. Reduction—This should be effected in every case, at the earliest possible moment. AVhile I have advised that in certain cases of suspected fracture, minute examination should be delayed until after the subsidence of swelling, the case meanwhile being treated as one of fracture, in a case of suspected dislocation no such temporizing course would be justifiable, for the reason that while reduction in a recent case is usually quite easy, a very short delay will render it difficult, and in some cases almost impossible. Hence, if the nature of the case be not perfectly clear, the surgeon should not hesitate to employ anaesthesia as an aid to diagnosis, more particularly as the use of the anaesthetic will greatly facilitate reduction, should the existence of a disloca- tion be determined. The principal obstacles to reduction, in any case of luxation, are muscular resistance and the anatomical relations of the joint. There are three distinct elements to be considered in estimating the influence of the muscles in hin- dering reduction; these are, (1) the passive force which the muscles possess in common with the other soft structures of the body, and which is brought out by the stretching of their tissues across the displaced bony prominences; (2) the active force, whereby the patient voluntarily though unconsciously resists the surgeon's efforts at reduction; and (3) a state of reflex tonic con- traction into which the muscles are thrown as the result of the traumatic irritation, produced by the injury itself; this, which is the most important form in which muscular resistance is manifested, is more and more fully de- veloped as the luxation remains longer unreduced. It often happens that if a patient is seen immediately upon the occurrence of a dislocation, the nius- TREATMENT OF DISLOCATIONS. 2(3 cular relaxation due to the general state of shock which accompanies the accident is so great, that the displacement can be reduced with the greatest facility, and, indeed, is often so reduced by the bystanders or by the patient himself. The knowledge of this fact led surgeons, before the discovery of anaesthetics, to prepare patients for the reduction of luxations by the use of the warm bath, the administration of tartar emetic, and even general bleed- ing. To obviate the unconscious though voluntary resistance of the patient, the older surgeons laid stress upon the importance of surprising the muscles, as it were, by diverting the patient's mind, by asking a sudden question, or making an unexpected remark, at the moment of attempting reduction. The tonic, reflex contraction of the muscles may be overcome, to a certain extent, by the use of opium, especially by the hypodermic method, or, as was done by Physick, by inducing intoxication ; but a more efficient and trustworthy plan than any of these, ami the only one which is habitually resorted to at the present day, is the administration of ether or chloroform, so as to produce anaesthesia and complete muscular relaxation. Amvsthetics are indeed invaluable in the treatment of dislocations, occurring in vigorous adults; but in cases met with in children, or in adults of feeble and relaxed muscular frame, reduction should be attempted, and may often be conveniently effected, without anaesthesia. Muscular resistance having been overcome, all that the surgeon has to contend with, in a case of recent dislocation, is the hindrance to reduction presented by the anatomical structure of the joint, the shape and altered rela- tions of the articular surfaces themselves, and the condition of the capsular and other ligaments which in a state of health keep the bones in apposition. Hence the paramount importance of an accurate knowledge of anatomy, in undertaking the treatment of these cases ; as Prof. Hamilton well observes, in a very large majority of instances force and perseverance will finally suc- ceed, by whomsoever they may be employed, but they succeed at the expense of great suffering, and perhaps permanent injury to the patient. It is the mark of the skilful surgeon not to employ blind force, but to adapt his ma- nipulations to the exigencies of the case, gently eluding the resistance to his efforts, and making the ligaments, muscles, and bones themselves act as effi- cient mechanical powers under his intelligent guidance. In the immense majority of cases, at least of recent dislocation, reduction call be effected without the use of greater force than can be applied simply through the hands of the surgeon and his assistants. The processes by which reduction is effected, are three in number, viz., manipulation, extension and counter-extension, and direct pressure. 1. Manipulation___This term is used in a technical sense to describe certain movements by which the surgeon aims to effect reduction by utilizing the structural elements of the joint itself. 2. Extension and Counter-extension___Here the proximal articular surface is fixed by the knee or heel of the operator, by the hands of an assistant, or by means of a folded sheet, padded belt, etc., while the extend- ing force is applied directly by the surgeon's hands, through Fig. 136. the medium of bandages or towels secured with the " clove- hitch knot" (Fig. 136), or by still more powerful means, such as the compound pulleys (Fig. 156), Fahnestock's and Gilbert's rope windlass (Fig. 154), Bloxam's tourniquet (Fig. 155), or Jarvis's adjuster. Continuous Elastic Extension, by means of India-rubber bands, has been utilized by Dr. H. G. Davis, of New York, in the treatment of old dislocations, and by Clove-hitch. this means Dr. Davis claims to have reduced a dislocation of the hip of fourteen years' standing. Continuous extension as a preliminary to reduction has also been successfully employed by Doutrelepont. 18 274 DISLOCATIONS. 3. Direct Pressure—By this alone, or in combination with the other methods, it is often possible to simply push the displaced bone into its normal position. AYhen extending bands are used, great care should be taken to prevent their excoriating the soft parts; for this purpose they should be smoothly and evenly applied, and should be wet—a wet bandage beihg less apt to slip, and producing less friction, than one that is dry. These bands may be applied directly over the displaced bone, or to the furthest extremity of the affected limb; thus, in luxations of the humerus, they may be fixed above the elbow, or around the wrist. I have already indicated my preference for simple and gentle means of effecting reduction in cases of dislocation, and may add that, in my own practice, I have never had occasion to resort, in recent cases, to anything beyond manipulation, with manual extension and pressure ; and though I should be loth to say that more powerful means should never be employed in cases of recent luxation, I cannot help thinking that the pulleys, and even extending lacs, are less often required in the treatment of these injuries than is commonly supposed. After-treatment___This consists in placing the joint at complete rest, by the use of suitable bandages and splints, as in cases of fracture; if there be much inflammation, it may be necessary to leave the part exposed, for the applica- tion of evaporating lotions or other topical remedies. Opium may be used to relieve pain, and the general condition of the patient should be attended to, laxatives, diaphoretics, etc., being administered, if necessary. To encourage the restoration of function, passive motion should be employed as soon as the inflammatory symptoms have subsided, usually in the course of the second or third week. Loss of tone in the muscles should be combated by the use of friction, electricity, and the cold douche, and by the cautious administration of strychnia. Compound Dislocation is always a very grave accident; if the wound be small and clean cut, with but little concomitant injury, an attempt may be made to save the part, by effecting reduction and then treating the case simply as one of wounded joint ; but if there be much laceration, and espe- cially if there be a fracture of either or both articular extremities, excision or amputation should be performed, according to the particular joint affected, and the extent of lesion present. As far as any general rule can be given in such cases, it may be said that excision should be practised in the upper extremity and at the hip, and amputation at the knee and ankle. Complicated Luxations__The complication of dislocation with frac- ture has already been considered in Chapter XL A graver complication is rupture of the main artery of the limb. This has occurred in connection with dislocations of the shoulder and of the knee; in the former situation, ligation of the subclavian artery (after reduction), as successfully practised in a case recorded by R. Adams, would be indicated, and in the latter (as a general rule), amputation. The consequence of non-interference would be the formation of a diffused traumatic aneurism, which would prove fatal either by hemorrhage, or by the supervention of gangrene. Extensive extra- vasation from the rupture of smaller vessels may, however, occur, and may usually be successfully treated by the enforcement of rest and the use of evaporating lotions. Paralysis from compression or rupture of nerve trunks is occasionally met with as a complication of luxation, and is to be treated by the use of friction, electricity, etc. OLD DISLOCATIONS. 275 Old Dislocations—The reduction of old dislocations is attended with more difficulty, and likewise with more risk, than the reduction of recent dis- locations. The increased difficulty is due to the permanent contraction and structural changes which occur in the muscles, to the abnormal adhesions which form between the displaced bone and the parts with wliich it is in con- tact, and to the changes which have already been described as taking place in the articular surfaces themselves. The increased dangers which attend efforts at reduction in these cases are dependent on the same morbid changes : among the accidents which have occurred under these circumstances, may be enume- rated laceration of the skin and subcutaneous tissues, rupture of muscles in the neighborhood of the dislocated joint, deep-seated inflammation and suppu- ration around the joint, rupture of arteries, veins, or nerves, fracture of the displaced bone or of neighboring bones, and finally avulsion of the entire limb, as happened in a remarkable case reported by Guerin. Hence, while greater force is required in the treatment of these cases than in that of recent luxations, the employment of such force is always attended with considerable risk. Even manipulation without extension is not free from danger, for the displaced bone may, in its new position, have acquired adhesions to the main artery or vein, rupture of which, in the action of reduction, would probably cause serious, if not fatal, hemorrhage. It is impossible to fix any definite period beyond .which reduction should not be attempted in cases of old dislocation. Dr. Nathan Smith reduced a luxation of the shoulder nearly a year after the accident, and luxations of the hip have been reduced by Dr. Blackman, and by Dr. Smyth, of New Orleans, at periods respectively of six and nine months after the reception of the injury. Even if the attempt at reduction fail, the surgeon's manipulations, if prac- tised with caution and gentleness, may be of service in increasing the mobi- lity of the limb, and thus adding to its usefulness in its abnormal position. Hence, in a case of dislocation, even of several months' standing, provided that the effort were warranted by the general condition of the patient, I should recommend an attempt at reduction, undertaken, of course, with the ex- tremest caution and delicacy. The patient should be thoroughly relaxed by anaesthesia, and gentle manipulation and moderate extension then employed, so as to stretch or slowly sever any morbid adhesions, and allow the displaced bone to be gradually brought into its proper position ; or the elastic extension recommended by Dr. Davis might be resorted to, and would certainly be worthy of a trial in the event of other means failing. Subcutaneous Division of Muscles, Tendons, and Ligaments, was proposed by Dieffenbach as a preparatory measure in the treatment of old dislocations, and by this plan that surgeon succeeded in effecting reduction, in a case of luxation of the humerus of two years' standing. In the hands of others, however, the operation has not been generally successful, while it has occa- sionally given rise to extensive suppuration and sloughing. A'olkmann has successfully excised the head of the femur, with antiseptic precautions, in a case of hip-dislocation of two months' standing. Treatment of Accidents occurring during Attempts at Reduction of Old Dislocations___If a fracture occur in the effort to reduce an old dislocation, the attempt should be at once discontinued, and the broken bone placed in such a position as to favor union. The rupture of an important muscle, such as the pectoralis major, would likewise oblige the surgeon to desist from further efforts at reduction. Rupture of the main artery, with formation of a traumatic aneurism, is a very grave accident when occurring under these circumstances ; it has been chiefly met with in the case of the axillary artery, in connection with dislocation of the humerus. There are two courses open to the surgeon in dealing with such a case, viz., to ligate the subclavian, or, 276 DISLOCATIONS. as has been recently done (unsuccessfully, however) by Callender and Lister, to resort to the " old operation," laying open the sac, and tying the vessel above and below the point of rupture. The latter course would probably be the safest under these circumstances, the case herein differing from one of arterial rupture accompanying recent dislocation (see p. 274); there the effect of the "old operation" would be to convert the injury into a compound luxa- tion of the worst kind, whereas in an old dislocation the connection with the joint would be less direct (from the effects of inflammatory action), and the prospects of the operation proportionably better. Ligation of the subclavian has been resorted to three times under these circumstances, by Warren, Gib- son, and Nekton; but AYarren's was the only case which was successful. In Fig. 137. Congeuital dislocation of both hips. (Holmes.) a similar case Blackman tied the axillary artery in its upper portion, but the patient died on the eleventh day from hemorrhage, and Maunder speaks of nine similar operations of which only one was successful. Rupture of the axillary vein proved fatal in a case recorded by Froriep, but in a similar case in the practice of Agnew, of this city, recovery ensued without the neces- SPECIAL DISLOCATIONS. 277 Fig. 138. sity of a resort to operative interference. Avulsion of the limb, as occurred in Guerin's case, would, of course, require immediate amputation. Spontaneous, Pathological, and Congenital Dislocations.— In the treatment of these cases there is usually not so much difficulty in effect- ing, as in maintaining reduction. Guerin, Brodhurst, and others, have successfully employed subcutaneous tenotomy and myotomy, followed by continued extension, in the treatment of congenital luxations, and the same treatment might be adopted in cases of the pathological variety, provided that no active joint disease were present at the time of operation. In cases depend- ent on muscular paralysis, the difficulty would be in maintaining reduction, and here external support (in the form of carved or moulded splints, elastic bandages, or some of the ingenious devices which are used in the treatment of deformities, and which will be hereafter alluded to) might be usefully employed. Congenital dislocation of both hips is well shown in Fig. 137. Special Dislocations. Dislocation of the Lower Jaw is a rare accident, occurring chiefly in early adult age, and rather oftener in women than in men. It is usually double or bilateral, though occasionally one side only is displaced. The most common cause of dislocated jaw is muscular action, though it may also result from a blow on the chin while the mouth is open, or from other forms of violence, such as the forcible introduc- tion of a foreign body into the mouth, or the extraction of teeth. AYhen the mouth is opened, the maxillary condyles ride forwards upon the articular eminences of the temporal bones, and a very slight degree of force is then necessary to make them slip still further forwards into the zygomatic fossae, thus producing disloca- tion. The contraction of the external pterygoid muscles, anjd perhaps of some fibres of the masseters, is thus quite suf- ficient to produce luxation when the mouth is widely opened, the tonic con- traction of the same muscles, combined with the position of the coronoid pro- cesses (which catch against the malar bones), being the principal obstacles to reduction. Symptoms___The symptoms of a recent dislocation of the jaw are sufficiently obvious. There is prominence of the chin, the mouth being widely open, and the jaw almost immovable; there is like- wise a marked depression over the seat of the articulation, with a slight fulness anteriorly. In unilateral dislocation the jaw usually inclines to the opposite side—a symptom which serves for the diagnosis between luxation and fracture, but which, according to lley and R. Smith, is not always pre- sent. There is generally, but not always, pain ; the patient speaks and swal- lows with difficulty ; and there is a constant flow of saliva from the mouth. Prognosis___Even if the dislocated jaw be unreduced, the patient gradu- ally acquires considerable use of the part, and is ultimately able to close the mouth, chew, swallow, and talk—much less inconvenience being felt from Double dislocation of the inferior maxilla. 278 DISLOCATIONS. the displacement than would at first be supposed. Reduction in a recent case is easily accomplished, and has even been effected (by Donovan) more than three months after the reception of the injury. Sometimes the ligaments are left permanently weakened, motion of the part being painful, and the joint being liable to a reproduction of the dislocation. Treatment___Reduction is effected by disengaging the coronoid processes from the malar bones, and the condyles from the zymotic fossae, by pressing the chin upwards, while a fulcrum is placed upon or behind the molar teeth. The surgeon, standing behind the patient, whose head is supported on the operator's chest, may use his thumb (protected by a piece of leather or folded towel) as a fulcrum, pressing the angles of the jaw downwards, while he ele- vates the chin with his fingers ; or pieces of cork or wood may be used as a fulcrum, in which case they should be provided with strings to facilitate their withdrawal. Nekton recommends simply pushing the coronoid processes backwards with the thumbs, applied either from within the mouth, or from without. In any case of difficulty, one side might be reduced at a time, taking care while manipulating the second, not to reproduce the luxation of the first. Anaesthesia is not usually required in these cases, though there would be no particular objection to its employment, if it were thought desira- ble. After reduction, the part should be supported for at least a week or ten days, by means of a four-tailed sling or other suitable bandage. Subluxation of the Jaw.—Under this name, Sir Astley Cooper has de- scribed a peculiar condition, met with chiefly in those of relaxed and feeble muscular frame, wliich is supposed to depend on the condyles slipping in front of the inter-articular cartilages, and thus rendering the jaw temporarily immovable. AYhatever be the true nature of this affection, it is undoubtedly accompanied by relaxation of the articular ligaments, which allow the con- dyles to slip about during the act of chewing, thus often producing a clacking sound, which is sometimes audible at a distance. The subluxation, if such it be, may be bilateral, or unilateral only ; it is sometimes produced by the act of opening the mouth widely, as in gaping or laughing, but, in other cases, occurs without any apparent exciting cause ; it may usually be reduced by the patient himself, by pressing the jaw sideways, or by lifting the chin slightly upwards. Sometimes this condition appears fo depend on spasm of the muscles of mastication, when it may be made to disappear by friction over the affected part. Tonics should be given, if the general condition of the patient appears to indicate their use, and the recurrence of the dis- placement may be prevented by wearing a sling, held in place by elastic bands. Hyoid Bone—Cases of dislocation of this bone have been recorded by Dr. Ripley, of South Carolina, and by Dr. Gibb, of London : the treatment consists in throwing back the head, depressing the lower jaw, and pushing the luxated bone into position.- Ribs, Sternum, and Pelvis__Dislocations of the Ribs are described as occurring either at their vertebral articulations, or at the junction of their costal cartilages. The symptoms would be much the same as those of frac- ture in the same localities, except that, of course, crepitus would be wanting. The treatment would be the same as for fracture. Dislocations, or rather diastases of the Sternum and Pelvis, were referred to in connection with fractures of those parts. Salleron has reported three cases of dislocation of the ilium at the sacro-iliac joint, without fracture, in each of which reduction was readily accomplished, and was followed by complete recovery. Gallez DISLOCATIONS OF THE CLAVICLE. 279 has met with diastasis of the pubic symphysis action. the result of muscular Fie. 139. Dislocation of sternal end of clavicle, forwards. (Bryant.) Clavicle.—The clavicle is more frequently dislocated at the acromial than at the sternal end, the former injury occurring, according to Hamilton, about four times as often as the latter. Dislocation of the Sternal End of the Clavicle usually results from indirect violence, and is almost always in a forward direction. Dislocation back- ivards, however, occasionally occurs, and sometimes gives rise to troublesome dyspnoea or dysphagia, from pressure on the trachea or oesophagus, or to ce- rebral congestion, from pressure on the cervical veins. Dyspnoea and dys- phagia may also occur in instances of upward dislocation, of wliich rare injury R. AY. Smith has been able to collect but eight cases, in- cluding one observed by himself, to which, however, may be added four others since re- corded by Bryant and Shaw. The diagnosis of these cases is usually easy, the subcuta- neous position of the clavicle rendering the deformity very apparent. Reduction can commonly be effected without much diffi- culty, by placing the knee against the spine, and drawing the shoulders outwards and backwards, but the displacement is exceed- ingly apt to be reproduced. The apparatus most generally applicable, consists in a compress over the projecting end of the clavicle (in cases of forward or upward displacement), held in position by adhesive strips, or by an elastic band passing under the groin and perineum, the shoulder and arm being fixed as in a case of fractured clavicle. In case of backward dislocation, the compress should be omitted, the shoulders being simply drawn backwards by a figure of 8 bandage, or some similar contriv- ance. Though the deformity in these cases (especially when the displace- ment is forwards or upwards) is seldom entirely overcome, yet the utility of the limb does not appear to be materially diminished by the accident. In one or two cases of backward dislocation, the pressure effects have been so serious as to in- duce the surgeons in attendance to resort to excision of the displaced portions of bone. The Outer End of the Clavicle is usually dis- located in an upward direction, resting upon the margin of the acromion process; the acci- dent results from indirect violence, and the na- ture of the case is usually apparent, though, if there be much swelling, it may be mistaken for a downward dislocation of the humerus. Occa- sionally the acromial end of the clavicle is dis- placed downwards, by direct violence, such as the kick of a horse; and dislocation under the coracoid process has been described, though the cases on record are somewhat apocryphal. An instance of backward dislocation is recorded by Nicaise. Dislocation of the acromial end of the clavicle may be commonly reduced without much trouble, though, as in case of luxation of the sternal end, reduction can with difficulty be main- tained. The after-treatment is the same as for fractured clavicle, with the Fie. 140. Dislocation of the clavicle on the acromion. (Bryant.) the 280 DISLOCATIONS. addition of a firm compress, held in place by broad adhesive strips passing from the point of injury to the elbow : although the deformity can be seldom entirely removed, the motions of the limb are less interfered with than might be anticipated. Dr. Montgomery, of Rochester, has reported a case success- fully treated by Moore's method for fractured clavicle, and a somewhat similar plan has been advantageously adopted by Dr. Doughty, of Georgia. Simultaneous Dislocations of Both Ends of the Clavicle have been ob- served by Richerand, Gerdy, Morel-Lavalle, Col, S. Haynes, Lund, and North, of Brooklyn, N. Y. Scapula.—Under the name of dislocation of the scapula, systematic writers describe a projection of the inferior angle of this bone, due either to its escape from beneath the edge of the latissimus dorsi muscle, or to great relaxation of the fibres of that muscle or of the serratus magnus ; the symp- toms consist in the deformity, wliich is obvious, with some pain and weak- ness of the corresponding upper extremity. The treatment would consist in the application of external support, with the administration of tonics, and, perhaps, the endermic use of strychnia, as recommended by Erichsen. Dislocations of the Shoulder___The head of the humerus may be dislocated downwards, forwards, or backwards. Dislocation Downwards, or into the axilla (Subglenoid Dislocation), is uauftliy due to direct violence, such as a blow on the upper and outer part of the humerus, though it is occasionally caused by indirect force, such as a fall Fie. 141. Dislocation of the humerus downwards, into the axilla; subglenoid. (Pirrie.) on the hand or elbow, the arm being abducted at the moment of injury. In other cases the dislocation is produced by muscular action, the head of the bone being, as it were, pulled out of its socket. In this dislocation, the head of the bone rests below and slightly in front of the glenoid cavity of the DISLOCATIONS OF THE SHOULDER. 281 scapula, being pressed forwards by the tendon of the triceps muscle ; the capsular ligament is widely torn, the long head of the biceps often ruptured or detached, and the supra- and infra-spinatus, subscapularis, coraco-bra- chialis and deltoid muscles much stretched and sometimes lacerated, while the axillary vessels and nerves are compressed. The symptoms, in a recent case, are usually obvious : there is, beneath the acromion process, a marked depression, which can commonly be seen as well as felt, the arm is lengthened by nearly an inch, and the head of the humerus can be felt in the" axilla, especially when the elbow is lifted away from the body. The arm is kept somewhat abducted, and pain is developed by pressing the elbow to the side ; the hand cannot be placed on the opposite'shoulder when the elbow is in contact with the chest. The diagnosis in a recent case is thus usually very easy, but when swelling and inflammation have occurred, it becomes more diffi- cult, if not occasionally impossible, to be again simplified upon the subsidence of the inflammatory condition. Hence, although by a careful and systematic examination, the true nature of the injury may almost always be eventually determined, the surgeon should hesitate before criticizing another practitioner, for a mistake which may have been unavoidable under different circum- stances^ Prof. Dugas, of Georgia, has proposed as a test of the existence of dislocation that the fingers of the injured limb should be placed upon the sound shoulder, and an attempt then made to bring the elbow into contact with the thorax; if this can be done, no dislocation, according to Prof. Dugas, can be present, while if it cannot be done, he considers the existence Fig. 142. Subcoracoid luxation of the humerus. (Pirrie.) of dislocation established, no other injury of the shoulder being capable of causing this disability. The prognosis should be somewhat guarded : al- though reduction is usually effected without difficulty, yet the arm not unfre- quently remains permanently weakened, partially anchylosed, or paralyzed 282 DISLOCATIONS. from injury to the axillary plexus of nerves. A certain degree of deformity may also remain in spite of reduction, the head of the humerus projecting anteriorly, probably on account of displacement or rupture of the long head of the biceps muscle. The laceration and stretching of the capsular liga- ment leave the joint predisposed to a recurrence of the dislocation. Dislocation Forwards___Of this form of dislocation there are two varieties, the Subcoracoid (Fig. 142) and the Subclavicular: the latter may be con- sidered as an aggravated condition of the former, which was, indeed, described by Sir Astley Cooper as a partial luxation. As the names imply, the head of the humerus, in these injuries, rests beneath the coracoid process, or beneath the middle of the clavicle. These luxations, which more often result from indirect than from direct violence, are accompanied by a great deal of muscu- lar and ligamentous laceration, and are attended with even more pain than the dislocation into the axilla. The symptoms are much the same as those of the downward luxation, except that the axis of the arm is even more altered, and that the head of the bone can be felt in a different position. The subcoracoid is more often met with than the subclavicular dislocation, and is said by Mr. Flower, and others, to be the most common form of luxation of the shoulder-joint. Reduction appears to be more difficult in cases of for- ward than of downward dislocation ; at least there are, according to Hamil- ton, proportionably more cases recorded of unreduced luxation of the former than of the latter injury. Dislocation Backwards (Subspinous Luxation) is a rare accident, there being probably not more than twenty or thirty cases of it on record; it is usually caused by indirect violence or by muscular action, and differs in its symptoms from the dislocations already described, in that the elbow is brought forwards, instead of backwards, while the head of the bone can be felt more or less distinctly beneath the spine of the scapula. Reduction has usually been effected without much difficulty in these cases, but in one instance, men- tioned by Cooper, it was impossible to maintain the reduction, on account of rupture of the subscapularis muscle. Partial Dislocation—Under this name has been described an injury, which appears to consist in a rupture or displacement of the long head of the biceps muscle,1 allowing the head of the humerus to project anteriorly, rather than in any positive luxation of the bone itself. As already mentioned, this condition occasionally remains after the reduction of an ordinary downward or forward dislocation. Le Gros Clark has reported a case of partial back- ward dislocation which resulted from injury, and in which reduction was readily effected. Treatment of Dislocations of the Shoulder___The subglenoid and the sub- coracoid dislocations may be reduced by the same means, Avhile the subspi- nous and subclavian varieties require slight modifications in the direction in which the force is applied. Thus, in the luxation beneath the clavicle, the head of the bone should be first drawn downwards, outwards, and subsequently backwards, so as to clear the coracoid process, while in the subspinous dislo- cation extension should be made downwards, outwards, and subsequently forwards. A great many different plans have been devised for the reduction of dislocations of the shoulder, but they may all be classified in four divisions, as aiming to effect their object, 1, by extension and counter-extension alone; 2, by leverage alone ; 3, by a combination of these methods; and 4, by ma- nipulation, in its technical sense (see page 273). 1 This inward displacement of the biceps tendon, which Soden and others have considered traumatic, is believed by Canton to be due to the existence of chronic rheumatic arthritis, which may or may not have been the result of injury. DISLOCATIONS OF THE SHOULDER. 283 1. Extension may be made (1) more or less doionwards, as in Cooper's method (Fig. 143), in which counter-extension is made by the heel in the axilla;1 as in Skey's method, in which the heel is replaced by an iron knob ; or as in Hamilton's plan, in which the scapula is fixed by the ball of the foot, placed against the acromion process ; (2) it may be made outwards, as recom- Fig. 143. Sir Astley Cooper's method of applying extension with the heel in the axilla. mended by Malgaigne ; or (3) it may be made upwards, as directed by AA'hite, of Manchester, Mothe, and others, the scapula being then fixed by the foot or hand placed above the acromion process. The latter, though painful, is probably the most efficient of any of the methods which professedly act by extension and counter-extension alone. AArhen extension is made with the heel in the axilla, an assistant may give aid by drawing the arm outwards, as advised by AArard, of Dublin. Fig. 144. Reduction of dislocated shoulder by White's and Mothe's method. 2. Leverage___The arm may be simply used as a lever, to pry the head of the bone into its place over a fulcrum placed in the armpit, as in Sir Astley Cooper's method with the knee in the axilla. 1 T. Smith has recorded a case in which in attempting to reduce a recent disloca- tion with the heel in the axilla, the anterior axillary fold was completely torn through ; the case terminated fatally. 284 DISLOCATIONS. 3. Extension and leverage combined are, I think, more effectual than either method separately. The plan which I am in the habit of employing, in these cases, is essentially that which was described by Dupuytren, as a modification of Mothe's method, and which, according to Bromfield, was in common use in his day; it consists in placing the patient, thoroughly etherized, if necessary, in a supine position, and then, having drawn the arm directly upwards, bringing it down fully extended in a broad sweep over an assistant's fist, placed in the axilla to act as a fulcrum—the scapula being at the same time steadied from above by the assistant's other hand. By this plan I have succeeded in reducing dislocations of the shoulder which had defied prolonged efforts made in other ways, and, indeed, have as yet never failed in effecting reduction in a recent case. The same principle, that of extension combined with leverage, is involved in the methods recommended by Sir AYilliam Fer- gusson and by Prof. N. R. Smith, of Maryland, in which, however, the force is applied through the medium of extending lacs or bands. The peculiarity of Prof. Smith's method is that counter-extension is made from the opposite wrist, so as to insure the fixation of the scapula, by provoking the contraction of the trapezii muscles. 4. Manipulation___The reduction of dislocations of the humerus by ma- nipulation alone has been practised by various surgeons, among whom may be mentioned La Cour and Sir Philip Crampton, but the credit of reducing the plan to a system, and of prominently bringing it to the notice of the profes- sion, in this country at least, is, I believe, due to Prof. H. II. Smith, of this city, whose method consists in first converting the luxation (if it be either forwards or backwards) into the ordinary downward or subglenoid variety, and then proceeding as follows: " Elevate the elbow and arm as high as pos- sible, and flex the forearm at right angles with the arm, thus relaxing the supra-spinatus muscle. Then using the forearm as a lever, rotate the head of the humerus upward and forward, so as to relax the infra-spinatus, carrying the rotation as far as possible, or until resisted by the action of the subscapu- laris muscle, keeping the forearm for a few seconds in its position with the palm of the hand looking upward; then bring the elbow promptly but stead- ily down to the side, carrying the elbow towards the body, and keeping the forearm so that the palm of the hand yet looks to the surgeon. Then quickly but gently rotate the head of the humerus upward and outward by carrying the palm of the hand downward and across the patient's body, and the bone will usually be replaced."1 In cases of old dislocation, Callender recommends, in order to avoid injuring the axillary vessels, to raise the elbow across the chest, and then force the raised arm outwards, rotating and somewhat depressing the arm while so doing. The reduction of shoulder dislocations by manipulation has also been illus- trated by Dr. A. Gordon, of Belfast. Kuhn, of Elbeuf, suggests, on account of the difficulty of fixing the scapula, that the humerus should be firmly held by an assistant, while the surgeon applies his manipulations directly to the former bone. After reduction, the arm should be fastened to the side and supported with a sling, for a week or ten days, so as to allow time for repair of the lacerated ligaments. Dislocations of the Elbow__Both bones of the forearm may be dislocated at the elbow-joint, or either separately. The Head of the Radius alone may be displaced forwards, outwards, or backwards, the forward dislo- cation being much the most frequent, and the cause of the injury being usually 1 Packard's Minor Surgery, p. 204. DISLOCATIONS OF THE ELBOW. 285 Fie. 14;, a fall on the hand, though the luxation may occasionally result from muscular action. The head of the bone can ordinarily be felt in its abnormal position. and the diagnosis can thus, unless there be much swelling, be readily made. The forearm is kept in a semi-fiexed position, and either pronated, or mid- way between pronation and supination ; any motion of the part is attended with great pain. Reduction is to be effected by making extension and counter-exten- sion in the direction in which the limb is found, the displaced bone being at the same time firmly pressed into its proper position ; the arm should subsequently be fixed on an angular splint, with a compress over the head of the radius. It is always difficult to maintain reduc- tion in these cases, and reduction itself is occasionally impossible; fortunately the usefulness of the limb does not ap- pear to be materially impaired by the persistence of the displacement. The Ulna alone may be displaced backwards, as the result of a fall on the hand, the olecranon then projecting be- hind the condyles of the humerus, while the head of the radius can be felt in its proper position. The elbow in such a case would be flexed at a right angle, and the forearm twisted inwards and pronated. Reduction may be effected by Sir Astley Cooper's method of flex- ing the elbow over the knee ; by ex- tension and counter-extension, com- bined with direct pressure upon the olecranon ; or (as recently recommended by Dr. AAkterman, of Boston) by extending the forearm on the arm beyond a straight line, thus using the ulna as a lever of the second order (the olecranon being the fulcrum), to bring the coronoid process over the condyles, into its proper place. Both Bones of the Forearm may be dislocated at the elbow, backwards, to either side, or forwards. The dislocation backwards, which is the most common, is usually caused by indirect violence, though occasionally by a direct blow, or by muscular action. Not only are the bones displaced back- wards, but they are drawn upwards by the powerful action of the triceps muscle. The diagnosis, if swelling have not occurred, can usually be made without difficulty; the arm is held in a slightly flexed position (rarely at a right angle), and the slightest attempt at motion causes great pain; the ole- cranon and head of the radius can be felt projecting backwards, while the condyles of the humerus form a hard and broad prominence on the front of the arm. The relative position of the olecranon and condyles is markedly altered, this being an important diagnostic mark between dislocation and frac- ture. Reduction in a recent case is usually easy, though instances are on record in which failure has attended the efforts of the most skilful surgeons; the prognosis is decidedly unfavorable as regards old dislocations, though re- duction's been several times effected at as late a period as six months after the reception of the injury. Dislocation of head of radius forwards ; ex- ternal appearance of limb. (Liston.) 286 DISLOCATIONS. The usual method of treatment is that recommended by Sir Astley Cooper, which consists in forcibly but slowly bending the arm over the knee, which is Fie. 146. Fie. 147. Dislocation of both bones of the forearm backwards. (Liston.) placed on the inner side of the elbow, so as to press on the.radius and ulna, separating them from the humerus, and thus freeing the coronoid process from its abnormal position (Fig. 147). Another plan is to forcibly extend the arm so as to relax the triceps, making counter- extension against the scapula (as advised by Liston and Miller) ; or the luxation may be reduced by simple extension (Skey), or by extension combined with direct pressure on the olecranon, accord- ing to the plan of Pirrie. In a child, or in a person of feeble muscular develop- ment, reduction can usually be effected without the aid of anaesthesia ; prolonged efforts at reduction are, however, so pain- ful, that in any case of difficulty an anaes- thetic should be employed. Sayre, of New York, has reported two cases of old dislocation of the elbow in which reduc- tion was greatly facilitated by subcuta- neous division of the triceps tendon. Hamilton recommends, as a test for re- duction, to flex the elbow to a right angle; if this can be done without much pain, it proves that reduction is complete. Lateral dislocation of the radius and ulna at the elbow is rarely complete, but in the majority of cases is partial, and in an outward direction. The cause is usu- Rednction with the knee in the bend of the all7 direCt violence. The deformity in elbow. these cases is usually so marked and DISLOCATIONS AT THE WRIST. 287 peculiar as to render the nature of the lesion unmistakable, although I have reduced an inward luxation of two weeks' standing which was at first attended with so much swelling that the gentleman in attendance did not recognize the existence of the injury; reduction may be effected by making moderate ex- tension, with direct pressure on the displaced bones, and counter-pressure on the lower end of the humerus. Lateral dislocation is sometimes found coex- isting with the ordinary backward displacement; in dealing with such an injury, the lateral luxation should be first reduced, and the case then treated as one of simple backward dislocation. Luxation forwards of both bones of the forearm, without fracture of the olecranon, is a very rare accident, there being not more than six or seven well-authenticated cases on record. The injury appears usually to have re- sulted from direct violence, and the most striking symptom is elongation of the forearm, which is in a state of supination, tin; elbow being fixed at a right angle. Reduction may be accomplished by making forced flexion, together with extension and counter-extension, the muscles being relaxed by the use of an anaesthetic. In a case recorded by my colleague, Dr. Forbes, reduction was effected by simply flexing the forearm, and then pressing it downwards and backwards. If the luxation were incomplete, the forearm making an obtuse angle only with the arm, reduction might be accomplished by making forcible extension. Dislocations at the Wrist___The Lower End of the Ulna may be dislocated from the radius, either forwards, backtoards, or inwards. These accidents, of which Tillmans, of Leipsic, has been able to collect but 48 cases, are usually caused by muscular action, the dislocation forwards being due to violent supination, and that in a backward direction to violent pronation. The inward is the rarest form of luxation, Tillmans's figures giving but 9 cases of this, as compared with 16 of the forward, and 18 of the backward variety, with 5 in wliich the direction of the displacement was not specified. Reduction is easily effected by fixing the radius, and simply pushing the ulna back into place, the limb being then placed between anterior and posterior splints. In connection with fracture of the lower end of the radius, the back- ward dislocation of the ulna is not uncommon. The ligaments sometimes re- main permanently stretched after the accident, so as to allow a certain amount of mobility of the ulna, and I have known such a condition to be mistaken for ununited fracture of this bone. The Carpus may be dislocated upon the bones of the forearm, either back- wards or forwards. These injuries are, however, rarely met with—Tillmans has collected but 24 cases—and in every case that has been submitted to the test of dissection, the luxation has, according to Hamilton, been found com- plicated with fracture. The usual cause of either form of dislocation is a fall on the palm, though in a case of backward displacement recorded by Hamilton, the injury resulted from a fall on the back of the hand, the wrist being strongly flexed. The diagnosis is made by observing the abruptness of the angle made by the displaced bones, their relation to the styloid processes, and (if the case be not complicated with fracture) the absence of crepitus. Reduction is easily effected by extension and pressure, and there is subsequently no tendency to reproduction of the displacement. Individual Bones of the Carpus are occasionally luxated in a backward direction, those bones which have been found thus displaced being the os magnum, semilunare, and pisiform, to which some writers add the cuneiform and unciform. The treatment would consist in effecting reduction by exten- sion and pressure, supporting the part afterwards with splints and compresses. 288 DISLOCATIONS. Chisholm reports a case of forward luxation of the semilunare, in which ex- cision of the displaced bone was required. Hands___The Metacarpal Bones, especially those of the thumb, index and middle finger, may be dislocated upon the carpus, the two latter bones backwards, and the metacarpal of the thumb either backwards or forwards. Reduction is effected by extension and pressure, the hand being afterwards secured to a straight splint with compresses. The Fingers may be dislocated at the metacarpophalangeal, or, more rarely, at the inter-phakngeal joints. The proximal phalanx of the thumb is not unfrequently dislocated backwards, reduction being sometimes very difficult, owing, probably, to the head of the metacarpal bone being caught, either between the lateral ligaments or between the heads of the flexor brevis muscle, or, according to Farabeuf, to the interposition of the external sesa- moid bone. In the treatment of these luxations, extension may be made with the ordinary clove-hitch, or with Dr. Levis's ingenious apparatus, or with the " Indian puzzle," as recommended by Prof. Hamilton and others. A better Fig. 148. Levis's instrument applied to the first finger. plan, perhaps, is that practised by Prof. Crosby, of New Haven, which con- sists, according to Gross, " in pushing the phalanx back until it stands per- pendicularly on the metacarpal bone, when, by strong pressure against its base, from behind forwards, it is readily carried by flexion into its natural position." In extreme cases subcutaneous division of the resisting ligaments or muscles may possibly be required. Forward luxation of the thumb is more rarely met with than the injury last described, and is to be reduced by forcibly flexing the thumb into the palm of the hand. Dislocations of the second phalanx of the thumb, or of the second or third phalanges of the fin- gers, may be reduced by simple extension and pressure, made with the sur- geon's hands, or, if more force be required, with the apparatus of Dr. Levis. Dislocations of the Hip__The subject of dislocation of the hip has been recently ably investigated by Prof. Bigelow, of Boston, of whose excel- lent monograph on the subject I shall not hesitate to make free use in the fol- lowing pages. To understand the pathology of these dislocations, and the mechanism of their reduction, it is necessary to turn for a few minutes to consider the anatomy of the joint, and especially of that portion of the cap- sule which is known as the ilio-femoral ligament, or ligament of Bertin, and for which Bigelow proposes the name of " Y ligament." This ligament " is more or less adherent to the acetabular prominence and to the neck of the femur; but it will be found, upon examination, to take its origin from the anterior inferior spinous process of the ilium, passing downward to the front of the femur, to be inserted fan-shaped into nearly the whole of the oblique 'spiral' line which connects the two trochanteis in front—being about half an inch wide at its upper or iliac origin, and but little less than two inches and a half wide at its fan-like femoral insertion. Here it is bifurcated, having two principal fasciculi, one being inserted into the upper extremity of DISLOCATIONS OF THE HIP. 289 the anterior inter-trochanteric line, and the other into the lower part of the same line, about half an inch in front of the small trochanter." Beth of these divergent branches remain unruptured in the ordinary dislocations of the hip, and their attachments must be borne in mind in attempting reduction of the various forms of displacement. The head of the femur may be dislocated in almost any direction ; but there are three forms of luxation which occur so much oftener than the others The V ligament; the inner fasciculus is known as Backward dislocation of hip; external ap- the ilio-femoral ligament, or ligament of Bertin. pearances. (Bigelow.) 1. The Dislocation Backwards, or Ilio-sciatic Luxation, presents two principal varieties, viz., upwards and backwards or on the dorsum ilii, and backwards only, the dislocation into the ischiatic notch of Sir Astley Cooper, or, which is a better name, dorsal below the tendon (of the obturator internus), according to Prof. Bigelow. These two forms of luxation, taken together, probably embrace more than three-fourths of the whole number of cases, Prof. Hamilton having found that of 104 cases, o~> were on the dorsum ilii, and 28 into the ischiatic notch. These injuries usually result from indirect violence : thus, the dislocation on the dorsum may be caused by any force which produces great adduction, or adduction with inversion, the head of the bone being driven at the same time upwards and backwards. A fall on the outside of the knee, or on the foot, while the limb is adducted,1 or a severe 1 Fabbri, Coote, and H. Morris, however, teach that all dislocations of the hip occur wliile the limb is abducted, the downward luxation being the primary, and the others consecutive displacements. 19 290 DISLOCATIONS. blow on the pelvis, while the body is bent forwards, may each in turn be a cause of this dislocation. The etiology of the ischiatic form of luxation is much the same, except that it is more apt to occur when the thigh is flexed at a right angle upon the body, the force then driving the bead of the bone more directly backwards, than backwards and upwards. The symptoms of these forms of dislocation are usually well marked. There is shortening of the affected limb, varying from about half an inch in the dislocation below the tendon, to one, two, or even three inches in that on the dorsum ilii. In the first-named variety, the shortening is, as pointed out by Allis, much more apparent when the limbs are flexed to a right angle than when they are extended. Inversion is present in both varieties, though most marked in the ordinary dorsal luxation. The hip itself is altered in shape, the trochanter being unduly prominent, and thrown forwards, while the head of the femur can often be felt rotating in its abnormal position. The axis of the limb is distorted, the thigh of the affected side crossing the other at its lower third in the dorsal dislocation, and just above the knee in the ischiatic variety ;l in the former case the foot of the affected limb rests on the instep of the sound side; in the latter, upon the ball of the great toe. The diagnosis has to be made from sprain and from fracture. From sprain the case can be distinguished by careful examination and measurement, the patient being etherized so as to obviate spasmodic muscular resistance. If the limb can be readily everted, the case is not one of luxation. From ordi- nary non-impacted fracture, a dislocation can be distinguished by the fact that in the former there is mobility, crepitus, and eversion ; in the latter, immobility, no crepitus, and inversion. From the rare cases of impacted fracture with inversion, the diagnosis is more difficult, but may be made by observing that in such cases the trochanter is flattened, and the head of the bone still rotates in its socket, while in dislocation the trochanter is unduly prominent, and the head of the bone can be felt beneath the gluteal muscles. A convenient mode of measurement, which bears the name of Nekton, con- sists in drawing a line from the anterior iliac spine to the tuber ischii; in a normal limb, the trochanter lies immediately below this line, but in any case of dislocation will be of course displaced in one or another direction. Reduction of Backward Dislocations___The capsular ligament is usually widely lacerated in these injuries, except at its anterior part, where it is rein- forced by what has been already described as the Y ligament. The liga- mentum teres also, is usually, though not necessarily, torn in these disloca- tions. The attachments of the Y ligament are such that extension in the line of the axis of the body, can only effect reduction by violent stretching or rupture of that ligament; hence, the first step in any rational method of treat- ment, consists in flexing the thigh upon the pelvis, so as to relax the ilio- femoral or Y ligament. The acknowledged difficulty which attends reduction of the ischiatic variety of this luxation is due (as shown by Bigelow), not to the head of the bone being lodged in the sciatic notch, but to its being fixed behind and below the tendon of the obturator interims muscle, which separates it from the acetabulum, and which renders reduction, by extension in the line of the body, almost impossible. By flexing the thigh on the pelvis, the head of the femur is unlocked from the grasp of the obturator tendon, and the luxation is then as easily reducible as one on the dorsum ilii; or, in case of 1 According to Bigelow, in the ischiatic variety (dorsal below the tendon), the axis of the luxated limb is more changed than in the ordinary dorsal variety, crossing the sound limb sometimes at a point as high as the middle of the thigh. Tile fact appears to be that the distortion varies according to the position of the head of the bone at the moment of examination, these varieties of dislocation being readily interchange- able, and the exact position of the bone differing in different cases. DISLOCATIONS OF THE HIP. 291 difficulty, the limb may be flexed over a pad placed as a, fulcrum in the groin, as advised by Dr. Sutton. The Y ligament being relaxed by flexing the thigh on the pelvis, the dislocation may be occasionally reduced by simply lifting or pushing the head of the thigh-bone into the socket, the rent in the capsular ligament being if necessary enlarged by circumducting the flexed thigh across the abdomen, and thus making the head of the bone sweep across the posterior aspect of the capsule. It will usually be better, however, to employ manipulation (see page 273), wliich, though practised empirically in Fig. 151. Backward dislocation ; reduction by rotation ; the limb has been flexed and abducted, and it remains only to evert it, and render the outer branch of the Y ligament tense by rotation. (Bigelow.) these cases for a great many years previously, was first reduced to a svstem by Drs. Nathan Smith, of New Haven, and Reid, of Rochester. In the form of dislocation now under consideration, the manipulation necessary for reduc- tion consists (1) in flexing the leg upon the thigh (to gain leverage), and the thigh upon the pelvis (to relax the Y ligament, and, in the case of an ischiatic luxation, to disengage the head of the femur from the obturator tendon); (2) in abducting and at the same time rotating outwards the thigh in a broad sweep across the abdomen ; and (3) in finally bringing down the limb into its natural position. The process in fact embraces the three motions of flexion, outward circumduction, and outward rotation. The mechanism of this mode of reduction is that, by the abduction and rotation, the outer branch of the Y ligament is made to wind around the neck of the femur, thus con- stituting a sliding fulcrum by means of which the head of the bone is lifted into the acetabulum. In executing this manoeuvre, care must be taken not to flex the thigh too much, or the Y ligament will be unduly relaxed, and the effort at reduction will fail; and not to abduct the limb too widely, or the posterior part of the capsule will be unnecessarily torn, and the head of the bone may slip below 292 DISLOCATIONS. the socket on to the thyroid foramen j1 the angle of extreme flexion should be from f)0° to 60°, and that of extreme abduction from 130° to 140°. The first mistake (that of undue flexion) is readily remedied, by repeating the manoeuvre with the limb somewhat more extended ; to remedy the second error, it is necessary, while making abduction, to lift the limb, when the head of the bone will usually slip readily into its socket. Fig. 152. Fig. 153. External appearances of down- Reduction of downward dislocation, by rotation and inward ward dislocation. circumduction. (Bigelow ) 2. Dislocation of the Head of the Femur Downivards, or downwards and forwards into the Thyroid Foramen, is produced by the application of force wliile the thigh is in a position of abduction, or by a blow on the back of the pelvis while the body is bent and the legs widely apart. The capsular liga- ment is extensively torn, particularly at its inner and back parts, the round ligament being also ruptured, and the head of the bone lodging usually on the external obturator muscle, over the thyroid foramen. The symptoms of this dislocation are very apparent: there is commonly an elongation of from half an inch to two inches, though, according to Rivington, there may be no lengthening, or even slight shortening; there is abduction ; the leg is ad- vanced, and the foot straight or slightly everted ; the trochanter is depressed, and, in a thin person, the head of the bone may be felt in its abnormal situa- tion. Reduction is effected by a process exactly the reverse of that recommended for the backward dislocations ; the leg and thigh being flexed as before, the limb is brought up in a position of abduction, then adducted and rotated in- 1 This accident is said by Dr. Erskine Mason, of New York, to occur only when there has been rupture of the obturator internus muscle. DISLOCATIONS OF THE HIP. 293 wards1 in a broad sweep across the abdomen (Fig. 13")), the inner branch of the Y ligament being in this case the sliding fulcrum by which the bone is lifted into its socket. Care must be taken, in this manoeuvre, to avoid ex- cessive flexion, and excessive adduction, which would throw the head of the bone past the acetabulum, on to the dorsum ilii. The manipulation may be sometimes assisted by drawing the upper part of the thigh outwards with a towel. Fig. 154. Application of the rope windlass, for backward dislocation. 3. Dislocation Upwards, or upwards and forwards on the Pubis, usually results from indirect violence, such as falling on the foot while the leg is stretched backwards, or stepping into a hole while walking, the foot being arrested while the body goes forwards ; it may also result from a blow or fall on the pelvis. In this luxation, the head of the femur rests on or above the pubis, being closely embraced by the inner branch of the Y ligament. The symptoms are shortening, abduction, great eversion, slight flexion (or. more rarely, extension), with great depression of the trochanter, and prominence of the head of the bone, which may be felt over the body of the pubis, and outside of the femoral vessels. The diagnosis from fracture is made by observing the absence of crepitus, the immobility, the impossibility or at least great difficulty of inverting the limb, and the presence of the head of the bone in its new position. Reduction may be accomplished, according to Prof. Bigelow, " by much the same method as in the thyroid dislocation, except that in the pubic luxa- tion the flexed limb should be carried across the sound thigh at a higher point. First, semi-flex the thigh, to relax the Y ligament, at the same time drawing the head of the bone down from the pubis. Then semi-abduct and rotate inward, to disengage the bone completely. Lastly, wliile rotating inward and still drawing on the thigh, carry the knee inward and downward to its place by the side of its fellow. As in the thyroid luxation, this ma- noeuvre guides the head of the bone to its socket by a rotation which winds 1 Dr. Markoe, in one case, succeeded in reducing a thyroid luxation by outward rotation (using, therefore, the outer branch of the Y ligament as a fulcrum), inward rotation having previously thrown the head of the bone on to the sciatic notch, from which it was immediately returned to its primitive position ; as remarked by Prof. Bigelow, inward rotation with less extreme flexion would, probably, have succeeded in the first instance. 294 DISLOCATIONS. up and shortens the ligament, enabling the operator, by depressing the knee, to pry the head of the bone into its place." As in the case of the thyroid luxation, this manipulation may be assisted by drawing the flexed groin di- rectly outwards with a towel. Dr. M. H. Henry has reported a case of pubic dislocation in which reduction was successfully accomplished after twenty-six days. I can testify, from my own experience, to the facility with which recent dislocations may be reduced by the methods above described, and believe, with Prof. Bigelow, that the pe- riod is not far distant " when lon- gitudinal extension by pulleys to reduce a recent hip luxation will be unheard of." As, therefore, I cannot recommend the use of pul- leys in these cases, I forbear to describe their application. Illus- trations are, however, given to show the positions in wliich the pulleys may be applied, and the directions in which extension is to be made, in the various forms of hip luxation, according to the teachings of Sir Astley Cooper and other standard authorities (Figs. 154, loo, 156). Beside the three regular forms of dislocation which have been above described, there are various anomalous forms, as (1) directly upwards (usually consecutive upon the pubic dislocation), (2) directly downwards, between the sciatic notch and the thyroid foramen, (3) downwards and backivards on to the body of the ischium, (4) downwards and backwards into the lesser sciatic notch, and (5) downwards, inwards, and for- wards into the perineum. These various forms of downward dislo- cation may be either primitive or consecutive upon the ordinary thyroid variety. In these irregular forms of dislocation, there is usually great laceration of the capsular ligament, with, in some cases, rupture of the external branch, or even both branches of the Y ligament. Reduction may usually be effected by simply flexing the thigh, and then lifting and pushing the displaced bone in the direction of its socket; or the luxation may be converted into one of the " regular" varieties, when manipulation can be applied according to the methods already described. Dislocations of both hips have been observed by Gibson, VZ. Cooper, Boisnot, and Crawford. In cases of old dislocation of the hip, greater force may be sometimes required than can be applied by the surgeon's unaided hands, and under such circumstances the apparatus recommended by Prof. Bigelow for effecting angular extension might be usefully employed. The difficulty, however, in these cases, will be often found to be not so much in effecting, as in main- Bloxam's dislocation tourniquet, applied for down ward dislocation. (Erichsen.) DISLOCATIONS OF THE PATELLA. 295 taining reduction, owing to the structural changes which occur in the aceta- bulum and head of the femur. To meet this difficulty, Prof. Bigelow suggests that the limb should be fixed Fig. 157. in the position in which re- duction was effected, until the socket has become again excavated by absorption ; the same plan should be adopted in cases of recent luxation, in which there is any ten- dency to reproduction of the deformity after reduction. The complication of dis- location of the hip with frac- ture of the thigh, should be met by applying firm splints, or Bigelow's " angular ex- tension" apparatus, before attempting manipulation. Should fracture occur dur- ing the effort to reduce an old dislocation, the attempts at reduction should be at once abandoned, but ad- vantage might be taken of the accident to obtain union in such a position as would diminish the deformity of , , Angular extension, in reduction of old dislocations of the After reduction of a hip ],jp- (Bigelow.) dislocation, it is usually suf- ficient to tie the knees together with a few turns of a bandage, keeping the patient in bed for a week or ten days. An unreduced dislocation, especially of the ischiatic variety, allows, after a time, much more use of the limb than would at first be supposed possible. Anaesthesia is almost always required for the reduction of hip dislocations in adults, though in cases of children, or of very feeble persons, it may often be dispensed with. Dislocations of the Patella__The patella may be dislocated out- wards, inwards, or upwards, or it may be rotated upon its own axis, consti- 296 DISLOCATIONS. tuting the vertical luxation of Malgaigne. These accidents may result from muscular action, or from direct violence. The Outward Dislocation is the most common, and may be either partial or complete; it may be recognized by the undue prominence of the inner condyle, and by the patella being felt in its new position; the limb is usually slightly flexed. Reduction is effected by extending the leg on the thigh, and flexing the latter on the pelvis, so as to relax the quadriceps femoris muscle, when the patella can be easily pushed back into its proper place ; Hamilton directs that the patient should be in a sitting posture, the surgeon sitting or standing in front of him, and raising the affected leg upon his own shoulder. If this manoeuvre fail, reduction may be accomplished by alternately flexing and extending the knee, while lateral pressure is simultaneously made upon the patella. Dislocation Inwards is very seldom met with ; its symptoms and treatment are (^mutatis mutandis) the same as those of the outward variety. Dislocation of the Patella on its Axis is produced by the same causes as lateral dislocation, of which, indeed, it may be looked upon as an aggravated form; either edge of the patella may project anteriorly, or the bone may be entirely reversed, so that its posterior surface is in front. The leg is usually fully extended, more rarely slightly flexed ; the prominence of the patella is so marked, as to render any mistake in diagnosis almost impossible. Reduc- tion may commonly be effected as in cases of lateral dislocation, by direct pressure, aided by alternate flexion and extension. A case is recorded by W. F. Marsh Jackson, in which, after the failure of other methods, reduction was readily effected by simply pushing up the displaced bone. It has been proposed to divide the ligamentum patellae and tendon of the quadriceps extensor muscle, with a view of facilitating reduction in these cases, but the operation does not appear to have been productive of any marked benefit, while in one case it caused fatal suppuration. Dislocation Upwards can only result from rupture of the ligamentum patellae; the treatment would be the same as for fracture of the patella itself. Dislocations of the Knee__The Head of the Tibia maybe dislocated to either side, forwards, backwards, or in an intermediate direction, as back- wards and outwards, etc. These accidents may result from direct or from indirect violence, such as twisting the thigh upon the leg by stepping into a hole while walking. The lateral dislocations are always incomplete, while the antero-posterior luxations may be either complete or partial. The symp- toms of these injuries are very obvious ; the complete luxations are usually accompanied with shortening. Reduction may be effected by forced flexion of the knee, with direct pressure, aided by rocking movements, to which, if there be shortening, extension and counter-extension may be usefully added. The antero-posterior luxations, if complete, are apt to be attended with serious injury to the popliteal vessels and nerves, a complication which may require amputation. After reduction, the limb should be placed at rest in a long fracture-box, or on a suitable splint, until the subsidence of all inflam- mation of the joint, the part being afterwards protected from sudden motion by the use of an elastic knee-cap or firm bandage. Compound Dislocation of the Knee is usually a case for amputation. Dislocation of the Semilunar Cartilages, or Internal Derangement of the Knee-joint (Subluxation of the Knee), consists, according to Erichsen, in the semilunar cartilages slipping either forwards or backwards from beneath the condyles of the femur, so that the latter come in direct contact with the articular surface of the tibia, pinching the folds of synovial membrane ; most authorities, however, teach that in this accident the cartilages themselves become wedged between the articulating surfaces, in such a way as to impede DISLOCATIONS OF THE TARSUS. 297 the motions of the joint, and give rise to the sickening pain which charac- terizes the injury. The accident is usually caused by twisting the knee, by tripping over a stone or other obstacle in walking, though it has occurred from simply turning in bed. The symptoms are inability to walk, or even to extend the limb, intense pain, and rapid swelling of the joint. Reduction is effected by alternately flexing and extending the knee, combining these move- ments with slight twisting and rocking of the joint. As the process is pain- ful, ether may appropriately be used in these cases. After reduction, the patient should wear an elastic knee-cap, to prevent recurrence of the displace- ment. Dislocation of the Head of the Fibula is a very unusual accident, except as a complication of more serious injuries of the knee. The displacement may be either forwards or backwards, and the subcutaneous position of the bone renders the diagnosis easy. Reduction may be effected by extension and direct pressure, and a compress and a bandage should be subsequently applied to keep the bone in place. Dislocations of the Ankle__These injuries are described by Sir Astley Cooper, Malgaigne, and Hamilton, as dislocations of the lower end of the tibia : I think, however, that it is better to speak of them, with Boyer and others, as dislocations of the foot upon the bones of the leg. The dis- placement occurs between the upper articulating surface of the astragalus, and those of the tibia and fibula, and the foot may be dislocated forwards, backwards, to either side, or, as in a case mentioned by Druitt, directly up- wards between the bones of the leg. The lateral luxations are usually at- tended with fracture of one or both malleoli, the outward dislocation being sometimes additionally complicated by fracture of the outer edge of the tibia into the joint, a circumstance which, as pointed out by Hamilton, may render reduction impossible. The backward dislocation is usually accompanied with fracture of the fibula, and sometimes of the tibia as well. The forioard dis- location is very rare, usually attended with fracture, and, according to R. TV. Smith, always incomplete. These injuries may result from either direct or indirect violence, the particular form of the displacement depending upon the position of the foot at the moment at which the accident occurs. The antero-posterior luxations can be easily recognized by the characteristic de- formity, the foot being lengthened in the forward, and shortened in the back- ward dislocation. True lateral luxation is a less frequent accident than is generally supposed, the majority of the cases which are called dislocation, being really instances merely of rotation of the astragalus, without actual separation of that bone from the articulating surfaces of the tibia and fibula. Reduction may be commonly effected in any of these varieties of luxation, by simple traction (the leg being flexed on the thigh), combined with direct pressure, and flexion and rotation of the ankle in various direc- tions, according to the nature of the displacement; section of the tendo Achillis may occasionally be required. After reduction, the limb should be placed in a fracture-box with suitable compresses, or on a Dupuytren's splint, until recovery is complete. Compound Dislocation of the Ankle is a very serious accident, and usually requires amputation, particularly when complicated with fracture, though in suitable cases an attempt may be made to save the limb by sawing off the projecting ends of the tibia and fibula. I have once succeeded in effecting a cure without operation, by the continuous employment of irrigation. Dislocations of the Tarsus.—The Astragalus may be dislocated at once from the bones of the leg and from the other tarsal bones, and may be 298 EFFECTS OF HEAT AND COLD. thrust backwards (when it projects beneath the tendo Achillis),/or-Mv/zv/.s and outwards, or forwards and inwards. These injuries result from falls upon the foot, the particular form of the displacement depending upon the position of the foot as regards flexion, abduction, etc., at the moment at which the accident occurs. In the forward dislocation, the leg is shortened, the astragalus projects in front of one or the other malleolus, and the foot is somewhat extended and twisted to the opposite side. In the backward lux- ation, which occurs least often, the foot is in a state of extreme flexion, and the heel is elongated while the instep is shortened. Reduction should be at- tempted by making firm traction (the leg being flexed upon the thigh), and rotating and twisting the foot in the opposite direction to that in wliich it is found, while firm pressure is made upon the projecting astragalus. Subcuta- neous division of the tendo Achillis has been found a useful adjuvant in cases of forward displacement, and in a case of great difficulty Desault's plan of dividing the attachments of the astragalus itself might be tried—or the sur- geon might resort at once to excision. I should, however, prefer, in a case of irreducible, simple dislocation, to temporize, as advised by Cooper and Broca, reserving excision of the bone as a secondary operation, should slough- ing or necrosis render it necessary. Backivard dislocation of the astragalus is usually irreducible, the patient notwithstanding recovering with a very useful foot. In a case of compound dislocation, it would be proper (unless reduction were readily accomplished) to excise the astragalus at once, or to amputate, if the concomitant injuries were so severe as to forbid excision. Other dislocations of Tarsal Bones are described, as of the calcaneum and scaphoid upon the astragalus, which remains in place below the arch of the malleoli (subastragaloid dislocation of Malgaigne) ; of the calcaneum upon the astragalus and cuboid, or upon the astragalus alone ; of the scaphoid and cuboid upon the calcis and astragalus; or of the cuboid, scaphoid, or cunei- form bones, separately or together. Reduction in these cases may usually be accomplished by pressure and traction in different directions, according to the nature of the particular dis- placement. Even if reduction cannot be effected, the limb will often be serviceable in spite of the deformity. Dislocations of the Metatarsus and Toes are of rare occurrence except as the result of great violence, when amputation will often be re- quired. In cases of simple dislocation, reduction may usually be effected simply by traction and direct pressure, the parts being afterwards fixed with suitable splints and bandages. CHAPTER XIV. EFFECTS OF HEAT AND COLD. Burns and Scalds. A Burn is usually defined as the disorganizing or destructive effect of the application of dry heat or flame, a Scald being considered as the correspond- ing effect of the application of a hot liquid, and it is often said that these two forms of injury may be distinguished by the fact that a burn singes the cuta- neous hairs, which are, on the other hand, uninjured by a scald. It is evi- EFFECTS OF BUKNS AND SCALDS. 299 dent, however, that though this distinction answers well enough for the burns and scalds met with in every-dav life, it is not strictly correct; for, in many cases, the two injuries are combined (boiling oil may be at the same time burning oil), and some of the most destructive burns are produced by hot liquids—such as molten lead or iron. Again, the injuries produced by caustic acids or alkalies are essentially burns, whether the agent be applied in a liquid or in a solid form. Effects of Burns and Scalds__The effects of these injuries are both local and constitutional. The Local Effects vary according to the tempera- ture of the body which inflicts the injury, and the length of time during which its application is continued. Thus a momentary contact with flame will pro- duce a less degree of disorganization than prolonged contact with a substance the temperature of which may be much lower. Dupuytren divided burns into six classes or degrees, according to the extent of injury inflicted ; and this classification, which is in some respects convenient, is still adopted by most surgeons. The first class embraces cases of very superficial burn, marked by redness, and followed by desquamation of the cuticle. In the second class the injury extends more deeply, and is followed by the formation of numerous vesicles and bullae. In the third class the whole depth of the skin is involved, and is thrown off in the form of thin superficial sloughs. In the fourth class the destructive effect reaches the subcutaneous areolar tissue, the sloughs are firmer and deeper, and. on separating, leave granulating ulcers. In the fifth class the deeper-seated structures, muscles, tendons, etc., are affected; while in the sixth class of burns, all the constituents of the part, including the bones, are involved in destruction. The various changes which take place in a part that is burnt, are those that have already been fully described in the chapter on Inflammation, and the processes of granulation, cicatrization, etc., by which repair is accomplished in these cases, are the same as in solutions of continuity from any other cause. The Constitutional Effects of burns vary according to the degree of the burn and the extent of surface involved. In almost all cases, the constitu- tional symptoms may be divided into three stages, viz., that of depression, that of reaction, and that of exhaustion. The stage of depression is particu- larly well marked in cases of extensive burn, even though the depth of the injury be not very great. Many patients die in this stage, either from shock alone, or from this in combination with other causes, such as intense pain, or suppression of the physiological action of the skin. Thus, of ten patients re- ceived into the Pennsylvania Hospital from a fire at the Continental Theatre, in September, 1S(>1, six died within twenty-four hours, some without any reaction, and others having reacted very imperfectly. The second stage is marked by the occurrence of inflammatory fever, accompanied often by vio- lent traumatic delirium; the duration of this stage is usually from the second to the tenth or twelfth day, and during this period death may occur from internal congestion, or from inflammation of the brain, air-passages, or ali- mentary canal; the locality of the burn influences the seat of these secondary complications, a burn of the chest being followed by bronchitis or pneumonia, while one of the abdomen is more apt to cause inflammation of the bowels or peritoneum. A peculiar and very grave complication of this stage, which has been particularly insisted on by Long and Curling, is perforating ulcer of the duodenum. This, according to Curling, results from the irritation due to the vicarious action of Brunner's glands in attempting to replace the deficient action of the skin, but, according to Feltz and "Wertheim, is, in common with the other visceral complications of burns, directly traceable to the occurrence of capillary embolism. The duodenal ulcer usually proves fatal either from 300 EFFECTS OF HEAT AND COLD. hemorrhage, or by perforating the abdominal cavity, and thus giving rise to peritonitis. In the third stage of burn,"the patient is in the condition of one suffering from profuse suppuration and wide-spread ulceration, without regard to the particular cause of the injury; death may occur from simple exhaus- tion, from secondary visceral degeneration (probably of the so-called amyloid or albuminoid variety), or from pyaemia. According to Ponfick, one of the chief causes of death, in cases of severe burn, is disintegration of the red blood-corpuscles, with secondary parenchymatous inflammation of the kidneys, and urremic poisoning. Symptoms.—The Local Symptoms of burns are those of inflammation of the tissue affected, without regard to the cause. The intensity of the inflam- matory process varies in different cases, and in different parts of the body in the same case, so that we generally find the first four, and sometimes all of Dupuy- tren's degrees of burn, in the same individual. The Constitutional Symjitoms vary according to the stage, as well as the extent and severity of the burn. The most prominent symptom in the first stage is a feeling of intense cold. resulting, probably, in part, from direct injury to the cutaneous nerves, and, partly, from the accumulation of blood in the central organs of the bod}'. The patient shivers, and complains of chilliness, the temperature of the sur- face is depressed, the features pinched, and the whole body in a state of par- tial collapse. "With the development of the second stage, thirst becomes the most distressing symptom; there is an insatiable craving for liquids, which are rejected by vomiting as soon as they are swallowed. The patient is now very restless and feverish, and tosses off the bedclothes, which, during the first stage, could not be too closely applied. In the third stage, the symptoms are those of exhaustion and debility; the patient does not suffer much pain, except from the necessary exposure of dressing, unless the burns are so placed as to be subjected to pressure. Troublesome cough and profuse diarrhoea are often the most annoying complications in this stage of the injury. Prognosis___The prognosis, in any case of burn, depends chiefly upon the extent of surface involved : as a rule, it may be said that if one-half of the cutaneous surface be affected, no matter how slightly, the case will pro- bably terminate fatally. Even if one-third, or one-fourth of the surface be burnt, the prognosis should be very guarded. Another point to be considered is the locality of the injury; a burn upon the trunk is more serious than one of similar extent upon the extremities. The depth of a burn is of less prog- nostic importance than its extent, at least as regards life, which may often be saved (when the lesion is in one of the extremities) by a timely amputation. There is a popular idea that patients who are burnt often die from inhaling flame; it is, perhaps, scarcely necessary to say that such an occurrence is impossible ; death, however, may occur from asphyxia (from the presence of smoke and noxious gases), or possibly from the flame entering the mouth, thus inducing rapid oedema of the glottis, and consequent suffocation. Hot steam may be inhaled (as is sometimes done by children from the spouts of tea-kettles), when death ensues from inflammation of the air-passages. The older writers spoke of critical days in cases of burn, and the third and tenth days were especially so regarded. According to Mr. Holmes, how- ever (and this corresponds with my own experience), most deaths from burn occur during the first forty-eight hours; of 194 fatal cases which were received into St. George's Hospital in sixteen years, 98 terminated during the first two days, oo more during the first fortnight, and only 41 at a later period. TREATMENT OF BURNS. 301 Treatment.—The Constitutional Treatment of burns is of the greatest importance. The first thing to be done is to promote reaction. The patient should be placed in bed and covered with blankets, wliile foot-warmers or hot bricks or bottles, are employed to maintain an elevated temperature. Brandy and opium may be given pretty freely, care being taken, of course, not to intoxicate the patient; if he be already inebriated, reaction may be promoted by the use of other stimulants, such as carbonate of ammonia. As soon as reaction has begun, nutritive liquids, such as beef-tea or milk-punch, should be given, in small quantities and at frequent intervals, taking care not to excite vomiting by overloading the stomach. Thirst may be allayed by per- mitting the patient to suck small lumps of ice, or by the moderate use of car- bonic-acid water; but the patient should not be allowed to deluge his stomach with liquids, as the consequent vomiting and attending depression would of themselves often suffice to insure a fatal result. Transfusion of blood is, on theoretical grounds, recommended by Ponfick. During the first week or ten days of a burn, the patient is often consti- pated, and requires mild laxatives or enemata ; diarrhoea is apt to supervene at a later stage, and must be met with chalk-mixture, astringents, and opium. Retention of urine must always be watched for, during the early stages of a burn, especially with female patients, who, from a feeling of modesty, fre- quently conceal their sufferings in this respect. When a patient has tho- roughly reacted, the treatment consists chiefly in the administration of food and stimulus. Two or three pounds of beef, in the shape of beef-tea, with ten or twelve fluidounces of brandy, and a quart or two of milk, is no unrea- sonable daily allowance for a bad case of burn. The only drug habitually required is opium : twenty minims of laudanum, or half a grain of sulphate of morphia, every six hours, is often not too much to relieve pain and pro- mote necessary sleep. Traumatic delirium, if it occur, is to be treated on the principles already laid down, and other complications are to be met as they arise. During the third stage, tonics are usually required, the best being iron, quinia, and the mineral acids. Secondary amputation may be required, either by the depth of the burn, or by the state of general exhaus- tion of the patient ; if by the latter, the operation should not be too long postponed, on account of the risk, already referred to, of the occurrence of visceral degeneration, probably of the so-called amyloid or albuminoid variety. With regard to Local Applications to burns, I do not believe that it makes a great deal of difference what article is used, provided that the surface is tho- roughly excluded from the air, and that the process of dressing is neatly and properly attended to. The application which I myself prefer in cases of recent burn, is the old-fashioned carron oil, made by stirring linseed oil and lime-water into a thick paste, which is then spread upon old linen or muslin, and covered with oiled silk. It is customary to speak of this as a filthy dressing, but I cannot see that it is any less clean than other applications, while it is certainly, according to my experience, extremely soothing and agreeable to the patient. Other dressings may, however, be used, if the sur- geon prefer, and excellent results are doubtless obtained with raw cotton, flour, white paint, lard, glycerine, iodoform, or any other of the host of sub- stances which have been recommended. More important than the particular article used is the mode of using it. Onlv a small portion of the surface should be uncovered at once, and the burn, if extensive, should thus be dressed, as it were, in detachments. Vesi- cations, if there be any, should be punctured with the point of a sharp knife, the contained serum being allowed to drain away of itself, so as to preserve the cuticle as a covering for the parts beneath. The dressings should be 302 EFFECTS OF HEAT AND COLD. covered with oiled silk or waxed paper, to prevent evaporation, and should be held in place with roller bandages, the injured parts being supported in an easy position, with soft pillows covered with oiled silk, or with pads of cotton wadding. The dressings should be entirely renewed, as a rule, once in two days ; while unnecessary disturbance of the patient is to be deprecated, the discharge is usually so profuse and offensive, that to delay a change of the dressings longer than this, does more harm than good. When the sloughs have separated, the remaining ulcers may be dressed with lime-water, dilute alcohol, or zinc or resin cerate, as in the case of any other granulating surface. While the dressing is to be conducted with all gentleness, it must be neat and thorough ; especial care should be taken to wipe clean the newly-formed skin around the healing ulcer, which may be advantageously stimulated from time to time by light touches with lunar caustic or blue stone. During the healing process, care must be taken to guard against undue contraction of the cicatrix, by the use of appropriate splints and bandages. This contraction is particularly apt to occur at the flexures of the joints, and in the neck, where it draws the chin down to the sternum, or ties the head to the shoulder, producing the most frightful deformity, which may be irremediable except by operative interference. Operations for Contracted Cicatrices__In the early stages, before healing is completed, or afterwards if the cicatrix be still soft and pliable, it may be possible to prevent deformity by the use of splints and careful band- aging, or by means of elastic rings and bands, so applied as to counteract the contractile tendency. In dealing with old cicatrices, in which the contraction is firm and long established, severer measures are necessary. In the hand or foot, the deformity may be so great, and the cause of so much inconveni- ence, as to require amputation. In the neighborhood of the joints, as of the elbow, it may be sufficient to divide the cicatrix by a free incision carried into healthy tissue on both sides of, and beneath, the scar ; the after-treatment consists in making extension by means of screw apparatus, or, which I think better, the ordinary weight extension, applied to the limb below the scar, with lateral support by means of side-splints or a fracture-box, the wound being allowed to heal while the limb is in the extended position. These ope- rations are not entirely free from risk, for important vessels and nerves some- times adhere very closely to the cicatrix, and may be wounded in its division, or may themselves be shortened in the general contraction, when their integrity will be endangered by the process of extension. Simple division of the cicatrix is not sufficient in the case of burns about the face and neck, and here various plastic operations have been practised by Mutter, Buck, and others, to remedy the deformity, which is both annoying and painful. No general rules can be given for the management of these cases, which must be left to the ingenuity and skill of the surgeon in each particular instance. It may be said, however, that when the extent of the injury permits it, flaps of sound tissue should be brought, by twisting or by sliding, to cover the space left by free division and dissection of the cicatrix. In cases, on the other hand, in which this cannot be done, an attempt may be made to utilize the cicatricial tissue itself, as has been ingeniously and successfully done by Butcher, of Dublin. Mr. Butcher's operation, which has for its object the restoration of the elasticity of the cicatricial flap, consists in scoring subcu- taneously the hardened tissue, with numerous incisions made with a long, narrow-bladed knife. The surgeon is thus enabled to unfold, as it were, the matted cicatrix, and render it available for autoplastic purposes. When the deformity is limited to dragging down and eversion of the lower lip, Teale's modification of Buchanan's cheiloplastic operation will be found very useful; EFFECTS OF COLD. 303 this consists in dissecting up flaps from the sides of the lower lip (Fig. 158, a), and then joining these fiaps together, and to the freshened edge of the central portion (b), which affords a firm basis for their support; the triangular spaces (c) which Fig. 158. are left are allowed to heal by granulation. James, of Exeter, has supplemented the use of the knife, in these cases, by the employment of a screw collar, which gradually pushes the chin away from the sternum. In the case of the upper lip, Teale makes a crucial incision of which the point of intersection is immediately below the septum of the nose. The incision involves the whole thickness of the part, and the operation is Teale,s operatioa; the flaps in completed by dovetailing together the resulting piace. (Erichsen.) lateral triangles, so as to increase the depth of the lip at the expense of its breadth. W. Adams has introduced an in- genious mode of treating small depressed cicatrices, by simply dividing sub- eutaneously the deep adhesions of the part, everting the scar, and maintain- ing it in the everted position by the use of hare-lip pins for three days. This mode of treatment is manifestly inapplicable to large scars, and is indeed particularly recommended by its author for the cicatrices resulting from glandular suppurations or from bone disease. Anchylosis, or at least Immobility of the Jaw, occasionally occurs as a result of burns upon the cheek and side of the neck ; under such circum- stances, operations analogous to those of Barton and Sayre in the case of the hip-joint have been proposed by Rizzoli and Esmarch. Rizzoli's operation consists in simply dividing the jaw with a narrow saw in front of the cicatrix, so that mastication may be accomplished by means of the natural articulation on one side, and the artificial false joint on the other. Esmarch meets the same indication by excising a wedge-shaped portion of bone, three-quarters of an inch wide at its upper part, and an inch below; but in a case thus operated on by Dr. Buck, of New York (for cicatricial contraction resulting from can- crum oris), though an inch and a half of bone was removed, the parts became re-approximated, and the operation seems to have been only partially success- ful: a better plan is, according to Durham, to separate the jaw with a screw- lever, and then endeavor to restore the functions of the part by practising passive motion. The cicatrix of a burn sometimes assumes a peculiar warty appearance resembling keloid, this condition being more common in children than in adults. When the nature of the case permits, excision should be practised, but the cicatrix is sometimes too large to admit of this remedy; the itching may be relieved, according to Erichsen, by the internal administration of liquor potassae. Occasionally a true cancerous formation appears to be de- veloped in an old cicatrix, rendering excision (if practicable) still more imperative. Effects of Cold. The effects of cold are both constitutional and local. The Constitutional Effects of prolonged exposure to cold consist in the development of a state of drowsiness and indisposition to exertion, which, if not interfered with, will terminate in coma and death. Hunger, great fatigue, or any circumstance which impairs the general tone of the system, may increase the susceptibility to the effects of cold, and hence the liability of soldiers in a winter campaign to suffer from this cause. The treatment of a person apparently dead from 304 EFFECTS OF HEAT AND COLD. cold, consists in placing him in a room of low temperature, and in practising systematic but gentle friction, with snow, or with flannel wrung out of tinc- ture of camphor or dilute alcohol, together with a resort to artificial respira- tion. These means should be continued until reaction is well established, when the body may be wrapped in blankets, stimulating draughts adminis- tered, and the temperature of the room gradually raised. Efforts at resusci- tation in such cases should not be prematurely discontinued, as patients have occasionally been saved, even when apparently dead for several hours. Xicokvsen reports a case in which recovery followed, although the tempera- ture in the rectum had sunk to 76.4° F. The Local Effects of cold are divided, according to their intensity, into Pernio or Cliilblain, and Frost-bite. Cold appears in some instances to cause the formation of a "perforating ulcer." (See Chap. XXVII.) Pernio or Chilblain is a very common affection, and is caused rather bv sudden alternations of temperature, than by intensity of cold. It affects principally the extremities, especially the toes, heel, and instep, though it is also met with in the hands and face. The part affected is more or less deeply congested and swollen, and the seat of intense itching and burning. Vesica- tion sometimes occurs, and may leave ulceration of an intractable character. A patient who has once had chilblains is very apt to suffer from a recurrence of the affection, upon even slight changes of the weather. The treatment consists in plunging the part into cold water or rubbing it with snow, follow- ing this application by the use of local stimulants, such as the nitrate of silver, tincture of iodine, or soap liniment. Fergus speaks very favorably of the employment of sulphurous acid. The remedy which I am in the habit of employing is the nitrate of silver in weak solution (gr. iv-v to f gj), frequently painted upon the part, wliich is then wrapped in raw cotton. The nitrate of silver seems to obtund the local sensibility, and certainly relieves the burning and itching which in these cases are so distressing. The ulcerations wliich sometimes attend chilblain require stimulating applications, such as resin cerate, or dilute citrine ointment. T. Smith has called attention to the periodicity with which the paroxysms of itching in chilblain are developed. and which he is disposed to attribute to the time at which the patient's prin- cipal meal is taken. The daily paroxysm may be anticipated, if the patient's convenience so dictate, bv immersing the part for a few minutes in a mustard bath. Frost-bite results either from exposure to an intense degree of cold, or from prolonged exposure to a less degree. The parts most often affected are the nose, lips, ears, fingers, and toes, though occasionally the effect is more extensively diffused, whole limbs becoming frost-bitten. The first effect of cold is the production of a dusky redness, with some tingling and pain ; but further exposure causes a tallowy whiteness of the affected part, which is also shrunken, insensible, and motionless, presenting much the appearance of gangrene from arterial occlusion. Mortification may be induced directly by the intensity of the cold depriving the tissues of vitality, though more usually death of the part follows from the violent inflammation which results from undue reaction. Thus, Larrey found numerous cases of frost-bite caused by a sudden thaw, when the previous severe cold had given the affected persons no inconvenience. The treatment of frost-bite consists in moderating the intensity of the reaction, and thus endeavoring to prevent the occurrence of mortification. For this purpose the affected part should be rubbed with snow or ice. or covered with wet cloths, which are kept cold by means of irrigation, the patient being meanwhile kept in a cold room. Bergmann recommends INJURIES OF THE SCALP. 305 that the injured part should be suspended in an elevated position. By assidu- ously persevering in this mode of treatment, gradual reaction may be obtained, and the patient may escape with moderate inflammation, manifested by slight swelling and tingling, with perhaps some vesication, and desquamation of the cuticle. In this stage advantage may be derived from the use of stimulating washes, such as the tincture of iodine, or soap liniment. Even if mortifica- tion occur, the use of cold applications should be continued, as long as the gangrene manifests any tendency to spread. The occurrence of mortification is manifested by the part becoming black, dry, and shrivelled, a line of de- marcation and separation forming as in gangrene from any other cause. If the mortified parts be of small extent, their removal should be left to nature, the process of separation being simply hastened by the use of fermenting poultices ; the reason for this is that the vitality of all the neighboring tissues is impaired, and that the use of the knife might therefore be followed by a recurrence of gangrene. When the mortification has extended further, in- volving the greater portion, or the whole, of a foot or hand, a formal amputa- tion will probably be ultimately required ; even in such a case, however, it may be better, at first, simply to remove the gangrenous mass by cutting through the dead tissue below the line of separation, waiting to improve the shape of the stump by a regular amputation at a subsequent period, when the patient's general condition has been improved by appropriate constitutional treatment. CHAPTER XY. INJURIES OF THE HEAD. Injuries of the Scalp. Contusions of the Scalp are chiefly of interest in a diagnostic point of view, the sensation which they communicate to the fingers of the surgeon being often deceptive, and leading to the supposition that the case is one of fractured skull. There is in both affections a rim of indurated tissue with a central soft depression, but in a contusion, firm pressure will usually detect the bone at the bottom of the cavity. The most skilful surgeons mav, how- ever, be deceived by these cases, and incisions have been made with a view of elevating depressed bone, the operation showing that no fracture existed. Large collections of blood, either coagulated or fluid, may result from contu- sions of the scalp, remaining apparently without change for a considerable period. As a rule, no incision should be made in these cases, but the surgeon should encourage absorption by the use of evaporating lotions, or of moderate pressure. If, however, suppuration occur, the pus must be evacuated by a free incision. Cephalhamatoma, or Caput Succedaneum, is a bloody tumor of the scalp in new-born children, resulting from pressure during birth. The blood is usually effused between the scalp and pericranium, though more rarely beneath the latter. The treatment is the same as for similar extravasations resulting from other causes. Wounds of the Scalp__Scalp Wounds do not differ materially from similar injuries in other parts of the body, as regards their pathology and 20 306 INJURIES OF THE HEAD. treatment. The tissues of the scalp are extremly vascular, hence the hemor- rhage in these cases is often profuse ; on the other hand, the vascularity of the scalp is of advantage, in enabling the parts to preserve their vitality after injuries which, in other tissues, would be certainly followed by extensive sloughing. In all ordinary wounds of the scalp, whether incised or lacerated, the detached flaps should be carefully replaced (the parts being cleanly shaved), and held in position with strips of isinglass plaster, or, which is better, with the gauze and collodion dressing, or one of its modifications (see page 145). A firm and broad compress should then be placed over the seat of injury, and secured by a suitable bandage ; bleeding is thus readily checked. and the flaps are held in such a position as to favor union. I do not advise the use of either sutures or ligatures, in ordinary cases of scalp wound, simply because I do not believe them to be necessary. They are, indeed, thought by many surgeons to act as exciting causes of erysipelas, when applied to the scalp, but there is no proof, as far as I am aware, that they exert any such influence. They are, however, usually unnecessary, and therefore, of course, undesirable. If a wound of the scalp be accompanied with so much contusion and lacera- tion that sloughing appears unavoidable, it would be proper simply to support the flaps with adhesive strips, and apply to the wound some warm and sooth- ing application, such as olive oil or diluted alcohol. As in every case of scalp wound there is at least a possibility of some con- comitant injury to the brain, a patient with such an injury should be carefully watched during: the entire course of treatment; the diet should be regulated (all irritating or indigestible substances being avoided, while at the same time easily assimilable nutriment is provided in sufficient quantities), and attention should be given to the condition of the various secretions and excretions of the body. Fig. 159. Fig. 160. Severe scalp wound. (From a patient in the Episcopal Hospital.) Erysipelas and Diffuse Inflammation of the Subcutaneous Areolar Tissue are usually said to be especially apt to follow upon wounds of the scalp. Such has not been my own experience, though I can readily understand that a patient should be predisposed to these affections, when treated by the plan of excessive depletion formerly in vogue in the management of these cases. The CEREBRAL COMPLICATIONS OF HEAD INJURIES. 307 proper course to be pursued in the event of such complications arising, would be to remove all pressure or sources of tension, by reopening the lips of the wound, and making counter-incisions, if necessary, for the evacuation of pus or sloughs. Necrosis of the outer table of the skull usually, though not necessarily, follows in cases of scalp wound in which the bone is denuded of pericranium. Such a case should be treated upon ordinary principles, the sequestrum being removed as soon as it has become loose. The accompanying cuts (Figs. 159, 160) illustrate the severest case of scalp wound which I have ever seen followed by recovery. The patient was a girl of fifteen, an operative in a cotton mill, who was caught by her hair between rollers which were revolving in opposite directions, her scalp being thus, as it were, squeezed off from her head and forming a large horseshoe- shaped flap. The linear extent of the wound was fourteen inches, the dis- tance between its two extremities being but four inches. This large flap was thrown backwards, like the lid of a box, the skull being denuded of its peri- cranium for a space of two and a half inches by one inch in extent. The anterior temporal artery was divided, and bled profusely, and the patient, when admitted to hospital, was extremely depressed by shock and hemorrhage. A ligature was applied to the bleeding vessel, and the flap, after it had been gently but carefully cleansed, replaced and held in position with the gauze and collodion dressing. A large compress soaked in warm olive oil was then placed over the entire scalp, covered, with oiled silk, and fixed with a recur- rent bandage. A considerable portion of the wound healed by adhesion, and the patient was discharged cured after fifty-four days. No exfoliation of bone occurred. Cerebral Complications of Head Injuries. The principal risk attending all injuries of the head is from simultaneous or subsequent implication of the brain, and I shall, therefore, before speaking of fractures and other lesions of the skull, consider the various cerebral com- plications which are met with in these injuries, and which may be classified, as a matter of convenience, under the heads of concussion, compression, and inflammation. Concussion of the Brain__It is a rather mortifying confession, that the ideas of surgeons of the present day, as to this condition, are much less definite than those of their predecessors. We have, however, advanced so far, that we are now enabled to say pretty clearly what concussion is not, and thus to separate it from other conditions with which it was, formerly, habit- ually confused. Thus, we now know that cerebral concussion is not shock (see page 133), and that it is not a purely functional, apart from an organic condition. The older writers had no hesitation in declaring that a man might die from concussion of the brain, without the existence of any physical lesion whatever, but the fallacy of this opinion has been ably exposed by modern authors, among whom should be specially mentioned Prescott Hewett, the well-known surgeon of St. George's Hospital. In fact, while there is no evi- dence that cerebral concussion is ever a cause of instant death, there are inva- riably found after death from this cause signs of contusion, compression, extravasation, laceration, or inflammation. Concussion of the brain, as its name implies, consists in a shaking or, to use a Johnsonian word, a tremefaction of the cerebral mass, and it is easy to understand that such a trembling might be attended by a more or less tempo- 308 INJURIES OF THE HEAD. rary arrest of cell-action, by capillary stasis,1 and by functional inactivity, without any persisting lesion, or permanent ill result. Such, indeed, is pro- bably the condition of affairs in the slight cases of concussion or stunning which are not unfrequently met with, especially among children ; though, these cases not proving fatal, our knowledge of their morbid anatomy must, of course, be purely conjectural. A more violent concussion of the brain may cause contusion or laceration of the cerebral structure itself, or rupture of the cerebral vessels, giving rise to extravasation with or without compression, and more remotely followed by inflammation, suppuration, or softening. Contusion and Laceration of the brain, like the same conditions in other organs, may vary from the slightest bruising or separation of fibres, to the most extensive crushing and tearing, sometimes amounting to complete pul- pefaction and disorganization of the whole cerebral mass. The symptoms and prognosis of these injuries depend upon their extent, and upon the particular part of the brain which is affected; thus, Mr. Callender has shown that pain is especially connected with lesions of the outer gray matter of the brain, and convulsions with lesions in the neighborhood of the middle cerebral arteries, and particularly in that portion of the right hemisphere which is above the corpus striatum. A laceration involving the medulla oblongata would, of course, be more apt to prove fatal than one of similar extent in a less vital part.2 The extravasation which invariably accompanies cerebral contusion, pre- sents various appearances in different cases; thus there may be numerous points or specks of extravasation, each not larger than a millet-seed (miliary extravasation), or the blood may be poured out in larger masses, forming collections the size of a split pea. The latter form of extravasation is easily recognized, but the former may be mistaken for the appearance presented by the cut surface of the cerebral vessels—from which, however, it may be dis- tinguished by the fact that the points of extravasation are not easily wiped away, and, if picked out, leave behind them small but distinct cavities. Contusion of the brain, with its attendant extravasation, may be circum- scribed or diffused; the former condition is frequent, and the latter rare. Certain parts of the brain are more exposed to contusion than others; thus the base of the brain is more often affected than the upper part; the middle and anterior, than the posterior lobes ; the cerebellum, than the pons and medulla. The reason for this difference is, doubtless, as pointed out by Brodie, the greater or less irregularity of the surface of the various portions of the skull. When extravasation takes place on the surface of the brain, or into its ventricles, or even (in large amount) into its substance, the characteristic symptoms of compression are developed—a condition which will be presently considered. Causes of Cerebral Concussion—Concussion of the brain may be caused by various forms of external violence, such as a direct blow or fall, by violence resulting from counter-stroke, as a fall on the loins, buttocks, or feet, 1 According to Fischer, of Breslau, the phenomena of concussion are due to reflex paralysis of the intracranial vessels, but, from experiments on the lower animals, Duret concludes that they depend on increased tension of the cerebro-spinal fluid. 2 According to Brown-Sequard, lacerations of the brain are followed by pleural ecchy- mosis or pulmonary apoplexy on the side opposite to that of the cerebral lesion. Fleischman and Ollivier have observed a similar condition of affairs in cases of non- traumatic disease of the brain. Extravasation has also been noted, in connection with brain lesions, in the heart, kidneys, and other organs. On the other hand, cerebral abscess appears sometimes to result from embolism following pulmonary disease, as in cases recorded by Gull and Sutton, Huguenin, and J. H. Hutchinson, of this city. CONCUSSION OF THE BRAIN. 309 or even by sudden and violent agitation of the surrounding air, as by an ex- plosion in a patient's immediate vicinity. Symptoms of Cerebral Concussion___Every case of concussion is, I believe, accompanied with shock, and in many instances the symptoms of the latter condition alone can be recognized. The patient, after a blow on the head, becomes pale and somewhat collapsed, with a cool surface, small and feeble pulse, diminished power of sensation and motion, and partial unconscious- ness ; after a variable period these symptoms pass off, vomiting may or may not occur, and the patient is apparently quite as well as before the accident. The symptoms here are evidently those of shock (with the exception of un- consciousness), and cannot be considered as in any degree characteristic of the brain lesion. So again, in cases in which death follows in a few minutes or hours after an injury to the head, the patient lying meanwhile senseless and collapsed, the fatal result may be due to shock, or to intra-cranial hemor- rhage, or to laceration of a vital part of the brain ; but there is no symptom which we can point out as pathognomonic of concussion, apart from other conditions. Even in the intermediate cases, which are often spoken of as typical instances of concussion, though, as a matter of convenience, we may trace their clinical history, and divide it into stages, we cannot point to any symptoms which definitely characterize the lesions of concussion, apart from those of other cerebral injuries. Indeed it would be better, I think, if we could dispense altogether with the term concussion as denoting a condition. and look upon it as merely indicating the cause of what have been described as concussion lesions, viz., cerebral contusion, laceration, extravasation, etc. With this explanation and reservation, the clinical history of a typical case of so-called concussion of the brain may be said to present three stages, the symptoms of which are as follows :— In the first stage the patient lies motionless, senseless, nearly pulseless, pale and cold, breathing feebly but naturally, the pupils dilated or contracted, fixed or acting freely (according to the particular seat and form of lesion),1 with perhaps involuntary discharge of feces and urine. From this first stage the patient may recover without any further trouble, or he may gradually sink and die without reaction. Or the first stage may be very evanescent, so that when the surgeon first sees the patient he has already passed into the second stage, which Mr. Erichsen regards as an entirely independent condition, and graphically describes under the name of Cerebral Irritation. The disap- pearance of the first stage, whether by passing into the second or by direct recovery, is commonly marked by the occurrence of vomiting. In the second stage the patient is no longer unconscious, though much indisposed to speak or pay attention to surrounding objects. If roused by a question, he will answer, but peevishly or angrily, turning away as if displeased at the inter- ruption. The posture of the patient is peculiar; he habitually lies on one or other side, curled up, with all his joints more or less flexed, and if a limb be touched, draws it away with an air of annoyance. The eyelids are kept firmly closed. The pulse during this stage, at first small and weak, becomes gradually fuller and more frequent, while the breathing is easier, and the surface regains its natural warmth and color. The symptoms now may be masked by those of the second stage of shock (see page 131), and thus, instead of being morose and taciturn, the patient, though still irritable, may be voluble and loquacious. The condition of cerebral irritation which marks the second stage of concussion, gradually subsides, after having lasted several hours or days, the patient almost 1 Cerebral compression appears to be marked by fixed or slowly moving pupils ; mere laceration does not affect their free action. (See Mr. Callender's paper in St. Bartholomew's Hosp. Reports, vol. v. p. 25.) 310 INJURIES OF THE HEAD. invariably complaining of severe headache as he regains ability and willingness to communicate with those around him. The third stage varies in different cases : in some, there is positive inflammation of the brain and its mem- branes ; in others, as irritability subsides, fatuity takes its place, and a state of weakmindedness supervenes, which may end in recovery, or in cerebral softening and death. Prognosis___From what has been said, it is evident that the prognosis in any case of cerebral concussion or contusion should be very guarded; the patient may die, as Ave have seen, in the first stage, from the shock of the injury; or, if he escape this risk, from intra-cranial congestion or inflamma- tion ; or, at a still later period, from softening of the brain or cerebral abscess. As a rule, however, if the first stage be slight, Ave may expect the others to be so likewise, and, numerically, the proportion of deaths to the number of cases of slight concussion, or stunning, is very small; still, it is not always possible to be sure that the amount of brain lesion is as slight as it at first appears, and every case of concussion must be, therefore, a subject of grave interest to the surgeon. Treatment of Cerebral Concussion and Contusion—There is a popular notion that a person who has received a stunning blow on the head should not be allowed to sleep, or even to lie quietly in bed: need I say that this is as unreasonable as it is cruel? The first indication for treatment is certainly to place the injured organ at rest, and it would be no more unphilosophical to insist that a man should Avalk with a contused foot, or Avrite Avith a lace- rated hand, than to expect him to exert the mental faculties when suffering from concussion of the brain. A patient thus affected should be placed at rest, in bed, in a cool and moderately darkened room, and should be disturbed as little as possible. If the state of shock be so great as to threaten death from asthenia, the patient must be stimulated, preferably, however, as far as possible, by external applications, such as sinapisms or hot bottles, and by those internal remedies Avhich are most evanescent in their effect, such as the spirit of hartshorn or carbonate of ammonia. As a matter of fact, it is very seldom indeed that a case of concussion requires any stimulus at all. Reaction usually begins in the course of an hour, or two or three hours, sometimes much earlier, and as the pulse rises, the stimulants, if any haATe been given, must be discontinued. The risk now is from congestion or extravasation, with subsequent inflammation, and the treatment must be directed accord- ingly. It is in this stage that cold, and especially dry cold, is particularly useful as a local application. In the first stage it would have added to the existing depression, but it is now eminently indicated, and is a most valuable remedy. Esmarch's ice-bag or Petitgand's apparatus may be employed, or, in the absence of these, cloths wrung out of cold Avater should be assiduously applied. The secretions and excretions should be regulated, the bowels being opened with enemata, or occasional mercurial or saline purges, and the bladder relieved by catheterization if necessary. The diet should be very light, and administered in small quantities at a time; there is no article of food better, under these circumstances, than milk, to which lime-water should be added if there be vomiting. Rest, both mechanical and physiological, should still be enforced ; and if the patient be restless, the surgeon need not fear to give opium. I am aware that there is a good deal of difference of opinion as to the propriety of administering opium in injuries of the head, hut surely there is nothing to contraindicate it in Avhat we know of the pathology of these cases, while its soothing and calming effect is exactly what is required. Metaphorically speaking, it puts the brain in splints, and thus places it in the most favorable position for the repair of its injuries. Of course, opium in these, as in all other cases, should be used with discretion, and if there be COMPRESSION OF THE BRAIN. 311 any threatening of coma, should not be given ; but in such a case the restless- ness wliich calls for it Avould not be present. By perseverance in this plan, the patient will, in most cases, be tided over the second stage, and may then be allowed gradually, and with great caution, to resume his usual mode of life. For a long time, hoAvever, he should live by rule, guarding against all sources of irritation, eating and drinking very moderately, and in fact remaining, if not under treatment, at least under surgical supervision. If, on the other hand, the case progresses less favorably, and the contused and lacerated brain becomes inflamed, the chances of re- covery are much diminished ; traumatic encephalitis is, however, of such importance as to demand separate consideration. Compression of the Brain.—It is not my purpose to enter into a theoretical discussion as to whether the brain is susceptible of being actually compressed, or whether, in the condition knoAvn as compression, it merely changes its form, expanding at other parts to compensate for its apparent contraction at the seat of lesion. The term cerebral compression is so uni- versally employed by surgeons, and is in many respects so convenient, that I shall not hesitate to use it, although it may not exactly describe the condition Avhich it is meant to represent. Causes.—Compression of the brain may be caused by various circum- stances : thus, it may be due to the pressure produced by a foreign body, as a bullet or piece of shell ; by a portion of displaced bone ; by effusion of blood, either on the surface of the encephalon or within its mass ; or by what are ordinarily called the products of inflammation, lymph, serum, and pus. Symptoms.—The symptoms of compression are as folloAvs : the patient lies unconscious and comatose ; the breathing is slow, and accompanied by ster- tor, and by a peculiar bloAving motion or whiff at the corners of the mouth ; this sign, Avhich is very striking, appears to be due to paralysis of the cheeks, and is compared by the French Avriters to the act of a man smoking a pipe. The pulse is full and rather sIoav, the decubitus dorsal, and the skin usually cool, though sometimes hot and moist. There is retention of urine, and the feces are passed unconsciously. The pupils are fixed and immovable, usually mid- Avay between contraction and dilatation, sometimes Avidely dilated, and rarely contracted ; or one pupil may be contracted, Avhile the other is dilated; the difference in different cases depending, as shown by Callender, upon the part of the brain involved. There is paralysis of motion, usually affecting the side opposite to the seat of injury. The period at which the symptoms of compression are developed, depends on the particular source of the pressure : if this result from depressed bone or a bullet, the symptoms Avill be instantly manifested, and the patient Avill probably continue in a completely comatose condition, from the moment of injury, either till the pressure is removed, or till the case ends in death ; this, it Avill be remembered, was the course of events in the case of President Lincoln. If, however, compression be caused by extravasation, it Avill begin gradually, and sloAvly increase during several hours, until the intra-cranial bleeding has spontaneously ceased, or has been artificially arrested; while compression from lymph, serum, or pus comes on at a still later period of the case. Diagnosis___I regret that I cannot agree Avith those surgeons who consider the diagnostic marks between compression and concussion to be plain and easily recognizable. Unfortunately, as our knowledge of the pathology of concussion has increased, the several symptoms1 which we formerly regarded 1 Bouchut has recently asserted his ability to distinguish concussion from com- pression of the brain by the use of the ophthalmoscope, the optic nerve and retina presenting a normal appearance in the former condition, and evidences of intracranial 312 INJURIES OF THE HEAD. as pathognomonic, are shown to be often common to both conditions ; and this is not surprising Avhen we remember that extravasation is an almost constant lesion of concussion, and a frequent cause of compression, thus rendering the difference betAAreen the two conditions, in many cases, one of degree only. It used to be said that the symptoms of concussion Avere immediate and tem- porary ; those of compression, often not immediate, but permanent. We have, however, seen that the first stage of concussion presents no definite symptoms, none in fact which might not be due to shock and syncope (con- ditions Avhich might equally complicate compression)—AAdiile, if concussion be attended Avith much extravasation, compression itself may result. Again, if compression be caused by a foreign body, or by displaced bone, the symp- toms Avill be immediate—while in many cases of slight compression, the brain in a short time becomes habituated to the source of pressure, when the symptoms may pass off without surgical interference. And so with the other symptoms Avhich used to be considered diagnostic, there is not one, I believe, Avhich can be implicitly relied upon. A man Avas brought into the Episcopal Hospital Avith a compound, comminuted, and depressed fracture of the frontal bone, with rupture of the membranes, and escape of brain substance. When I saAV him he was comatose, and evidently suffering from compression of the brain ; I removed those fragments of bone that Avere loose, and elevated the remainder; the patient breathed somewhat less stertorously, and turned on his side ; the next day he was conscious, and rapidly recovered. Here there Avas manifestly compression from an obvious cause—depressed bone; and yet the only change in symptoms produced by relieving this compression (the accompanying concussion remaining), Avas a diminution in stertor, and the substitution of lateral for dorsal decubitus. Hence, though in certain cases Ave can say without hesitation, in vieAv of the one-sided paralysis, profound coma, and other symptoms mentioned, this is compression or that is concus- sion, there are other cases in Avhich it is impossible to draw such a distinc- tion ; compression may disappear spontaneously, leaving concussion, Avhile concussion, by a continuance of intra-cranial hemorrhage, may end in fatal compression. Prognosis.—Compression in itself is not a very fatal condition ; in many cases, in Avhich the pressure is not very great, the brain accustoms itself to the neAv state of affairs, and the patient regains consciousness, and goes on to recovery. In other cases it is possible by surgical interference to relieve the compression, and then, if the brain itself be not structurally altered, there is a good prospect of recovery. The gravest forms of compression are those which result from intra-cranial hemorrhage or suppuration, the latter condi- tion being particularly dangerous, and proving almost ahvays sooner or later fatal. Treatment of Cerebral Compression___AYhen the cause of compression is recognizable, an attempt should obviously be made to remove it. Thus if compression be due to a fragment of bone, this should be elevated or removed, provided that it can be done Avith safety ; or if to hemorrhage, in a situation which can be reached, the surgeon may make an effort to evacuate the effused blood and secure the vessel; if, however, the cause of the compression be uncertain, and still more if the existence of compression itself be doubtful, it will, I. think, be usually Aviser to abstain from operative interference, and to treat the case on the general principles which have been laid down, in speak- ing of the management of the second stage of cerebral contusion (page 310). pressure (" choked disk") in the latter : but it is evident that if the views advanced in these pages as to the pathology of "concussion" be correct, this test could only serve to distinguish those slight cases in respect to which no confusion would be likely to exist. TRAUMATIC ENCEPHALITIS. 313 Purgatives may be employed in these cases pretty freely ; and, if the patient cannot swalloAv, a drop of croton oil in mucilage may be placed on the tongue, Avhile the boAvels are solicited by turpentine enemata. The question of trephining in these cases Avill be considered hereafter. Traumatic Encephalitis, or inflammation of the cranial contents as the result of injury, is a very serious complication, both of fractured skull, and of the severer forms of cerebral concussion and contusion. The brain substance itself may be affected, or the meninges, or both together; the arachnoid membrane is perhaps more commonly involved than any other part of the cranial contents. The meninges are injected Avith blood, while yel- loAvish, or greenish, and sometimes puriform lymph occupies the cavity of the arachnoid and the meshes of the pia mater, the arachnoid itself becoming thickened, and assuming an opalescent appearance. According to HeAvett, in cases of meningitis originating from injuries of the skull, lymph Avill be chiefly found on the dura mater and in the cavity of the arachnoid ; Avhile in those cases which originate from injury of the brain (as after concussion), the pia mater is chiefly affected, the arachnoid cavity often escaping. Inflamma- tion of the brain substance itself, chiefly affects the gray matter and superfi- cial Avhite substance, and is marked by great congestion, a dusky leaden hue, and softening, Avhich comparatively seldom affects the central Avhite parts, such as the fornix. Traumatic encephalitis may end in suppuration, cerebral abscesses not unfrequently following upon seemingly slight injuries, and oc- curring after long intervals of apparent health. Symptoms of Traumatic Intra-cranial Inflammation.—These are pain (especially referred to the seat of injury), heat of head, fever, contraction of pupils, photophobia, and intolerance of sound; at a later period there are added vomiting, jactitation, delirium, convulsions, stupor, subsultus, paralysis. and coma. The occurrence of suppuration is frequently marked by repeated rigors. The period at which encephalitis is developed varies in different cases; thus, after general and Avide-spread concussion, inflammation may come on in a few hours; after limited laceration, probably not for several days—Avhile inflammation resulting from contusion or fracture of the skull may occur at a still later period. No very trustAvorthy information as to the precise seat of inflammation can be derived from the symptoms. The researches of Callender would seem to sIioav that pain is especially connected with lesion of the gray matter, and convulsions with disease about the track or distribution of the great vessels, especially the middle cerebral arteries. Solly, hoAvever, looks upon convul- sions as characteristic of inflammation of the tubular portion of the hemi- spheres, and Dr. Watson, of the pia mater or arachnoid; while Brodie and Ilewett have seen convulsions folloAV injuries of the head when there was no evidence of any inflammation at all. Death may result from pressure of lymph or pus on the surface of the brain (in cases of arachnitis), from soften- ing of the brain tissue, from the occurrence of intra-cranial hemorrhage, or from an abscess bursting into the ventricles ; or it may result secondarily from thrombosis and pyaemia. Intra-cranial Snpp oration may occur between the skull and dura mater (subcranial), in the cavity of the arachnoid and the meshes of the pia mater (inter-meningeal), and in the substance of the brain itself (intra-cerebral). Subcranial suppuration results from lesion of the bone, and is only met with at the seat of injury; the other varieties may also result from counterstroke, and may therefore be found at a distance from the point at which the violence Avas applied. The first and third forms of intra-cranial suppuration are cir- 311 INJURIES OF THE HEAD. cumscribed, the latter constituting the ordinary cerebral abscess, which may last for an indefinite time without producing any marked symptoms. Inter- meningeal suppuration is commonly widely diffused, occupying the region of the vertex, usually on the side of the external injury, but occasionally oppo- site to it. The symptoms of intra-cranial suppuration are those of cerebral irritation and compression; but I do not know of any signs Avhich will enable the sur- geon positively to distinguish the presence of suppuration from that of arach- nitis. The prognosis in all these cases is very unfavorable; pus has been occa- sionally evacuated from beneath the cranium, the patient recoATering; and incisions have been made through the dura mater, and even into the brain substance, in search of pus. Operations of this kind have been reported by Dupuytren, Detmold, Noyes, Clark, Weeds, Holden, Maunder, and Tillaux, and five of the eight cases are said to have terminated successfully. Treatment of Traumatic Encephalitis__Intra-cranial inflammation is to be treated on the general principles laid down in Chapter II. Bleeding Avas formerly considered absolutely necessary in these cases, and is still resorted to by some surgeons. I have already expressed my vieAvs so fully as to the employment of venesection in the management of inflammation, that I shall not revert to the subject here, further than to say that I have neA-er had oc- casion to bleed for encephalitis. Purging is doubtless a most valuable means of treatment in these cases, but should be employed Avith due caution, and not pushed so far as unnecessarily to Aveaken the patient. Desault derived advantage from the use of large doses of tartar emetic, but the remedy is a dangerous one, and is noAv seldom employed. Calomel and opium are, I think, of great service in the treatment of these cases, and may be given in doses of a quarter of a grain of the former, with a sixth of a grain of the latter, every three hours, till the gums are slightly touched, when the mercu- rial should be suspended, and iodide of potassium may be substituted. Cold to the head is a valuable remedy, and is very grateful to the patient, as re- lieving the headache, which is one of the most painful symptoms of intra- cranial inflammation. In the latter stages, a blister to the nape of the neck, or even to the entire scalp, is recommended by some authorities. The diet should consist of fluids, and should be light and unirritating ; if the general condition of the patient require it, howeA-er, the surgeon must not hesitate to administer concentrated nutriment, or even stimulus. After injuries of the head, the brain often appears to be left in an irritable condition, the patient suffering from headache, vertigo, insomnia, etc. Under these circumstances, I have derived benefit from the use of the bichloride of mercury (in very small doses), or of the bromide of potassium, Avhich may be given freely, and seems to act well as a hypnotic. The state of the bowels should always be looked to, in these cases, care being taken to avoid consti- pation. The question of trephining, for intra-cranial suppuration, "will be discussed in its proper place. Injuries of the Skull. Contusion.—Contusion of the skull, without fracture, is a Aery serious injury, being commonly accommpanied with grave lesions of the brain ; the part of the skull which is bruised may become necrosed, and eventually ex- foliate ; or, from separation of the dura mater, subcranial suppuration may occur and prove fatal. These injuries are chiefly met with as the result of gunshot wounds, though occasionally resulting likeAvise from the accidents of civil life. The treatment consists in combating cerebral irritation, by the FRACTURE OF THE SKULL. 315 means already described, and in removing sequestra, in case of exfoliation. If a patient Avith contused skull become comatose, it is usually recommended to apply a trephine, with the hope of being able to evacuate pus from beneath the skull; the facts already referred to, viz., that it is impossible to distin- guish intra-cranial suppuration from arachnitis, and that, even if the existence of pus were certain, its locality could not be determined, are, however, suffi- cient to show Iioav slight Avould be the prospect of benefit from such an oper- ation. Thus, in a case of gunshot contusion of the left parietal bone, which proved fatal at Cuyler Hospital, there Avere found after death arachnitis of the right side, and abscess of the left hemisphere of the brain, at a point corre- sponding to the seat of injury—showing that trephining on either side Avould have been utterly useless. The operation was, according to Dr. Otis, resorted to in twelve case? of gunshot contusion of the skull, during the late Avar, but in every instance unsuccessfully. Fracture of the Skull__Fractures of the skull may be simple or com- pound, comminuted, etc. They may be conveniently classified as fractures Avithout displacement (fissured fractures), and fractures with displacement (depressed fractures), the latter class being again subdivided into impacted and non-impacted depressed fractures.1 In some rare cases, the fracture may be limited to the outer table, Avhich is depressed upon the inner; in other instances, the inner or vitreous table is alone broken, the outer escaping. As a rule, the inner table is more extensively shattered than the outer, the ex- ception being Avhen the force is applied from Avithin, as in the discharge of a pistol into the mouth. The cause of this difference is to be found, as pointed out by Teevan, in the well-known fact in mechanics, that fracture begins uniformly in the line of extension, and spreads further in this than in the line of compression, and that (in the case of gunshot fracture) the bulk of the frac- turing body is absolutely augumented in its passage through the bone. Any part of the skull may be broken by either direct or indirect violence, the parietal and frontal bones being most often affected in fractures of the vault, and the temporal and sphenoid bones in those of the base of the skull. Fracture of the base of the skull is the most fatal form of simple fracture, usually resulting from indirect violence, such as a bloAv on the top or side of the head, or a fall from a height on the feet or hips; it is generally, if not (as believed by Aran and Hewett) universally, complicated by one or more fissures extending upwards into the vault. Depressed fracture of the skull is very rarely met with except in the vault, and results from direct violence. C. B. Ball, an Irish surgeon, has, however, collected several cases in Avhich the base of the skull Avas driven in, and the condyle of the jaAV impacted in the opening, by force transmitted through the lower maxilla. Symptoms of Fractured Skull___A Simple Fissured Fracture of the vault of the skull presents no symptoms which can be considered diagnostic. If there be an external wound, the line of fracture can be usually recognized, though a mistake has arisen, even under these circumstances, from an abnor- mal position of one of the cranial sutures. Fracture with Displacement, if compound, is readily recognized; but, if unaccompanied by an external wound, may, as already mentioned, be con- founded AAUth a simple scalp contusion (p. 305). In some rare instances the displacement is outwards, but much more commonly inwards, constituting the ordinary depressed fracture of the skull. The displacement in the impacted fracture is slight, the depression being less than the thickness of the skull ; 1 Other subdivisions are sometimes made, such as the starred fracture, and the cameratedfracture (a form of the depressed A^ariety). 316 INJURIES OF THE HEAD. in the non-impacted variety it is usually much greater, fragments being often deeply imbedded in the substance of the brain itself. Fracture of the Base of the Skull may be suspected in any obscure case of injury to the head, which present marked brain symptoms ; and there are two signs in particular, which, though they cannot perhaps be considered pathognomonic, are unquestionably very significant, and render the exist- ence of fracture at least extremely probable. These signs are the occurrence of intra-orbital ecchymosis and of bloody and watery discharges from the ear. 1. Fracture, involving the anterior fossa of the base of the skull, may cause hemorrhage from the nose, or into the deep parts of the orbit. The blood may flow backAvards through the posterior nares into the mouth, and, being swallowed, may subsequently cause haematemesis, giving rise to a sus- picion that some lesion of the abdominal viscera may have occurred. Hem- orrhage into the orbit and areolar tissue of the eyelids, constituting in the former position what is known as Intra-orbital Ecchymosis, is commonly considered as presumptive evidence of the existence of fracture of the an- terior fossa, though this symptom may, of course, be due to the giving way of a bloodvessel, Avithout lesion of the bony structures, and may even, as pointed out by Lucas, result from a superficial injury, the blood passing back- Avards from the eyelids to the subconjunctival ocular tissues. This form of ecchymosis may, however, be distinguished from the subconjunctival and subcutaneous palpebral ecchymosis which constitutes the ordinary " black eye," by the fact that it is unaccompanied by contusion of the superficial structures, and that it is not a primary phenomenon ; it is, indeed, caused by the gradual leakage of blood from within (the subconjunctival tissue being involved before the eyelids), and frequently does not reach its point of greatest intensity until several days after the time of injury. The hemorrhage is usually venous, probably resulting from laceration of the cavernous sinus, though it may be arterial, going on to the formation of a circumscribed trau- matic aneurism, and eventually requiring ligation of the carotid artery—an operation which has been successfully resorted to under such circumstances by Busk, Scott, and others. 2. Hemorrhage from the Ears cannot, of itself, be considered a sign of much importance, as it may arise from any injury Avhich ruptures the mem- brane of the tympanum, Avithout necessarily implying the existence of frac- ture. If, however, it be profuse and long continued, the blood Avhich remains in the meatus pulsating, and other symptoms of cerebral injury being simul- taneously present, it becomes probable that a fracture of the petrous portion of the temporal bone has occurred, and that the blood proceeds from one of the large venous sinuses in that neighborhood. The occurrence of a Discharge of Thin Watery Fluid from the ear or nose, or tlirough a Avound of the scalp, is very significant of fracture : this discharge appears, in most cases, to be due to the escape of cerebro-spinal fluid, though instances have occurred in which the secretion of the tympanic cavity, and even saliva (leaking backAvards through a perforation of the meatus, produced by the fragment of a broken jaw), have been mistaken for the characteristic discharge of fracture at the base of the skull. If, however, a profuse Avatery discharge occur from the ear immediately after the accident, or if it follow a profuse and continued aural hemorrhage, there can be little doubt that the cerebro-spinal fluid is indeed escaping, and that a fracture, therefore, is neces- sarily present.1 Watery discharge from the nose is, of course, much less sig- 1 Roser, however, believes that, if the meninges be ruptured, cerebro-spinal fluid may leak through the pores of the cranial bones without these being broken. INJURIES OF THE CRANIAL CONTENTS. 317 nificant, and as an accompaniment of fracture is less often met Avith than that from the ear. Compound fracture of any part of the cranial vault may be attended by a discharge of cerebro-spinal fluid, provided that there be a com- munication between the external wound and the sub-arachnoid cavity. It is stated by Robert, who has given much attention to this subject, that cases of fracture accompanied with discharge of cerebro-spinal fluid are always fatal; this is probably a mistake, for several Avell-authenticated cases are on record, in which recovery has taken place in spite of the occurrence of these discharges, though, of course, in any case Avhich recovers, there is always the possibility of an error having been made in the diagnosis. A sudden cessa- tion of the watery discharge is apt to be quickly followed by fatal coma. Prognosis—As far as the injury to the bone is concerned, there is very little risk from fracture of the skull : osseous union commonly occurs without difficulty, unless there has been loss of substance, in which case the gap is filled by means of a firm and dense membrane. If necrosis takes place, the sequestrum is thrown off by a process of exfoliation, and, if both tables of the skull be involved, the dura mater may be seen covered Avith healthy granula- tions, and pulsating at the bottom of the avouikI. Very large portions of the skull may be lost, either at the time of the accident, or at a later period by necrosis, Avithout injury to the patient; and, indeed (paradoxical as it may seem), those cases often appear to do best, in Avhich the skull has suffered most extensively, the force of the Woav or other injury spending itself, as it were, upon the bone, and the brain escaping with comparatively little harm. The danger in any case of fractured skull depends upon the amount of injury done to the cranial contents, this injury consisting in contusion, laceration, and subsequent inflammation, conditions which have already been considered. Treatment___The treatment of a fracture of the skull must have reference to the condition of the cranial contents. The question of trephining in these cases will be most conveniently considered hereafter; after the operation, if it be resorted to, or in cases in which operative measures are not required, the treatment should be conducted on the principles already laid down for the management of cerebral contusion and laceration, and traumatic encephalitis. Cold to the head, opium, purgatives, liquid food, calomel (in cases of arach- nitis), with perhaps blisters or local bloodletting, if coma be threatened, will be found the most useful remedies in the majority of these cases. In cases of compound fracture, loose fragments and foreign bodies should be removed if po-sible, and depressed but adherent portions of skull elevated, provided this can be effected without too much disturbance. The danger is, however, less from compression than from inflammation, and hence rough handling or care- less probing of the brain must be rigorously avoided. Injuries of the Cranial Contents. Wounds of the Brain and Meninges—The brain or its membranes may be Avounded, and portions of the cerebral mass itself driven out of the skull in cases of fracture, recovery yet ensuing; it is indeed surprising to see what serious Avounds may occasionally be inflicted upon the brain and its membranes, without a fatal result. I saw, at Cuyler U. S. A. Hospital, a soldier who had survived a perforating gunshot fracture of the skull, and Dr. O'Callaghan gives the case of an officer, who lived seven years with the breech of a foAvling-piece Avithin his cranium ; perhaps, hoAvever, the most remarkable cases on record, of recovery after wound of the brain, are those narrated by Prof. Bigelow, and by Dr. Jewett; in the former case an iron bar, three and a half feet long, and weighing thirteen pounds, passed through 318 INJURIES OF THE HEAD. the head, and in the latter, a someAvhat similar injury was produced by a gas- pipe. The symptoms and prognosis of brain wounds will of course vary Avith the particular part involved. Lesion of the optic tract may cause blindness ; or a wound in the neighborhood of the fourth ventricle, saccharine diabetes. Wounds of the base of the brain are more dangerous, and more quickly fatal, than those of its convexity. The treatment of brain Avounds consists in the adoption of the measures which have already been so often referred to, as appropriate in all cases of injury to the contents of the cranium. Hernia Cerebri__Under this name have been included several distinct conditions, which have merely in common the protrusion of a fungous-looking mass through an opening in the skull. This mass may be merely a collection of coagulated blood, or may consist of exuberant granulations, proceeding from the dura mater or from the wounded brain itself, but the true hernia cerebri consists of softened and disintegrated brain matter, mixed Avith lymph, pus, and blood. The mass projects through the dura mater and skull, and the superficial portions, which slough and are cast off", are usually replaced by fresh protrusions, until the patient dies exhausted. More rarely the patient may recover, the whole projecting mass being disintegrated and removed, or slowly shrinking Avithout the occurrence of sloughing. It Avas taught by Guthrie that hernia cerebri Avas more likely to occur through small openings in the skull, than through large apertures. This A-ieAv, however, is not con- firmed by the experience of all observers, and the occurrence of the affection appears to depend more upon the condition of the brain, than upon that of the skull. Hernia cerebri usually manifests itself in the course of the first or second week of the injury, the period varying with that of the development of cerebritis. The treatment is that of encephalitis in general. I doubt if advantage can be obtained from any local treatment, though it is said that in the early stages slight pressure has proved useful. Avulsion, excision, and ligation are all to be reprobated, as more apt to add fresh irritation than to be productive of benefit. As the affection seems often to result from the imbedding of spiculae of bone in the brain, we should be careful to remove all loose fragments that can be detected ; Avhile, on the other hand, as hernia cerebri cannot occur without wound of the dura mater, this membrane should be scrupulously respected in all our operations upon the skull. Trephining in Injuries of the Head. The objects sought to be attained by the use of the trephine are the removal of compression, Avhether caused by extravasation, by displaced bone, or by the presence of pus, and the prevention of inflammation, by the removal of foreign bodies, such as sharp spiculae of bone, musket-balls, etc. Trephining is also occasionally employed in the treatment of epilepsy, when it appears probable that the disease is caused by a morbid condition of the skull. Sedillot recom- mends trephining as a prophylactic in many cases of fractured skull, but his views are not shared by surgeons generally. Trephining for Extravasation__If it were possible to be sure that the seat of extravasation were between the brain and dura mater, and that there were no other lesions, operative interference might be employed Avith some hope of benefit. When it is remembered, hovvever, that the seat of extravasation can very rarely be determined, and that these cases are almost invariably complicated with grave injury of the brain substance, it ceases to be a matter of surprise that, as Mr. Hutchinson puts it, " the modern annals TREPHINING FOR DEPRESSED BONE. 319 of surgery do not . . . contain any cases in which life has been saved by tre- phining for this state of things." There are, indeed, a few cases on record, in which blood has been evacuated from between the dura mater and skull, or even from the cavity of the arachnoid, the patients recovering; but in the immense majority of instances, the operation, which is now seldom performed under these circumstances, has been useless, or has even hastened death. Hence, I cannot but think that, as a rule, the surgeon will do wisely to abstain from the use of the trephine in these cases, relying upon medical treatment, as in dealing Avith ordinary apoplexy. If the trephine be employed, a large circle of bone should be removed, in order to give room for the evacuation of coagula, and to afford a fair opportunity to secure any vessel that may be found bleedins;. Trephining for Depressed Bone__Probably few surgeons, at the present day. Avould think of operating in a case of Simple Depressed Fracture, Avithout symptoms of compression. Even if there be such symptoms, the ad- vantages to be derived from trephining are, at least, very problematical, for (1) the symptoms, if due to the depressed bone, will probably pass off by the brain accustoming itself to the pressure; and (2) if the compression persist, it will, most probably, be found to be due to extravasation from laceration of the brain itself, a condition which evidently would not be benefited by trephining. Indeed, Hutchinson goes so far as to consider compression of the brain as the result of depressed fracture " an imaginary state," and declares that he has -• never seen a case in which there seemed definite reason to think that de- pression produced symptoms." Although the rule is still gi\'en, in most of our surgical works, that trephining is indicated in simple fracture accompa- nied with marked symptoms, there can be no doubt that hospital surgeons are becoming more and more averse to operating in these cases ; and for my oavii part, I can only say that I have never seen a case of this kind in Avhich I thought the use of the trephine justifiable, nor an autopsy Avhich showed that the operation could possibly have saved life. With regard to Compound Depressed Fractures, it seems to me that the course to be pursued should A_ary, according as they are or are not impacted. In an impacted fracture, the depression is necessarily inconsiderable, and if symptoms of compression are present in such a case, they are due to extravasation or laceration, and not to the depression ; moreover, the impaction prevents the access of air to the cranial contents, and thus lessens the risk of disorganizing inflammation folloAving the injury. Hence, in impacted fracture, though compound and depressed, I would not advise an operation, even if symptoms of compression Avere present. For one case like Keate's, in which by a happy acci- dent, the operator might discover a wound of a large artery, and thus relieve the compression, there are many cases in Avhich trephining could be productive of no benefit, but Avould, by admitting the atmosphere, seriously complicate the prospects of recovery. If, however, in a case of compound impacted frac- ture, convulsions or other symptoms of cerebral irritation come on at a later period, the surgeon should explore the vvound, and if it appear that suppuration has occurred between the tables of the skull, may properly apply the trephine, as I have myself done Avith advantage under these circumstances. In the case of a non-impacted fracture, the rule has already been given, to remove the loose fragments, and elevate the remainder. In most cases this can readily be done by means of the elevator Hey's Saw. Fig. 161. ^J 320 INJURIES OF THE HEAD. and forceps, Avithout enlarging the opening in the skull. If, hoAvever, the aperture be too small to admit of safe manipulation, there can be no objection to enlarging it, either with a Hey's saw, Avith cutting pliers, or with a small trephine. The risks of atmospheric contact are unavoidable in such a case as this, and the best that the surgeon can do is to clear the wound as well as possible, by the removal of osseous spiculae and foreign bodies. It will thus be seen that I would restrict the use of the trephine within very narrow limits; it is not to be used with the idea of relieving compression, nor with the idea that there is any special virtue in the operation, to prevent encephalitis. The trephine should be used merely as Hey's saAV is used, mechanically, to enlarge an opening Avhich would be otherwise too small to allow the surgeon to carry out plain therapeutic indications. The surgeon should cautiously explore every compound non-impacted fracture, and if there be loose spiculae, remove them, whether there be symptoms of compression or not. As the inner table is often more extensively involved than the outer table (especially in punc- tured fractures), it may be necessary slightly to enlarge the opening in the skull in order to remove these spiculae, and this enlargement may be done with or without the trephine, according to the nature of the case. All this must be accomplished, however, Avith the utmost caution and gentleness; and I believe, with Brodie, that it is better to leave, imbedded in the brain, a foreign body, or e\'en a fragment of bone, than to add to existing irritation by reckless attempts at its removal. Trephining for Intra-cranial Suppuration—Some years ago, under the influence of the teaching and example of the celebrated Percival Pott, this operation was more frequently resorted to than it is at the present day. As we have already seen, there is, in the large majority of cases, no symptom which renders it certain that pus is present; and, as Hutchinson remarks, if we adopt the rule of trephining in all cases in which, after bruise or fracture of the skull, the patient has become hemiplegic or comatose, Avith inflammatory symptoms, we will operate in twenty cases of arachnitis, for one in which we will find any pus to be eA^acuated; while even if pus be found, and can be removed, in the immense majority of cases arachnitis Avill coexist, and cause death in spite of the operation. " I have repeatedly," says Hewett, "seen the trephine applied under such circumstances, and matter evacuated, but Avithout any permanent benefit. Indeed, the successful issue of a case of trephining for matter betAveen the bone and dura mater is, I be- lieve, all but unknown to surgeons of our OAvn time." When the chances of a successful issue after operative measures are so slight, the surgeon Avill, I think, do wisely to abstain from the operation ;x more especially as these cases Avill occasionally recover, at least temporarily, under expectant treatment. Even if pus be present, it is impossible to know that it is Avithin reach, and cerebral abscess may continue for many years, producing little or no disturb- ance; while, though recovery has occasionally followed trephining under these circumstances, the operation has in many more cases but superadded a new injury to those already existing. Chassaignac has proposed to trephine as a prophylactic against pyaemia, in cases of contused skull; but the opera- tion is surely not justified, either by experience, or by what Ave know of the etiology of the affection meant to be prevented. With regard to Trephining for Epilepsy, I can only say that I consider the operation usually unadvisable. Its risks are not inconsiderable, seven 1 Unless, as in cases successfully trephined by P. H. Watson, N. R. Smith, and Cras, an orifice in the skull should plainly communicate with an intra-cranial ab- scess. Under such circumstances, if the opening were insufficient, the operation would of course be indicated. OPERATION OF TREPHINING. 321 out of tAvelve cases operated on in the Massachusetts General Hospital, and sixteen out of seventy-tAvo cases collected by Billings have proved fatal; and when we remember the Avell-knoAvn fact that epilepsy is apparently and tem- porarily curable by very various remedies, Avhich have at least the merit of being harmless, we should pause before recommending an operation Avhich may not improbably itself cause death, and of which the prospective benefits, as regards permanence, are certainly doubtful. Operation of Trephining__The form of trephine ordinarily em- ployed is shown in the accompanying illustration (Fig. 162). It is to be applied evenly on the surface of the skull, with the centre pin1 slightly projected, and is to be worked cautiously by light turns of the Avrist from left to right and from right to left, until a grooAre is formed, when the centre pin must be AvithdraAvn, lest it puncture the skull and wound the dura mater. The surgeon then proceeds sloAvly and gently, brushing aAvay the bone-dust, from time to time, and testing the progress made by means of a fine probe or toothpick. AVhen the diploe is reached (if there be any), the trephine works more freely, and blood escapes with the bone-dust. As the inner table is approached, the surgeon must renew his precautions, lest undue pressure, or an accidental slip of the instrument, should wound the dura mater, an occurrence Avhich would be very apt to proA~e fatal. The disk of bone which has been separated will often come away in the crown of the trephine, or may otherwise be readily removed with the elevator (Fig. 163) Common trephine. Fig. 163. Different forms of elevator. and forceps. If the external wound be not large enough to allow the applica- tion of the trephine, more room may be afforded by means of a crucial or T incision, the flaps of the scalp being held out of the way, and carefully replaced when the operation is completed. The Avound should then be lightly dressed, and the constitutional treatment of the patient carried out in accord- ance Avith the principles already kid down for the management of cerebral injuries. There are certain regions of the skull to Avhich the trephine should not be applied, if it can be avoided ; these are the various sutures, the lines of the large venous sinuses, the anterior inferior angle of the parietal bone (where there Avould be risk of Avounding the middle meningeal artery), and 1 If the use of the centre pin be undesirable, the crown of the trephine may be steadied by applying it through a piece of perforated pasteboard, as suggested by Dr. P. H. Watson, of Edinburgh. 21 322 INJURIES OF THE HEAD. Fig. 164. the frontal sinus ; it it should be necessary to operate in the latter situation, the outer table should be removed Avith a large trephine, and the inner table with a smaller instrument. The Conical Trephine (Fig. 164) is an old instrument, the use of which has been recently revived by Gait, of Virginia. It has the advantage over the common instrument, that its peculiar shape prevents the possibility of its unexpectedly plunging into the brain; it, however, has the disadvantage that it divides the skull obliquely, and thereby exposes the part to greater risk of necrosis. The results of the operation of trephining are very unfavorable, the pro- portion of recoveries having been in the New York Hos- pital only about 1 in 4, and in University College Hospi- tal (London) 1 in 3, while in Paris almost every case operated on of late years has, according to Nekton, proved fatal. The majority of deaths after trephining are, how- ever, due, not to the operation, but to cerebral lesions on Avhich the operation could have no effect, so that sta- tistics are yet wanting to sIioav the absolute mortality of the operative procedure. During our late Avar, 227 ter- minated cases of trephining gave 126 deaths and 101 re- coveries ; 451 cases of removal of splinters or elevation of fragments, without trephining, gave 176 deaths and 275 recoveries ; Avhile 3447 cases treated by expectancy gaA-e 2159 deaths and only 1288 recoveries. (Otis.) As, how- ever, the latter group of cases contained almost all the in- stances of penetrating and perforating fracture, as well as those Avhich proved fatal before any treatment could be adopted, it would be manifestly unfair to found upon these statistics any argument as to the value of the operation of trephining. The most elaborate statistics of trephining yet pub- lished are those of Dr. Bluhm, avIio has collected 923 cases, Avith 450 recoveries and 473 deaths, a total mor- tality of 51.25 per cent. The death-rate varies according Conical trephine. J .-,,■,•■,,■, .• • r i tu„ to the period at Avhich the operation is performed, the primary cases being the most fatal. The following table is condensed from that of Dr. Bluhm, in Langenbeck's Archives (Vol. XIX., Part 3). Total. Recovered. Died. Mortality, per cent. Primary ...... Secondary ...... Late ....... Period unknown .... 114 158 59 592 51 94 39 266 63 64 20 326 55.26 39.24 33.90 55.07 Aggregate ...... 923 450 473 i 51.25 Perhaps Ave can most nearly approach a correct estimate of the risks of the operation itself, by considering Billings's statistics, already referred to, of trephining for epilepsy. In these cases the only traumatism, to borrow a Gallicism, is that due to the operation itself, and here we find that 72 cases gave 16 deaths, a mortality of about 22 per cent. But, even Avith this com- paratively small figure, it behooves the surgeon to be very cautious not unne- INJURIES OF THE SPINAL CORD. 323 cessarily to employ an operation Avhich of itself kills one out of every four or five patients, more especially as, upon consideration of the pathology and natural history of brain injuries, the probability of benefit from the operation is seen to be limited to an exceedingly small number of cases. CHAPTER XVI. INJURIES OF THE BACK. Wouxds or other injuries of the soft tissues of the back present no pecu- liarities requiring special comment. It is, indeed, only in consequence of the liability of the vertebral column and its important contents to be involved in lesions of the back, that injuries of this region acquire the interest Avhich they possess in the eyes of the surgeon. In entering upon the important subject of spinal injuries, I shall consider, first, the traumatic lesions of the spinal cord itself, reserving for a later page what I have to say with regard to sprains, fractures, and dislocations of the vertebral column. IXJUEIES OF THE SPINAL CORD. Concussion of the Spinal Cord.1—This may vary, like concussion of the brain, from the slightest jarring or shaking, up to complete disorgani- zation. Unlike concussion of the brain, however, it is very seldom that the spinal injury is so severe as to prove immediately, or even rapidly, fatal (except when accompanied by fracture or dislocation), death as a result of spinal concussion usually occurring after a considerable interval, and being preceded by inflammation of the spinal meninges or of the cord itself, or by progressive softening Avithout inflammatory symptoms. The reason for this difference is, as pointed out by Lidell, Shaw, and others, that the spinal cord floats loosely in an elastic medium (the cerebro-spinal fluid), and is therefore not so readily exposed to injury as the brain, which fits comparatively closely to its bony imestment. I do not believe it possible for death to occur from concussion of the spinal cord, without lesions demonstrable by post-mortem inspection. Though several cases have been recorded by Boyer, Frank, and others, in which such an event has been supposed to occur, it is probable that, with the more accurate means of examination which are now possessed, positive lesions could have been discovered. Death may, of course, occur from shock, Avhich is an occasional complication of spinal injuries ; or from concomitant lesions of other organs—lesions Avhich may readily escape detec- tion, if attention be directed chiefly to the condition of the spine.2 The post- mortem appearances, in fatal cases of spinal concussion, may be classed as (1) extravasation of blood—which may occur in the substance of the cord itself, betAveen the cord and its membranes, or between the latter and the vertebral column; (2) laceration of the membranes, or of the cord; (3) inflam- 1 The term concussion is retained from motives of convenience. It is not, however, scientifically correct, the various conditions which are designated by the term con- cussion, being really instances of contusion, partial rupture of the cord fibres, etc. See remarks on Concussion of the Brain, in Chap. XV. 2 See, in connection with this subject, an interesting paper by Dr. W. Moxon, on thrombosis of the renal vessels through injury to the lumbar spine (Guy's Hasp. Re- ports, 3d s., vol. xiv. pp. 99-111). 324 INJURIES OF THE BACK. matory changes—meningitis or myelitis—with or without compression of the cord from the so-called products of inflammation, lymph, pus, etc.; and (4) degeneration of the structure of the cord, without any evidences of pre-exist- ing inflammation. Hemorrhage into the Vertebral Canal is a not unfrequent occur- rence in severe cases of spinal injury. If in small amount, it may give rise to but transient paralysis, the effused blood becoming coagulated and partially absorbed, and the compressed cord becoming gradually accustomed to its presence ; in other cases it may remain in a fluid condition, or may possibly be clotted and subsequently reliquefied. In some cases it Avould appear that slow extravasation may continue for a considerable period, fatal paralysis not coming on for some time after the injury (in Mr. Heaviside's case nearly a year), and death thus resulting, as pointed out by Aston Key, from the cumu- lative effect of spinal compression. I do not know of any sign by Avhich the surgeon can positively determine the exact seat of extravasation, in cases of spinal hemorrhage ; in the majority of instances the effused blood is found outside of the membranes, or betAveen the latter and the cord ; and it is pro- bably in one of these positions that extravasation usually occurs, Avhen the symptoms are sIoav and progressive in their development, and when the power of motion is more affected than that of sensation. Extravasation into the substance of the cord itself, Avould probably cause instant paralysis, both motor and sensory, Avhich might be permanent, or in a favorable case might subsequently disappear. This is the most plausible explanation of the symp- toms in the remarkable case recorded by Hughes, of Dublin, in which an injury of the cervical spine caused instant but temporary loss of both motion and sensation, in the lower extremities, folloAved by gradually developed but long-persistent motor paralysis, in the upper extremities. Instant loss of both motion and sensation, if temporary, may be supposed to be due to a slight hemorrhage into the substance of the cord itself; Avhile gradually deve- loped paralysis, especially affecting the motor poAver, may be reasonably attributed to hemorrhage upon the surface of the cord, or even outside of the membranes. The upper limit of paralysis will, of course, indicate clearly the height at which the extravasation has occurred. Laceration or Rupture may occur in the spinal membranes (particu- larly the pia mater, alloAving a hernia of the medulla), or in the fibres of the spinal cord itself. These lesions are, however, more frequently produced by violent twistings or bendings, or by fractures or dislocations of the spinal column, than by any injury to which the term concussion can be properly applied. Inflammation of the Spinal Membranes (Meningitis), and of the Cord (Myelitis), are very frequent secondary occurrences in cases of spinal injury. In spinal meningitis there is great congestion, and often effusion of serum, or formation of lymph or pus. Myelitis may affect the Avhole thickness of the cord, or principally the gray matter; though, if con- secutive to meningitis, the Avhite portion may alone be involved. Inflamma- tion of the cord substance is commonly attended Avith softening, Avhich may end in total disappearance of the nervous structures at the part affected— nothing but connective tissue remaining; more rarely induration occurs, the nervous substance being increased in bulk, and of a dull whitish color. The occurrence of inflammation, in cases of spinal injury, is attended Avith great pain, distressing sensations, as of a cord tied around the AAraist or limbs, tetanic spasms, general convulsions, etc. SYMPTOMS OF SPINAL INJURIES. 325 Progressive Disorganization of the Cord may occur as the result of injury to the spine, Avithout the manifestation of any evidence of inflamma- tion, either during life, or upon post-mortem inspection. Paralysis, both motor and sensory, sometimes accompanied Avith muscular rigidity, gradually creeps upwards, until death ensues from interference Avith the respiratory function. The autopsy sIioavs diffused .white softening of the spinal cord, Avithout eA'idence of either meningitis or myelitis. In other instances the cord, to the unaided eye, appears perfectly healthy, though marked changes are subsequenth' discovered by careful microscopic inspection (II. C. Bastian, Med.-Clnr. Trans., vol. 1. pp." 499-542). Wounds of the Spinal Cord__The spinal cord may be wounded by sharp-pointed or cutting instruments, by pistol-balls, etc., without any, or with very slight injury to the vertebral canal. The symptoms of such a lesion are those which we shall presently consider as common to all spinal injuries, though there may be some modifications, owing to the greater limi- tation of the injury to certain parts of the cord, than in cases of spinal concus- sion, or of vertebral fracture or dislocation; thus, Avhile in the latter classes of cases paralysis is usually bilateral, and iiwolves both motion and sensation, in cases of wound of the cord we not unfrequently find paralysis only of the side injured, as in instances recorded by Vignes, Peniston, and others ; or loss of motion on the injured, and loss of sensation on the opposite side, as in cases narrated by Boyer, and by Hughlings Jackson. Symptoms of Spinal Injuries__The folloAving account of the symp- tomatology of injuries of the spine is to be understood as applying to all forms of injury in wliich the cord is involved, Avhether the A'ertebral column itself has or has not escaped : as Ave shall see hereafter, the differential diagnosis of the various forms of spinal injury is often impracticable, and always difficult, a fact Avhich is not surprising Avhen we reflect that the rational symptoms are the same in the various forms of lesion. I shall adopt the classification of symptoms which I employed in my monograph on Injuries of the Spine, published in 1867, and Avhich is pretty much the same as that used by Brodie, in his classical paper in the Medico-Chirurgical Transactions, vol. xx. Motor Paralysis___The most striking, and probably the most constant, symptom in cases of spinal injury, is paralysis of the voluntary muscles be- Ioav the seat of lesion. When the injury is below the second lumbar vertebra, there mav be no paralysis, or, if it exist, it is usually partial and temporal}', the spinal cord itself not usually extending beloAV this point, and the cauda equina appearing to be comparatively free from risk of injury. In lesions beloAV the eleventh dorsal vertebra, the paralysis is usually less complete than in those at a higher point, the cord being protected in this part by the roots of the cauda equina. Paralysis, ordinarily, does not extend to parts Avhich derive their nervous supply from the portion of the cord above the seat of injui'A", and the exact point of lesion can be thus determined in most cases : the apparent exceptions reported by Stafford, Brodie, and others, are probably explicable by the fact that a second lesion, such as contusion or extravasa- tion, existed at the higher point, as the result of indirect violence to Avhich the older writers would, have given the name of counterstroke. The extent of the spinal lesion in a dowmvard direction, may be determined by means of the electrical test, proposed by M. Landry. This surgeon found, in a case of luxation of the fifth dorsal vertebra, that the muscles of the thigh ceased to respond to electricity, Avhile those of the leg, though equally paralyzed, con- tinued to contract in response to the electric stimulus. The autopsy shoAved that the part of the cord wliich supplied nerves to the femoral muscles Avas 326 INJURIES OF THE BACK. disorganized, while that Avhence arose the nerves going to the leg was quite healthy. Thus the fact that each segment of the cord constitutes a separate nerve centre, affords a means of accurately determining the extent of that portion Avhich has been injured. Motor paralysis is usually symmetrical; Avhen unilateral (as in a case of fractured spine obseiwed by Liston), it indi- cates that one side only of the cord is involved, as in the instances of Avound of the cord already referred to. Motor paralysis after spinal injuries may be due to various causes, as to division of the cord fibres, to compression (either from extravasation, or from the products of inflammation), or to progressive disorganization of the nervous structures. If the paralysis be immediate, complete, and permanent, the cord is probably divided ; if the paralysis be immediate, but not permanent, the case is one of so-called " concussion"— the lesion probably being a slight extravasation into the substance of the cord, though this is, of course, mere matter of conjecture ; paralysis coming on gradually, and subsequently diminishing, is probably due to compression on the surface of the cord, from extravasation or from inflammatory changes; Avhile slowly but continually extending paralysis gives reason to fear progres- sive disorganization of the cord—a condition which, almost always, ultimately proves fatal. A feAV cases are referred to by Velpeau, in Avhich the cord is said to have been completely divided, without any paralysis having existed during life; it is scarcely necessary to say that these cases admit of but tAvo explanations— either, as believed by Brodie, that they were incorrectly observed, the divis- ion of the cord fibres not being complete—or, as suggested by Prof. Brown- Set [uard, that the division Avas at a point below the origin of most of the spinal nerves. Muscular Spasms or Convulsions after spinal injuries were believed by Brodie to indicate compression of the cord, and I believe this statement to be correct, as regards the spasms met Avith in the early stages of these cases. The value of this symptom for diagnostic purposes is, hoAveA'er, diminished by the fact that the cord is often found compressed, after death, without spasms having been observed during life. The occurrence of convulsions, at a later period (as already mentioned), may denote the onset of spinal menin- gitis; Avhile again, in cases wliich recover, muscular tAvitchings not unfre- quently accompany the return of motor poAver. Loss of Sensation usually accompanies and is coextensive Avith motor paralysis, in injuries of the spine. So complete Avas the loss of feeling in a case recorded by Purple, that the patient submitted to amputation of both thighs, Avithout the use of an anaesthetic, and Avithout manifesting any emotion during the operation. Occasionally sensory precedes motor paralysis, Avhile, on the other hand, in favorable cases, the poAver of feeling is not unfrequently regained while that of motion is still very imperfect. Hyperesthesia is occasionally observed in connection Avith motor paralysis. South saw a case of fracture of the cervical spine in Avhich there Avas loss of motion with hyperesthesia on the right side, and anaesthesia on the left. On the other hand, in a case reported by Gama, intense hyperesthesia folloAved a bayonet wound of the posterior columns of the spinal cord, there being abso- lutely no paralysis; a circumstance Avhich, as pointed out by Brown-Sequard, would indicate that the anterior portion of the cord had escaped injury. A zone of hyperasthesia sometimes marks the upper limit of sensory paralysis, due probably to irritation of the spinal nerves, before their exit from the ver- tebral canal. J'ain is a symptom of frequent occurrence in spinal injuries ; it may be felt at the seat of lesion, or may be referred to various other parts of the body. Unusual and often most distressing sensations, as of burning, constriction, SYMPTOMS OF SPINAL INJURIES. 327 etc., may be referred to parts, the nervous connection of Avhich Avith the sen- sorium is entirely destroyed. Dyspnoea—This is a marked and distressing symptom of injuries of the cervical and upper dorsal regions of the spine. It is often said that, in lesions of the cervical cord, respiration is performed by the diaphragm alone; this is not strictly correct, for, as pointed out by ShaAv, in many cases the diaphragm is helped by the serratus magnus muscle (supplied by the external thoracic nerve), which, Avhen the shoulders are fixed, tends to lift and expand the chest. If the spinal cord be destroyed above the origin of the phrenic nerve, death is instantaneous. The occurrence of dyspnoea in dorsal injuries depends upon tAvo causes : first, the abdominal muscles being paralyzed, the act of ex- piration is necessarily incomplete : and, secondly, paralysis of these muscles alloAvs the bowels to become distended Avith gas, thus thrusting the diaphragm upwards, and mechanically impeding its motion. The occurrence of dyspnoea at a late period of spinal injuries is attributable to progressive disorganization of the cord, extending upward to the cervical region. Dysphagia and Vomiting have been observed in injuries of the cervical spine, as has Jaundice in those of the dorsal region, without any hepatic lesion having been discoATered after death. Involuntary Fecal Discharges are met with in those cases in which the in- jury has involved the loAvest portion of the cord—that which presides over the sphincter muscle of the rectum; when the lesion is at a higher point, this part, having escaped injury, continues to act, for a time at least, as a separate nerve centre, and Costiveness ensues. In some cases there may be temporary fecal incontinence, depending on shock, which is coincident with, though not necessarily dependent upon, the spinal lesion. Retention of Urine is present in most cases of spinal injury, being followed after a time by Overflow, and subsequently by true Incontinence. A few cases are recorded by Morgagni and others, in which incontinence Avas pre- sent from the outset. Suppression of urine is a more serious, but, fortunately, a rarer symptom than retention. Several remarkable instances of this occurrence have been recorded by Brodie, Dorsey, Comstock, and others. Haematuria, from coincident contusion or partial laceration of the kidneys, is not unfrequently met with in cases of sprain of the lumbar spine. This symptom is- not usually one of serious import, though Mr. Shaw reports a case in Avhich the bleeding was so profuse as to render the patient anaemic. There is, according to Le Gros Clark, no reason to believe that organic dis- ease of the kidney ever ensues in these cases. Glycosuria has been met Avith in connection with injury of the cervical spine; the circumstance is interesting, in vieAvof the experiments which have been made as to the artificial production of diabetes. Change in the Urine Occurring after Spinal Injuries___Within a short time, varying from the second to the ninth day after a severe injury to the spine has been received, the urine, from being clear and acid, becomes turbid, ammoniacal, and loaded Avith mucus, and at a later period with phosphate of lime. This condition may continue indefinitely, or may disappear, or acidity and alkalinity of the urine may alternate, without any very obvious reason. In some rare cases, according to Brodie, the urine first secreted after a spinal injury, though acid and free from mucus, has a peculiarly offensive and dis- gusting odor. In other cases, it is highly acid, having an opaque yelloAv appearance, and depositing a yellow amorphous sediment, Avhich, in one in- stance, stained the mucous membrane of the bladder, though the latter pre- sented no marks of inflammation. Cystitis is an almost constant sequence of severe spinal lesions; it is pro- 328 INJURIES OF THE BACK. bably due, chiefly, to the mechanical injury to the bladder from over-disten- sion and the frequent use of the catheter, but is, no doubt, further aggravated by the altered character of the urine. This alteration, however, is itself usually secondary, depending on the inflamed state of the lining membrane of the bladder, though, in some cases, according to Hilton, the urine is alkaline as it comes from the kidneys. Priapism.—This curious symptom is occasionally met with in connection with lesions of all portions of the spinal cord, except the lowest. It is totally unconnected with any voluptuous sensation, and is only found in cases accom- panied by motor paralysis. In some cases, particularly Avhen the injury is in the cervical region, priapism may occur spontaneously, immediately after the accident, and is then due (as pointed out by Hilton) to the excito-motor function of the portion of the cord beloAV the lesion being unduly excited, because deprived of the regulating influence of the brain. In other instances this symptom is developed—also spontaneously—at a later period, OAving to central irritation, generally from slight extravasation into the substance of the cord ; Avhile in still other cases it occurs merely as a reflex phenomenon, and may be excited by touching the scrotum or by passing the catheter. The existence of priapism is usually evidence of severe and permanent injury to the spinal cord, though that this symptom may occur in connection Avith simple concussion is shown by a case recorded by Le Gros Clark, in Avhich sensation returned on the ninth day, though the poAver of motion was not restored for several months. Flushed Face, usually accompanied by Lachrymation, and by Contracted or merely Myotic Pupils, is, I believe, only met Avith in cases of injury involving the cervical portion of the cord. It appears to be due to a partial paralysis of the sympathetic nerve, which derives its cerA'ico-cephalic branch from the so-called " cilio-spinal region" of the spinal cord. This symptom is one of very grave import. Alteration of Vital Temperature is a symptom Avhich has been particularly investigated by Chossat and Brodie. The temperature of the paralyzed parts frequently rises much above the normal standard, this symptom being prob- ably most frequent in lesions of the upper portion of the cord, though a tem- perature of 100° has been noted by Hutchinson, in a case of fracture of the lumbar spine. In a case of injury of the cervical region, observed by Brodie, the thermometer placed betAveen the thighs rose to 111° Fahr., and this ele- vated temperature persisted even after the patient's death.1 This symptom, to which Hutchinson gives the name of Paralytic Pyrexia, is probably due, like the flushing of the face, to a paralyzed condition of the sympathetic or vaso-motor nerve. Persistent elevation of temperature, in spinal injuries, is a very grave symptom, and always affords grounds for a gloomy prognosis. In the later stages of spinal injuries, the temperature of the paralyzed parts often becomes greatly reduced ;2 and even AAdien there is no real diminution of temperature, the patient often experiences a distressing sensation of coldness. Nutritive Changes in Paralyzed Parts___In patients Avho survive the first risks of spinal injury, the paralyzed extremities usually, but not always, become flabby and atrophied; the skin assumes a salloAV hue, and often desquamates 1 J. W. Teale has reported a case of spinal injury in which the temperature is said to have ranged during nearly nine Aveeks from 108° to 125° F., and in which the patient ultimately recovered ; but, as in cases recorded by Schliep and Sellerbeck, deception may have been practised by the patient making friction upon the bulb of the thermometer. 2 Temperatures of 820 F., 81.750 F., and 80.6© F. were observed in fatal cases reported by Van der Kolk, Wagstaffe, and Nieden. CONCUSSION OF THE SPINE. 329 in flakes; the joints are often contracted and stiff. Partly from the lessened vitality of the tissues, but more particularly from the patient's insensiti\*e- ness to pain and inability to change his position, gangrene and sloughing are apt to occur in parts that are exposed to pressure ; large bed-sores are thus formed over the sacrum, hips, knees, or any part that touches the bed, and may sloAvly exhaust the patient's strength,-or, more rarely, may give rise to pyaemia, and thus quickly induce a fatal result. Bed-sores are most fre- quently met Avith in cases of injury of the loAver portion of the cord, simply, I believe, because in these cases life is more often prolonged than when the upper part of the spine is involved. Tetanus, contrary to Avhat might & priori be expected, is rarely met Avith in cases of spinal injury; in a case at St. Thomas's Hospital, it occurred three Aveeks after a bloAv on the spine, the patient recovering; Avhile in one of seven cases which occurred during our late Avar, the autopsy showed, in addition to the spinal lesion, a contusion of the anterior crural nerve. Cerebral Complications___Concussion of the Brain may complicate injuries of any portion of the spinal cord, resulting either from direct A-iolence simul- taneously inflicted on the head, or from counterstroke. Delirium, Coma, and Insomnia have each been occasionally noted in cases of spinal injury ; the latter symptoms, howeAer, I belieA'e, only in instances in Avhich the cer- vical region has been involved. Cerebral Meningitis, as observed by Ollivier, often complicates inflammation of the spinal membranes. Concussion of the Spine from Indirect Causes ; Railway Spine___LTnder these, or similar names, is described by Erichsen, and other English surgeons, a peculiar morbid condition characterized by Aery varied nervous symptoms, both physical and mental, which, according to these authors, are all directly traceable to the state of the spine. This subject has excited a great deal of interest, and a great deal of controversy, chiefly because of the numerous suits for damages, wliich have been brought against railway companies, on account of alleged injuries received in collisions. The symptoms appear to be rather those of general nervous prostration and debility, than the definite spinal symptoms which have been discussed in the preceding pages, and are often accompanied by remarkable perversions of the special senses, double vision, photophobia, tinnitus aurium, loss of tactile sen- sibilitA', etc. Many of the symptoms resemble those of ordinary progressive locomotor ataxia. "The state of the spine," says Mr. Erichsen, " Avill be found to be the real cause of these symptoms. On examining it by pressure, by percussion, or by the application of the hot sponge, it will be found that it is painful, and that its sensibility is exalted at one, Iavo, or three points. These are usually the upper cervical, the middle dorsal, and the lumbar regions. The exact vertebrae that are affected vary necessarily in different cases; but the exalted sensibility ahvays includes two, and usually three, at each of these points. It is in consequence of the pain that is occasioned by any movement of the trunk in the Avay of flexion or rotation, that the spine loses its natural suppleness, and that the vertebral column moves as a Avhole, as if cut out of one solid piece, instead of Avith its usual flexibility." Other writers of eminence are disposed to doubt the necessary connection of these symptoms Avith any particular morbid condition of the spine, looking upon " these cases of so-called railway spinal concussion as, generally, instances of nervous shock, rather than of special injury to the spinal cord."1 There is, as far as I knoAv, but one case, in Avhich the post-mortem appearances after death from "railway concussion" have been recorded, and that is Mr. Gore's 1 Le *rros Clark, Lectures on the Principles of Surgical Diagnosis, etc., p. 152. 330 INJURIES OF THE BACK. case, Avhich has been successively published by Dr. J. Lockhart Clarke, Mr. Erichsen, Mr. Le Gros Clark, and Mr. ShaAv. The condition of the cord in this case closely resembled, as pointed out by Le Gros Clark, that Avhich, according to Dr. Radcliffe, is found in ordinary cases of locomotor ataxia, so that there is at least room for suspecting, Avith Mr. Shaw, that the spinal injury was a mere coincidence—particularly as Mr. Gore, the attending sur- geon, did not see the patient until a year after the injury. " On the Avhole, it may be affirmed," says Mr. ShaAv, " that what is most wanted for the better understanding of those cases commonly knoAvn under the title of ' concussion of the spine' is a greatly enlarged number of post-mortem examinations. Hitherto our experience has been derived almost Avholly from litigated cases, deformed by contradictory statements and opinions ; and the verdicts of juries have stood in the place of post-mortem reports." In vieAv of the great obscurity Avhich is thus seen to surround this subject, I think that the surgeon Avill do Avisely to exercise great caution in declaring that a patient is suffering from " concussion of the spine from indirect causes," Avhether the result of railway, or of other injury; at the same time there can be no doubt that grave morbid changes in the spinal cord do result from comparatively slight blows upon the back, and, of course, in a railway collision, it is very possible that an injury might be received, Avhich would induce such changes. This fact has long been recognized in a general manner, but is clearly proved by a case which Dr. II. Charlton Bastian has published in the fiftieth volume of the Med ico-Chi rurg iced Transactions, and which has been already referred to (see page 325). Injuries of the Vertebral Column. Sprains___When we consider the number of joints in the vertebral column (nearly eighty), it is not surprising that twists and sprains in this part are occasionally met with, but rather that they are not more frequent than expe- rience sIioavs them to be. The part of the spine most exposed to sprains is the lumbar region, next the cervical, and lastly the dorsal, Avhich is rarely affected. Apart from the risk of concomitant lesion of the cord, these in- juries, though quite painful, are not commonly attended Avith danger. They may be caused by various forms of accident, as by falls or sudden tAvists, and are not unfrequently met Avith as the result of railway collisions. The symp- toms, provided that the cord be not involved, are those of sprains in other parts of the body, local tenderness, pain on motion, etc. In most instances the liga- mentous and other affected tissues gradually return to a healthy condition, but under other circumstances, if great stretching and laceration have occurred, permanent Aveakening of the part may ensue, requiring the constant employ- ment of artificial means of support. An occasional but more dangerous con- sequence is the extension of inflammation to the structures Avithin the vertebral canal, fatal meningitis or myelitis thus sometimes supervening upon Avhat at first Avas a simple sprain, in other instances, particularly in the case of the occipito-atloid and atlo-axoid articulations, the accident becomes the exciting cause for the development of chronic disease (Avhite swelling) of the joint, an affection Avhich in this situation may prove suddenly fatal, through the occur- rence of secondary dislocation. The treatment of vertebral sprains, unaccom- panied by cord lesion, is essentially that of sprains in other parts of the body. Pest, mechanical support, soothing applications at first, and at a later period stimulating embrocations, with friction, and perhaps the cold douche, Avill usually be found sufficient to effect a cure. It is often desirable to continue the use of mechanical means of support, such as a moulded gutta-percha splint, or leather belt, for some time after apparently complete recovery. The INJURIES OF THE VERTEBRAL COLUMN. 331 treatment of the cord complications, when present, is the same as in other forms of spinal injury, and Avill be considered Avhen Ave have disposed of the remaining varieties of mechanical injury to the vertebral column. Fractures and Luxations of the Vertebral Column__I shall consider these tAvo forms of spinal injury together, because, in the first place, they are very commonly associated in the same case, and because, secondly, it is often quite impossible to determine whether a giAren injury of the spine be a fracture or a dislocation, until a post-mortem examination reveals the exact nature of the lesion. The possibility of luxation occurring in the ver- tebral column has been denied by many surgeons, and Sir Astley Cooper, Avith his large experience, declared that he had never met with a case of this nature ; other Avriters, hoAvever, luiA-e considered them comparatively fre- quent, and Mr. Bryant states, that of seventeen autopsies made at Guy's Hospital in cases of spinal injury, during six years, no less than six showed the lesion to have been pure dislocation. I have not myself met with any instance of absolutely uncomplicated spinal dislocation, but the elaborate tables Avhich I have published in the monograph, already referred to, sIioav that 124 of 394 recorded cases of spinal injury Avere believed by the surgeons who reported them to have been of this nature. I cannot help suspecting, hoAvever, that in many, if not most, of these cases there was some slight bone lesion which escaped attention, so that perhaps the term diastasis Avould, in many instances, be more strictly applicable than dislocation. The large majority of reported cases of vertebral luxation have involved the cervical spine, the smallest proportion being found in the lumbar region. Causes.—The causes of these injuries of the vertebral column are very various : in most of the instances, met Avith in civil practice, the alleged causes have been falls or blows, acting sometimes by direct, but probably more often by indirect violence. In the cervical region, these injuries have resulted from falls upon the head or the buttocks, from plunging headlong into shalloAv water, from falls in turning somersaults, from the head being tAvisted in executions by hanging, etc. It is popularly believed that hanging usually causes death by dislocating the cervical spine—breaking the neck, as it is called—but this is an error. Unless the head be after suspension Avrenched to one side (as, according to Louis, Avas formerly done by the Lyons hangman, avIio sat on the shoulders of his victims, and twisted their necks until he heard a crack), dislocation does not commonly occur. Fractures and luxations of the vertebrae are, as might be expected, more frequent among men than women, in the proportion of nearly seven to one. No age is entirely exempt from these injuries, though most cases occur among those in early adult life. Maschka has recorded a case of dislocated axis, in a child killed by its mother, Avhen it Avas only eight days old, Avhile Arnott saAv a fracture of the same bone, produced by falling down stairs, in a man aged seventy-four. Symptoms.—The rational symptoms of vertebral fracture and dislocation, are due to the accompanying lesions of the spinal cord, and are those which have already been described as common to all forms of spinal injury. The physiccd signs, or those Avhich are peculiar to the mechanical disturbance of the vertebral column, are deformity, increased or diminished mobility, and crepitus. Local pain and tenderness on pressure, though often present in these cases, are in no Avise distinctive, for they are frequently more strongly marked in sprains, than in these more serious injuries. (1.) Deformity is usually more perceptible in the dorsal or lumbar, than in the cervical region. A depression in the position of one or more spinous processes may be generally taken to indicate fracture, Avhich may involve the vertebral arches, or merely the spinous processes themselves. Fracture 332 INJURIES OF THE BACK. Fie. 165. of the body of a vertebra, by allowing the approximation of the vertebrae above and below, usually causes angular deformity marked by undue promi- nence of the spinous process of the affected vertebra, or of that next above. Rotatory deformity, or twisting of the spinal column upon its long axis, may be considered indicative of luxation, Avhich may or may not be accompanied by fracture : it is seldom recognized, I believe, during life, except in the cer- vical region. Bilateral dislocation, an in- jury almost exclusively confined to the neck, Avould be marked by angular deformity, and, if in a backAvard direction, probably could not in most eases be distinguished from fracture of the vertebral body. Though deformity, Avhen present, is probably the most significant of all the physical signs of these varieties of injury, its absence by no means proves that fracture or luxation has not occurred. Indeed, my tables of spinal injuries sIioav that deformity has only been noted in about one-fourth of the Avhole number of cases, and it is easy to under- stand, in vieAv of the deep-seated position of the vertebral column, that fatal dis- placement might occur, which yet might not be revealed except by careful post- mortem dissection. (2.) Undue Mobility has been occasion- ally observed in cases of vertebral injury, chiefly in the cervical region, and, on the other hand, Immobility has been noted in about the same number of instances. I do not know that either of these symptoms can be relied upon to distinguish the injury, in any given case, from simple sprain of the vertebral column, and the surgeon should exercise great caution in his tactile investigations upon this point, as very slight force, or even an unwary movement, might induce displacement, Avhich in the cervical region would probably cause instant death. (3.) Crepitus, if present, would of course warrant the diagnosis of fracture, though it could not indicate in Avhat part of the vertebra the lesion existed. Statistics sIioav, hoAvever, that crepitus has been observed in about tAVO per cent, only of recorded cases. Diagnosis___From Avhat has been said, it will be perceived that, as already observed, the differential diagnosis of spinal injuries is ahvays difficult, and often impossible. This is, however, fortunately a matter of no practical moment, for, as Ave shall presently see, the treatment is essentially the same, whatever may be in any case the exact nature of the injury. Prognosis___The prognosis of fracture or luxation of the vertebrae, Avhile ahvays grave, is not by any means so gloomy as is ordinarily represented. Sir Astley Cooper, and more lately Prof. BroAvn-Sequard, have surmised that the proportion of recoveries in these cases is less than one per cent., Avhile Mr. Erichsen goes so far as to declare that " fractures of the spine through the bodies of the vertebrae, with displacement, are inevitably fatal." The opinion of these authors is not, hoAvever, borne out by the results of statistical investigation, which show that the mortality of terminated cases met with in civil practice varies from 78 per cent, in injuries of the cervical region to so Bilateral forward dislocation of the fifth cervical vertebra. (Ayres.) INJURIES OF THE VERTEBRAL COLUMN. 333 low a figure as 61 per cent, in those of the lumbar spine, the corresponding proportions of recoveries being 18 per cent, in the former, and 27 per cent. in the latter region. The chances of a fatal issue in these cases vary in\-ersely with the distance of the point of injury from the brain. Lesions above the third cervical vertebra prove usually immediately, or very quickly, fatal, though instances of long survival, or even of complete recovery, after fractures of the atlas or axis, have been recorded by Phillips, the elder'Cline, Willard Parker, W. Bayard, Stephen Smith, C. S. May, and several other surgeons. The prognosis in cases of gunshot injury of the vertebrae is, also, less un- favorable than has been commonly supposed. Many such cases no doubt prove fatal upon the field of battle, but of 642 tabulated by Dr. Otis, as having been treated during our late war, only 349 terminated in death, while 279 ended in more or less perfect recovery. Duration of Life in Fatal Cases___ With regard to this point, it may be said, in general terms, that of cases of fatal injury in the cervical region, tvvo- thirds die during the first week ; in the dorsal region, two-thirds during the first month ; and in the lumbar region, about the same proportion during the first year. Condition after Recovery. — Bony union is, according to Rokitansky, rarely met with after fracture of the vertebrae, though instances of its occur- rence have been recorded by Cloquet, Aston Key, and others. The accom- panying cuts (Figs. 166, 1G7, 168), from photographs given me by Dr. Richard A. Cleemann, of this citv, illustrate very beautifully the occur- rence of osseous union after spinal frac- ture. The specimen, which Avas derived from the body of a patient Avhom I saAV in consultation Avith Dr. Cleemann, is one of very great interest, showing, in addition to a fracture of the lumbar vertebrae, unilateral dislocation, Avhich is a rare lesion in this region of the spine. The case illustrates the difficulty of diagnosis in these injuries, for careful examination during life revealed merely prominence of one vertebral spine, with a corresponding depression beloAV it—thus indicating fracture of a vertebral body, but giving no reason to suspect the existence of luxation. With regard to the general condition of patients, after recovery from in- juries of the vertebral column, the prognosis Avill, of course, depend chiefly upon the nature and extent of the lesion to the spinal cord. If any portion of the cord be completely divided or disorganized, the parts of the body which derive their nervous supply from beloAV the seat of the injury Avill necessarily be permanently paralyzed. Prof. Eve has collected seven cases, in which the cord Avas found by post-mortem inspection to be for a greater or less space entirely deficient, and in Avhich life Avas yet prolonged for periods varying from a feAv days to twenty-two years ;x and the only instance of these Bony union of fractured vertebrae. 1 Am. Journ. of Med. Sciences, July, 1868, pp. 103-112. 334 INJURIES OF THE BACK. in Avhich paralysis Avas not constant from the time of the injury, was Mr. Shaw's case, in Avhich the cord appears at first to have been comparatively slightly injured, its Avant of continuity, as found at the autopsy, having been due to subsequent disorganization, which produced a return of paraplegia before death. The only case Avith which I am acquainted, in which complete recovery is supposed to have followed complete division of the cord, is one reported by Dr. Eli Hurd, of jNcav York, in Avhich, however, the diagnosis was not confirmed by post-mortem inspection. Fig. 167. ' Fig. 168. Fracture of vertebral body, and unilateral dislocation of a lumbar vertebra. When the injury to the cord is less severe, the prognosis is of course more favorable. The proportion, of recoveries, Avith restoration to a useful and comparatively active life, is, for injuries of the dorsal and lumbar regions, about 23 per cent, of terminated cases, but in injuries of the cervical region, if instances of partial luxation be excluded, the proportion is much less. Treatment of Spinal Injuries. The treatment of injuries of the spine involves attention to the state of both the vertebral column and the spinal cord. Treatment as regards Vertebral Column__If in any case there be evident vertebral displacement, or marked deformity, with paralysis, so that the surgeon has reason to believe that he has to deal Avith a spinal luxa- tion, whether complicated or not with fracture, he should at once proceed to attempt reduction by means of extension and counter-extension, aided by cautious manipulation, rotation, and pressure. I am aware that this advice will be looked upon by many as injudicious ; but statistical investigation sIioaa's that Avhile there is but one case recorded (Petit-Radel's), in Avhich efforts at reduction were the cause of death, there are many perfectly authen- tic instances, in which such efforts have been followed by the most gratify- ing success ; and Ave should no more be deterred from attempting reduction, by the fatal result in one case of vertebral luxation, than we are from at- TREATMENT OF SPINAL INJURIES. 335 tempting to reduce dislocations of the shoulder or hip, by the fact that death has occasionally folloAved such attempts, in the hands of the most skilful sur- geons. The mortality after spinal dislocation has been about four times as great Avhen reduction has not been attempted, as Avhen this treatment has been employed. If manual extension and counter-extension should fail to remoAre the de- formity, in a case of injured spine, it Avould, I think, be right to apply per- manent extension, by means of the ordinary Aveight apparatus ; the surgeon should, however, in such a case take great care, lest, from the pressure of the adhesive plaster or bandages, excoriations or sloughing should occur, and seriously complicate the patient's condition. I have not had occasion to em- ploy splints in cases of fractured spine, but Hodgen reports favorable results from the use of a plaster of Paris jacket. Treatment as regards Spinal Cord__In every case of spinal in- jury, the patient should be placed in bed, and kept at complete rest, both physical and physiological: a Avater-bed, if it can be obtained, or doAyn pil- lows, will be found of great use in preventing the formation of bed-sores. If the vertebral column itself be not affected, the prone position, as advised by Erichsen, will probably be found the best, as facilitating the application of local remedies to the spine. In cases of fracture, howe\_er, the supine position is preferable, and the patient should not be incautiously turned upon his side, lest sudden displacement should occur, which might prove fatal. The patient should be kept scrupulously clean, and parts exposed to pressure should be frequently bathed with astringent or slightly stimulating Avashes. The bowels should be emptied from time to time by the use of enemata. It is usually recommended to draw off the urine at stated intervals, by means of a flexible catheter, and such has ahvays been my OAvn practice. It has, however, recently been recommended, by Mr. Hutchinson, to dispense with the catheter, except in the rare cases of spinal injury in which retention is painful, alloAving the bladder to become distended, and then trusting to the mechanical OAerflow to preATent injurious consequences. Fatal ulceration of the bladder has undoubtedly been occasionally traced to the use of the cathe- ter, which in any case must aggravate the cystitis produced by distension and the ammoniacal state of the urine ; and hence, though not prepared to go quite as far as Mr. Hutchinson, I would urge the importance of great gentle- ness in catheterization, Avhich should only be done with a flexible instrument, used without the stillette. If bed-sores form, they should be carefully and frequently dressed, with as little disturbance as possible to the patient. The alternate application of ice and hot poultices, has been highly recommended by Prof. BroAvn- Sequard. Topical remedies are not of much value in the early stages of spinal in- juries, though, if there Avere much tenderness and local pain, ice-bags might perhaps be used with advantage ; at a later period, various forms of counter- irritation may be employed, Avith a view to a derivative action on the spinal cord and membranes. Constitutional Treatment__The general treatment, during the early stages, should be such only as is indicated by the constitutional condi- tion of the patient. Opium may be given at any period, to relieve pain or nervous irritation. Dr. McDonnell highly recommends the administration of belladonna, as a sedative to the spinal cord, and advises that it should be combined with opium, Avhenever the latter remedy is prescribed in these cases. On the onset of inflammatory symptoms, small doses of calomel, or of 336 INJURIES OF THE BACK. the corrosive chloride of mercury, may be employed, or the iodide or bro- mide of potassium. Ergot has proved useful, in the hands of Prof. Ham- mond, in cases of myelitis folloAving spinal injury. After the subsidence of inflammation, strychnia has often proved of the greatest benefit ; at the same time, electricity, systematically applied to the paralyzed parts, Avith friction, and cold or AATarm douches to the spine, may often be serviceable. Tonics, especially iron, quinia, and cod-liver oil, Avhich may be required at an early period, are peculiarly indicated in the latter stages of spinal injuries. The diet throughout should be nutritious but unirritating, Avith or without stimu- lus according to the circumstances of each individual case. Trephining or Resection in Injuries of the Spine— This operation has been suggested and described by surgical Avriters for a very long period, its history reaching back, indeed, to the days of Paulus JEgineta. The first surgeon, hoAvever, Avho actually practised the operation on the living subject, was the elder Cline,1 in the early part of the present century, and his example has been folloAved by other surgeons from time to time, the Avhole number of cases now on record amounting to forty. The object, of course, is to remove the vertebral arches at the seat of injury, and thus, if possible, relieve the cord from pressure, which is supposed by the ad- vocates of the operation to be the cause of paralysis in these cases. But, as a matter of fact, post-mortem inspection has shown that compression exists in but a small number—less than one-third—of fatal cases, and that even in these instances the cord is usually so much lacerated or disorganized as to preclude any benefit from operative interference; moreover, compression, Avhen it does exist, is almost always due to the pressure exercised by the body of the vertebra, so that all that resection could possibly do Avould be, as Dr. McDonnell has phrased it, to take away the " counter-pressure." The operation is by no means an easy one,2 and is in itself attended Avith no small danger to the patient; beside the inevitable risks Avhich must folloAV the conversion of the injury into a compound fracture, the exposure of the delicate structures within the vertebral canal, and the permanent loss of firm- ness and strength in the spinal column, consequent on the removal of one or more of the vertebral arches, the operation entails immediate peril upon the patient, death having occurred in one case (Willett's) before the operation could be completed. Finally, the statistics of the operation shoAV beyond question that, far from increasing, it positively diminishes the chances of re- covery. The following table embraces a record of 40 cases, being, as far as I can ascertain, all in which the operation of spinal resection for fracture3 has been hitherto performed. 1 Louis's operation, in 1762, often referred to as an instance of spinal resection, consisted merely in the renKwal of detached fragments in a case of gunshot injury ; a perfectly legitimate and conservative procedure, which was resorted to twenty-four times during our late war, with fourteen recoveries. 2 "I am satisfied," says Prof. Eve, "that this operation, in the dorsal vertebrae, if not almost impracticable, is certainly one of the most difficult in surgery" {Am. Journ. of Med. Sciences, July, 1868, p. 106). 3 Resection of the spine for disease has been performed by various surgeons, in- cluding Heine, Roux, Holscher, Dupuytren, and Jacobi, of Ncav York. Dr. Blackman is reported to have operated more than once, but I can find no record of bis other cases. He excised a portion of the sacrum, upon one occasion, but without benefiting his patient. Dr. J. B. Walker, of Boston, excised a spinous process. RESECTION IN INJURIES OF THE SPINE. 337 Cases of Resection of the Spine. No. Result. Operator's name. Reference. 1 Died. Cline, Sr. Chelius's Surgery; ed. by South, i. 590. 2 " Wickham. Lancet, 1827. 3 i« Oldknow. Hutchison, in Am. Med. Times, 1861. 4 a Tyrrell. Malgaigne, Fractures et Luxations, i. 425. 5 it Id. Ibid. 6 u Barton. Malgaigne (Packard's translation), p. 343. 7 Boyer. Heyfelder, Traite des Resections (trad, par Boeckel), p. 244. g it D. L. Rogers. Am. Journ of Med. Sciences, o. s., vol. xvi. 9 it Attenburrow. Chelius and Heyfelder, op. cit. 10 a Laugier. Malgaigne, op. cit. [256. 11 " Holscher. Brown-Sequard, Central Nervous System, p. 12 Relieved. A. G. Smith. N. A. Med. and Surg. Journ., vol. viii., p. 94. 13 Died. Mayer. Heyfelder, op. cit. 14 it South. Notes to Chelius, vol. i., p. 591, etc. 15 it Blackman. Hutchison, loc. cit. 16 EdAvards. Brit, and For. Med. Review, 1838. 17 Blair. Ballingall, apud Hutchison, loc. cit. IS Goldsmith. Gross's Surgery, 2d edit., vol. i. 19 Died. Stephen Smith. Hutchison, loc. cit. 20 <( Hutchison. Ibid. 21 (< G. M. Jones. Brown-Sequard, op. cit., p. 255. 22 " H.A.Potter. Hurd, N. Y. Journ. of Med., 1845. 23 " Id. Am. Journ. of Med. Sciences, n. s., vol. xlv. 24 Not improA*ed. Id. Ibid. 25 Died. R. McDonnell. Ibid., vol. 1. 26 Relieved. Sam. Gordon. Med.-Chir. Trans., vol. xlix., p. 21. 27 Died. Tillaux. Brit, and For. Med.-Chir. Review, 1866. 28 Willett. Med. Times and Gazette, Feb. 2, 1867, and St. Barth. Hosp. Rep., vol. ii., p. 242. 29 H. J. Tyrrell. Dub. Quart. Journ. of Med. Sci., Aug., 1866. 30 Died. Maunder. Med. Times and Gazette, Feb. 23, 1867. 31 Not improved. Eve. Am. Journ. of Med. Sciences, n. s., vol. lvi. 32 Died. Cheever. Boston City Hosp. Reports, 1870, p. 577. 33 a Id. Ibid., p. 580. 34 it St. Bartholomew's Hosp. Reports, vol. vi. 35 a Nunneley. Med. Times and Gazette, Aug. 7, 1869. 36 tt Id. Ibid. 37 " Id. Ibid. 38 Relieved. Id. Ibid. 39 Died. Willard. Am. Journ. of Med. Sciences, n. s., vol. lxiii. 40 Stemen. Clark, Clinic, June 5, apud Monthly Abstract of Med. Science, Aug. 1875. In 35 of the above 40 cases the result is knoAvn: 30 patients died; 3 Avere relieved, and 2 received no benefit from the operation. The most successful cases Avhich the advocates of spinal resection have yet been able to produce, are those of Dr. Gordon and of Mr. Nunneley; in the first, more than a year after the operation, the patient Avas " unable to stand or walk," Avhile in the second, the patient, during the tAVO and a half years Avhich he survived, Avas, though strong in the arms, " weak and partially paralyzed in the legs." Considering, therefore, the not infrequent favorable issue of these cases under expectant treatment, and in vieAV of the fact that the mor- tality after the operation has been over 8."> per cent, of terminated cases, and that no well-authenticated instance of complete recovery after its employment, has yet been recorded; surely Ave are justified in declaring, with Le Gros Clark, that we " cannot regard trephining the spine as brought Avithin the pale of the justifiable operations in surgery." 22 338 INJURIES OF THE FACE AND NECK. I Avould respectfully invite the reader, avIio is interested in the further in- vestigation of this subject, to consult the elaborate statistical tables, embraced in my monograph on Injuries of the Spine, already referred to. If the operation of spinal resection is to be done at all, it can, probably, be best accomplished, as recommended by Dr. McDonnell, by making a free and deep incision, and then dividing the bony laminae, on either side of the spin- ous process of the injured vertebra, with strong cutting forceps bent at an angle—an instrument wliich Avould prove more serviceable, in this position, than either a trephine, or a Hey's saAV ; a single arch having been removed, any additional portions of bone may be readily taken aAvay with the ordinary gouge forceps.1 Dr. McDonnell recommends very highly the internal ad- ministration of belladonna, or atropia, during the after-treatment of these cases, in order to prevent the development of inflammation of the membranes or spinal cord. CHAPTEK XVII. INJURIES OF THE FACE AND NECK. Injuries of the Face. Wounds of the Face present no peculiarities requiring different treat- ment from that of similar injuries in other parts. The tissues of the face are so vascular, that primary union is usually attainable, at least in the case of incised wounds. As it is desirable to avoid any disfigurement, in a part which is- constantly exposed to observation, I think it best to dispense Avith sutures, in the treatment of superficial Avounds of the face, approximating the parts as accurately as possible by means of the gauze and collodion dressing. In certain localities, however, as in the eyelids or eyebrows, nose, ears, and lips, the employment of sutures is usually indispensable; in penetrating wounds of the cheeks, also, stitches, embracing almost the entire thickness of the parts, should be applied. Harelip pins, Avhich may always be used with advantage in Avounds of the lips, may be employed in any of these cases to control arterial bleeding, the pin being passed under the vessel, which is then compressed above it by means of the twisted suture. No matter how much contused and lacerated any part of the skin of the face may be, it should not be removed, but should be replaced, after having been carefully cleansed, in hope that reunion may occur. The deformity Avhich sometimes results from such an injury, may often be remedied by a plastic operation— which may also be required in cases of deformity from burn, in which me- chanical extension has failed to procure relief (see p. 302). Orbit and Eyeball___Injuries of the Orbit may prove fatal through implication of the brain, either primarily, or, at a later period, by the exten- sion of inflammation. Pointed instruments, such as a sword, a stick, or the end of an umbrella, may be thrust through the orbital plate of the frontal bone directly into the brain. In a case recorded by Dr. AVm. Pepper, a knife Avas thrust through the sphenoidal fissure, Avounding a large meningeal vein, and causing death from intra-cranial hemorrhage. In other instances, again, wounds of the orbit have been followed by the formation of arterio- 1 See Dr. McDonnell's paper in the Dublin Quarterly Journal of Medical Sciences, for August, 1866, pp. 31-33. INJURIES OF THE ORBIT AND EYEBALL. 339 venous aneurisms, as in a case of Nelaton's, in which the point of an umbrella Avounded the cavernous sinus and internal carotid artery of the opposite side— death ultimately resulting from the bursting of the aneurismal tumor. Deep- seated suppuration may occur as the result of orbital injury, the abscess point- ing in either eyelid, or proving fatal by extending backwards to the brain. Wounds of the orbit may cause blindness, Avithout directly involving the eye- balls, either by injury to the optic nerves, or, possibly, by inducing a reflex condition, depending upon lesion of other neighboring nerves, as of branches of the fifth pair.1 In a case reported by Dr. Packard, immediate and total blindness folloAved a gunshot Avound of both orbits, the patient surviving the injury for four years and a half, and eventually dying from other causes. Foreign Bodies lodging on the eye may be embedded in the cornea, or may be concealed betAveen the ball and either eyelid. From the cornea, the offend- ing particle may be removed without much difficulty, simply by picking or gently prying it off with an ordinary cataract needle; if, in doing this, the cornea be superficially abraded, it is Avell, before dismissing the patient, to apply a drop of castor oil, Avhich Avill effectually protect the surface until the slight breach of continuity has been repaired. A foreign body on the cornea can usually be readily detected by carefully examining the part in a bright light; in any case of doubt, however, oblique illumination should be employed (Fig. 169), a second convex lens being used, if necessary, as a magnifier. Fis. 169. Oblique illumination. (Wells.) The conjunctival fold of the lower eyelid may be explored, by simply draw- ing doAvn the lid, and directing the patient to look upwards ; to explore the fold of the upper lid it is necessary to evert the eyelid, Avhich may be done either Avith the forefinger and thumb (Fig. 170), or with a probe, or the end of a pencil or quill, laid transversely across the lid. This little operation, Fig. 170. which is more difficult than it appears, is done by firmly but lightly seizing the edge of the lid between the thumb and forefinger (the patient looking down- wards, and the lid being drawn avcII doAvn, and slightly away from the ball), and then by a quick movement turning up the edge of the lid over the point of the finger, Avhich is simultaneously de- pressed. If the probe be employed, the central eyelashes, or the edge of the lid, must be taken between the thumb and finger of one hand, while the probe is Eversion of upper lid for detection of foreign bodies. (Eriahsen.) 1 The possibility of such an occurrence is doubted by Holmes Coote, and other sur- geons, avIio attribute the amaurosis in these cases to a "concussion of the retina," rather than to the effect of sympathy. 340 INJURIES OF THE FACE AND NECK. manipulated Avith the other. The eyelid being everted, its edge is pressed against the edge of the orbit, when almost the Avhole conjunctival fold comes into vieAV. The foreign body may then be removed Avith delicate forceps, the smooth end of a probe, or a moistened camel's-hair brush ; it is sometimes possible to feel the foreign body with the tip of the finger, Avhen, from its transparency, it cannot be seen. In some cases, in Avhich the offending object has eluded both touch and vision, I have succeeded in dislodging it by sweep- ing out the fold of the eyelid with a camel's-hair brush ; and in one instance, after I had failed to detect the foreign body by everting the lid, I succeeded by placing the patient in a bright light, with his head throAvn very far back- wards, Avhen, by simply drawing the lid away from the ball, I was enabled to see almost up to the sulcus. Contusion of the Eyeball may cause temporary blindness, by inducing a condition of the retina, analogous to concussion of the brain ; in other cases, the loss of sight may be permanent, from detachment of the retina, hemor- rhage, or inflammatory changes. The ordinary " black eye" of pugilists consists in an extravasation of blood beneath the conjunctiva, and into the loose areolar tissue of the eyelids. In this situation absorption is often very slow, the subconjunctival stain sometimes persisting for several AAreeks; the best application is cold water, or a mild alcoholic lotion. Contusion of the eyeball is sometimes accompanied by rupture of the cornea or sclerotic, allow- ing the escape of the humors of the eye, and causing permanent loss of A'ision ; in other cases the rupture may be internal, extravasation occurring, and filling the anterior chamber of the eye with blood, the iris being some- times torn from its ciliary attachment, or the lens dislocated from its position. The treatment consists in the frequent instillation of a solution of atropia, gr. ij-iv to f§j, and in the administration of calomel and opium, while the pa- tient is kept in bed, in a darkened room, and upon milk diet. After the ab- sorption of the effused blood, Avhich is usually soon effected, vision may be restored, though it is often rendered imperfect by bands of lymph crossing the anterior chamber and the pupil. A dislocated lens usually becomes cata- ractous, and often causes intense pain and frequent attacks of iritis, by press- ing upon the ciliary bodies and iris ; in either case, extraction should be promptly resorted to. From the anterior chamber, the lens may be removed by simple corneal section, and from the posterior chamber, by a similar ope- ration, a preliminary iridectomy having been first performed. If suppurathe disorganization of an eyeball occur, excision may be necessary to prevent the other eye from becoming sympathetically involved. Non-penetrating Wounds of" the Eyeball are not usually of a serious nature. The treatment consists in the removal of foreign bodies, followed by the ap- plication of a drop or tAvo of castor oil, with the use of cold compresses if the injury be attended Avith much pain. Penetrating Wounds are attended Avith much greater risk, the chief dangers being from prolapse of the iris, escape of vitreous humor, and, at a later period, from inflammation. If the iris protrude, an effort should be made to replace it by means of a fine probe; if this be impossible, the projecting portion should be snipped off with curved scissors, and if a staphyloma be subsequently formed, an iridectomy should be done opposite the most transparent part of the cornea ; this operation is, according to Soelberg Wells, much preferable to the old mode of treatment, by the repeated application of nitrate of silver. Incised AA'ounds of the scle- rotic, if not very large, may be brought together Avith one or two fine sutures, any protruding portion of iris or vitreous humor being first cut away. In cases of extensive Avound, with escape of a large portion of the contents of the eye, excision should, as a rule, be immediately performed, especially in pa- tients of the poorer class, to whom the time required for treatment is a matter INJURIES OF THE NOSE, EAR, AND CHEEK. 341 of importance. If an attempt be made to save the ball, cold compresses should be applied, atropia being very freely used, and calomel and opium administered internally. It may be necessary at a later stage to make an artificial pupil, to extract the lens (if this have become the seat of traumatic cataract), or to perform excision, if vision be lost and suppurative disorgani- zation of the eyeball have occurred, particularly if sympathetic implication of the other eye be threatened. The lodgment of a foreign body in the deeper parts of the eye usually requires excision of the globe, though it may occa- sionally be possible to remove the offending substance Avhile preserving useful vision. Dr. McKeoAvn, of Ulster, has recorded several cases in which frag- ments of steel Avere removed by the aid of a pointed magnet introduced through the Avound, and recommends the use of a large magnet, moved about externally to the eye, as a means of diagnosis. A magnet Avas also success- fully employed in a case recorded by Mr. McHardy. Nose—Foreign bodies, such as beads, peas, bits of sponge, etc., are often introduced by children into the nostrils, Avhere they occasionally become firmly fixed, and, if alloAved to remain, cause a troublesome form of ozaena. The foreign body may usually be removed Avithout much difficulty, by means of delicate forceps, a bent probe, a small scoop (such as is often placed at one end of a grooAred director), or by means of Thudichum's douche, the current being of course directed through the opposite nostril. Politzer's air-bag is used for the same purpose by J. O. Tanslev, of NeAv York. FQrTf1 Ear___Foreign bodies may be removed from the external ear with for- ceps, scoop, wire loop (as advised by Hutchinson), or, wliich is certainly the safest means, by long-continued, and, if necessary, repeated syringing with tepid Avater, the pinna being draAvn upivards, or, in the case of very young infants, downwards, so as to straighten the auditory canal. Prof. Gross uses a steel instrument, spoon-shaped at one end, and provided at the other with a delicate tooth, placed at a right angle. This instrument is doubtless very efficient and safe in skilful hands, but the general practitioner will, I think, do Avisely to be satisfied with simple syringing, which is indeed, according to Dr. Roosa, and to Gruber, of Vienna, much preferable to any other means of treatment. An ordinary hard rubber syringe of the capacity of three or four ounces may be used, the returning water being received in a boAAd held be- neath the ear. When there is much inflammation, Gruber advises that at- tempts at removal should be postponed until the subsidence of acute symp- toms, when the auditory passage may be dilated with sponge tents, and shrinking of the foreign body promoted by the use of astringent solutions. Guersant prefers to ordinary syringing, irrigation, wliich may be conve- niently effected with a Thudichum's douche, or by means of the double hand- ball syringe used for the administration of enemata. Should syringing fail, or should a perforation of the membrana tympani render its employment un- advisable, Lowenberg's agglutinative method may be properly tried ; this, which is a revival of the plan long since taught by Paulus iEgineta, consists in the introduction of a delicate pencil tipped with glue or plaster of Paris, wliich is alloAved to remain in contact with the foreign body until adhesion takes place, when both may be withdraAvn together. Cheek___Wounds of the cheek occasionally result in the formation of troublesome fistulae. If very small, a cure may be effected by the application of nitrate of silver, of a red-hot wire, or of the electric cautery ; if larger, the edges of the fistula should be pared, and closely approximated with sutures and a compress. If the wound involve the parotid duct, its opening into the 342 INJURIES OF THE FACE AND NECK. mouth may be obliterated, and a true Salivary Fistula result. The treat- ment consists in establishing an artificial inner opening—by forming a seton, by means of a small trocar and canula passed in the natural direction of the duct, the external opening being subsequently closed—or by the ingenious operation of the late Prof. Horner, which consists in cutting out the diseased tissues with a large and sharp saddler's punch, pressed firmly against a Avooden spatula previously introduced into the mouth, the external Avound being then immediately closed with the tAvisted suture. Mouth___Wounds of the Lips should be treated by the application of harelip pins, with additional points of the interrupted suture, special care being taken to secure accurate adjustment of the prolabium. Additional firmness may be afforded by the use of broad adhesive strips, passing from side to side, or of Hainsby's cheek compressor, as after the operation for hare- lip. Wounds of the Tongue do not require sutures, unless a considerable portion of the organ be nearly detached. Hemorrhage may require the appli- cation of ligatures, or of the hot iron. Wounds of the Soft Palate, unless very small, require stitches, which may be applied as after the operation of staphyloraphy. Foreign bodies, such as pistol-balls, teeth, or pieces of tobac- co-pipe, may be lodged deeply in the tongue or pharynx, giving rise in the latter situation to suppuration, and sometimes to fatal secondary hemorrhage. Injuries of the Neck. Wounds___These injuries, Avhich are usually of the character of Incised Wounds, are most commonly inflicted in attempts to commit suicide. It is occasionally a matter of some importance, in a medico-legal point of vieAv, to be able to determine whether a given wound of the neck has been self-inflicted, or received at the hands of another; it is, of course, impossible to arrive at absolute certainty upon this point, but it may be said, in general terms, that suicidal Avounds commonly begin on the left side of the neck (the person being right-handed), and pass transversely or obliquely downwards across the part, the extent of the wound on the right, being usually less than that on the left side. They rarely penetrate so deeply as to divide the great vessels; hence the prima facie probability with regard to a very deep wound, " pene- trating as by a stab perpendicularly towards the spine," and perhaps involving the vertebral column, would be that it was not self-inflicted.1 Wounds of the neck maybe divided into—1, Non-penetrating Wounds, which do not involve the air-passage or oesophagus; and 2, Penetrating Wounds, which do involve one or both of those important organs. 1. Non-penetrating Wounds___The danger of non-penetrating wounds of the neck, is chiefly from hemorrhage, Avhich is often very profuse ; if the carotid artery or internal jugular vein be wounded, death may be almost instantaneous, and even bleeding from comparatively small vessels may prove fatal in the depressed state, both physical and mental, Avhich is usually present in patients Avho have attempted suicide. Another danger is from the entrance of air into the large veins in this region, which may cause sudden death, or, as in a case recorded by Le Gros Clark, may prove fatal at a later period, by the air becoming gradually mixed with the blood, and thus interfering with the heart's action. The pneumogastric or phrenic nerve may also be Avounded in these cases, and either event Avould of itself almost certainly cause the 1 See upon this point a paper by Dr. Taylor, in Guy's Hosp. Reports, 3d s., vol. xiv., pp. 112-144. INJURIES OF THE NECK. 343 death of the patient. The treatment of non-penetrating wounds of the neck, consists in arresting hemorrhage, and in approximating the edges of the cut, in such a Avay as to favor union. Every bleeding vessel, Avhether artery or vein, should be secured by ligatures above and below the opening in its coats, or to either extremity if it be completely divided. In cases of arterial bleed- ing, in which the precise source of hemorrhage cannot be detected, the sur- geon should not hesitate to ligate the common carotid, an operation Avhich, according to Pilz, has been done, in cases of punctured and incised wounds, in 1-1 instances Avith 20 recoveries, the total number of cases in which the carotid has been tied for hemorrhage, being, according to the same author, 228, Avith 94 recoveries. Approximation of the lips of the wound is best eflected by numerous points of the interrupted suture, the ligature threads being brought out at the angles of the wound, Avhere they serve to secure drainage. The sutures should embrace the skin and superficial fascia only, and the deeper parts of the Avound should be approximated by means of broad strips of adhesive plaster, brought obliquely around the neck. The parts should be further relaxed by bending the head forwards, Avith the chin almost touching the sternum, and by securing it in this position, by means of a night- cap, or sling, which should pass from the occiput to a circular band around the chest. Primary union, though ahvays to be sought, is rarely attained in cases of cut-throat, the whole surface of the Avound not unfrequently slouo-hino-, and eventually healing by granulation. 2. Penetrating Wounds of the neck may involve any portion of the air-tube, though the larynx is the part usually affected. The relative fre- quency of these wounds, in different situations, may be seen from the folloAv- ing table of 158 cases, collected by Mr. Durham:— Situation of wound. Number of ca«es. Above the hyoid bone ......... 11 Through the tbyro-hyoid membrane ...... 45 Through the thyroid cartilage ........ 35 Through the crico-thyroid membrane or cricoid cartilage . . 26 Into the trachea .......... 41 The special dangers of penetrating Avounds of the neck, apart from such as are common to these injuries and to those which are non-penetrating, are the occurrence of asphyxia, or more correctly apnoea, emphysema, dysphagia, and, at a later period, bronchitis and pneumonia. Difficidty of Breathing, ending, perhaps, in complete Suffocation or Apncea, in wounds of the throat, may depend upon several causes. It may result directly from the accumulation of blood, either liquid or clotted, in the air-passages; from displacement of divided parts, as from a portion of the tongue, the epiglottis, or a fragment of cartilage, falling backAvards and obstructing the rima glottidis ; or, if the rings of the trachea be widely sepa- rated, from the external soft parts being sucked inwards, and producing val- vular occlusion of the air-tube. Again, suffocation may result from oedema of the glottis, from submucous emphysema, or from the pressure of an abscess. Emphysema is not usually a grave complication; it may, hoAvever, as already mentioned, produce suffocation, when seated beneath the laryngeal mucous membrane, or, according to Hilton, may prove directly fatal, by pres- sure on the phrenic nerves. Dysphagia, sometimes amounting to complete inability to swallow, is occa- sionally a source of great danger. Either from a wound of the oesophagus— or, Avithout this part being involved, from insensibility of the glottis—saliva, 344 INJURIES OF THE FACE AND NECK. and even particles of food, may escape into the air-tube, and make their appear- ance at the external Avound. Bronchitis and Pneumonia may arise from the irritation produced by the presence of blood, pus, or food, in the air-passages, from the admission through the wound of cold and dry air to the lungs, or possibly from the direct exten- sion of inflammation from the seat of injury. Among the occasional remote consequences of penetrating wounds of the throat may be mentioned alteration or loss of voice, and the formation of a traumatic stricture of the trachea or gullet, or of an aerial or oesophageal fistula. Treatment___After the arrest of hemorrhage, as in cases of non-penetrating wound, the surgeon may apply a feAV sutures to either extremity of the inci- sion, leaving, however, the central portion, as a general rule, to heal by gra- nulation ; an exception should be made in those cases in which the air-tube is completely cut across, when, to prevent wide separation, it may be neces- sary to apply a stitch on either side, so as to hold the parts in apposition. The sutures, which in such a case should be of fine thread, may be passed through the superincumbent connective tissue, or even superficially through the cartilages themselves, one end being cut off, and the other brought like a ligature through the external wound. In other cases, from the persistence of venous oozing, or from the occurrence of dyspncea on attempting to close the AA'ound, it may be necessary to introduce, for a time at least, a tracheal tube, as after the operation of tracheotomy. If, at any time, apnoea be threatened, the wound should be instantly reopened, and, if necessary, artificial respira- tion resorted to. Tracheal or laryngeal stricture may, at a later period, require the performance of tracheotomy, followed by systematic dilatation or even external division, as in a case recorded by Trendelenburg, or by excision of one of the tracheal rings, as practised by H. Lee ; aerial fistula may (pro- vided the larynx be unobstructed) be closed by a plastic operation. Injuries of the Larynx and Trachea. A blow upon the larynx may prove fatal through shock, or by inducing spasm of the glottis; when the injury is less severe, temporary insensibility only may result. The treatment, in slight cases, consists in the adoption of such measures as may prevent subsequent inflammation, but if breathing have stopped, kryngotomy should be performed, and artificial respiration at once resorted to. Fracture of the Larynx is an exceedingly dangerous accident, the mortality, according to Durham's statistics, being over 80 per cent. No age is exempt, though the injury usually occurs among young adults ; five of fifteen cases analyzed by Hunt were in children, and only one in a person over forty-five years of age. The usual causes, apart from gunshot Avounds, are, according to the same Avriter, "falls against bard and projecting sub- stances, blows, kicks, and pressure." The symptoms are local pain and tender- ness ; swelling of the neck, Avith an alteration of its form, consisting either of flattening or of undue prominence; mobility of the cartilages, and occa- sionally crepitus. There are besides, often, dyspnoea and lividity of face, with the ordinary evidences of collapse, emphysema, and expectoration of bloody mucus; the latter symptoms are considered by Hunt particularly unfavorable, as indicating laceration of the laryngeal mucous membrane. The annexed table, from Durham, gives a summary of 62 recorded cases, ~f2 collected by Henoque, and 10 added by Durham himself. It will be ob- INJURIES OF THE LARYNX AND TRACHEA. 345 served that death folloAved in every case in Avhich the cricoid cartilage1 Avas involved. Cartilages fractured. No. of cases. Deaths. Recoveries. Thyroid only Cricoid only Thyroid and os hyoides Thyroid and cricoid Thyroid, cricoid, and os hyoides Thyroid, cricoid, and trachea Cricoid and trachea Cricoid, trachea, and os hyoides "Fractures of larynx1' 24 11 4 9 2 2 2 1 7 18 11 2 9 2 2 2 1 3 6 2 4 Total..... '62 50 12 The treatment, in cases in Avhich the displacement is slight, and in Avhich there is no dyspnoea, may consist simply in supporting the parts with com- presses and strips of adhesive plaster. If, however, the respiration be embar- rassed, and particularly if there be bloody expectoration, no time should be lost in resorting to tracheotomy, which, under such circumstances, affords almost the only chance of saving the patient. Eight of the twelve cases of recovery were saved by operation, Avhile in the remaining four, from the absence of haemoptysis and emphysema, there is reason to believe, as remarked by Hunt, that the fractures were in the median line, and did not involve the mucous membrane. After the operation, an attempt may be made to restore the displaced parts to their proper position by manipulation. Dr. E. Holden, of Newark, N. J., has recently recorded a remarkable case of dislocation of the inferior cornu of the thyroid cartilage. Fracture or Rupture of the Trachea, without injury of the larynx, and Avithout external wound, is an extremely rare and very fatal accident. Cases are reported by Lonsdale, Berger, Beck, J. L. Atlee, Jr., Robertson, Corley, Long, and Drummond—those seen by the two last-mentioned sur- geons being the only instances of reco\'ery. In Long's case, life was saved by tracheotomy, supplemented by removal of blood from the air-passages by suction, and by artificial respiration. Dr. Lang, a German surgeon, has reported a remarkable case of intussusception of the trachea, which proved fatal at the end of ten Aveeks. Bums and Scalds of the mouth, pharynx, and glottis are occasionally met with, especially among children, the most usual form of the injury re- sulting from an attempt to drink boiling water from the spout of a tea-kettle. It is probable that, in some cases, steam may reach the larynx itself, but in the majority of instances the air-passages become secondarily involved, by the extension of inflammation from the mouth and glottis. The dangers are those of submucous laryngitis and oedema glottidis, and the treatment consists in the application of leeches and ice to the throat, and in the administration of antimony, or of calomel and opium. Free mercuriahzation is considered by Bevan and Corley, of Dublin, to be the most important measure, and the 1 A remarkable case has been recently recorded by S. Treulich, in which both thyroid and cricoid cartilages were broken—the latter in two places—and the trachea ruptured by the bite of a horse ; life was saved by tracheotomy. 346 INJURIES OF THE FACE AND NECK. latter surgeon reports a successful case in a child less than three years old, who in seventeen hours took twenty-four grains of calomel, and had six drachms of mercurial ointment rubbed into his groins and axillae. The oede- matous mucous membrane of the fauces and epiglottis may be scarified with a long needle, or Avith a curved bistoury, wrapped almost to its point Avith a strip of sticking plaster, and, if suffocation appear imminent, tracheotomy must be performed, as a last resort, though its results under these circum- stances are far from satisfactory, 23 out of 28 cases collected by Mr. Durham having ended in death. A similar injury may result from drinking corrosive liquids, such as the stronger mineral acids, or caustic alkalies. The treatment should be the same as in the case of scald of the glottis or larynx. Of three cases mentioned by Durham, in which tracheotomy Avas performed for such an injury, two died and one recovered. Foreign Bodies in the Air-Passages__A great variety of sub- stances have been met with as foreign bodies in the air-passages, the most common being, according to Prof. Gross, grains of corn, beans, melon-seeds, pebbles, and cherry-stones. Several such objects, sometimes of a dissimilar character, have been occasionally met with in the same case. In four in- stances leeches have been extracted from the larynx, by Marcacci, Trolard, Massei, and Clementi. Foreign bodies usually enter the air-passages through the glottis, being drawn in, in the act of inspiration, or simply dropping in, as in the case of coins tossed in the air and caught in the mouth, or—as has probably happened in some cases, in which suffocation having occurred during sleep or intoxication, the air-passages have been found to contain partially digested food—the foreign body may be regurgitated from the stomach, and may then make its AA-ay through the glottis, the sensibility of which is ob- tunded by the patient's condition. In other instances, foreign bodies have entered the air-passages through accidental wounds or ulcerations of the oeso- phagus, of the tissues of the neck, or of the walls of the chest. Finally, in one case referred to by Prof. Gross, a lymphatic gland passed through an ulcer in one of the bronchi, and caused death by becoming impacted in the rima glottidis. Situation—A foreign body may be arrested in any portion of the air- passages, or, more rarely, may be moArable, changing its position from time to time. The parts in which extraneous substances are most apt to become impacted, are the larynx and one of the bronchi, usually the right. Symptoms—The primary symptoms, or those of Obstruction, are similar to those of inflammatory or spasmodic croup, only, if possible, more violent. The patient feels a sense of impending death, and is, indeed, for the time, in most imminent danger. The face becomes livid, the eyes apparently start from their sockets, the patient gasps and utters piercing cries, foams at the mouth, is perhaps convulsed, or falls insensible. The first paroxysm passing off, the symptoms of Irritation become prominent. There is a short, croupy cough, Avith pain, especially referred to the top of the sternum, and mucous or bloody expectoration. Paroxysms of dyspnoea, with a sense of suffocation, recur from time to time, and are due to the dislodgment of the foreign body, and to its being impelled against the larynx by the act of coughing. Ausrid- tation will reveal various signs, according to the position of the foreign body ; if this be loose in any part of the tube, it may be heard moving up and doAvn with a flapping sound, and occasionally striking the wall of the trachea; if fixed in the larynx, there will be a harsh, rough sound in respiration, coin- ciding with croupy cough and the other symptoms of obstruction ; if im- pacted in a bronchus, or one of its subdivisions, the respiratory murmur will FOREIGN BODIES IN THE AIR-PASSAGES. 347 be usually deficient, or quite absent, in the corresponding portion of the lung, and probably puerile on the opposite side, percussion giving an equally clear sound in both localities. Occasionally peculiar rales are due to the nature of the foreign body, as in a case referred to by Gross, in which an impacted plum-stone, perforated tlirough its middle, gave rise to a strange Avhistling sound. Diagnosis___The diagnosis, though often very obscure, may, in most in- stances, be made, by careful inquiry into the history of the case, and investi- gation of its symptoms. From croup the diagnosis can be made, as pointed out by Prof. Gross, by observing that in that affection the dyspnoea is most marked in inspiration, Avhile expiration is most affected in obstruction from a foreign body. Aphonia is, according to the same author, the most trustwor- thy sign of impaction in the larynx, as distinguished from impaction in other portions of the air-tube. From pharyngeal, or oesophageal obstruction, the diagnosis is to be made by careful exploration with the finger and probang. In some cases, by means of the laryngoscope, the foreign body has been act- ually seen lodged in the larynx. Prognosis.—As long as a foreign body remains in any portion of the air- passages, the patient is in imminent danger; the causes of death are suffoca- tion (Avhich may occur at any moment), hemorrhage, inflammation, ulcera- tion, abscess, or simple exhaustion. The annexed summary, taken from Mr. Durham's essay, shows compendiously the results in 554 cases—these being, I belie\*e, the most comprehensive statistics which have yet been published. 1. Cases in which no operation was performed:— Result. Death without expulsion of foreign body..... Spontaneous expulsion of foreign body...... Expulsion after emetics (recorded as useless in 46 cases) Discharge at a late period through thoracic abscess . Total of cases not operated on ... . 2. Cases in which operative measures were adopted:— Operation. Laryngotomy, followed by expulsion..... " not followed by expulsion Tracheotomy............. Laryngo-tracheotomy.......... Direct extraction........... Inversion of body and succussion...... Total of cases operated upon Total number of cases operated upon or not The mortality therefore is, in general terms, as nearly as may be, 1 in 3, the death-rate after operation being less than 1 in 4 (24.8 per cent.), but without operation more than 2 in 5 (42.5 per cent.). The period during which a foreign body may remain in the air-passages, and yet be spontane- ously expelled, varies from a few hours up to many years; in 64 of 124 cases of spontaneous expulsion with recovery, collected by Mr. Durham, this period was between one and twelve months. Total number Re- Deaths. of cases. coveries. 95 95 164 149 15 5 5 7 2 5 271 156 115 14 13 1 3 3 231 170 61 20 15 5 3 3 12 12 283 213 70 554 369 185 348 INJURIES OF THE FACE AND NECK. Treatment___In a case in which the dyspnoea is not urgent, a careful laryn- goscopy examination should be made, and if the position of the foreign body be recognized, attempts may be made to remove it by direct extraction with suitable forceps; the same means may be employed after opening the Fig. 171. Application of the laryngoscope. (Erichsen.) trachea, and will then be more likely to succeed, as the risk of strangulation is removed. Voltolini proposes to search for the foreign body by introducing, through the tracheal wound, a speculum modelled after the ear speculum of Brunton. Inversion and succussion, which, though occasionally successful before tracheotomy, are under such circumstances both dangerous and pain- ful, may, after the operation, be of much service in facilitating the escape of Throat-mirror usod in laryngoscopy. the offending substance. In the large majority of cases the surgeon should, as soon as he is satisfied as to the nature of the case, perform tracheotomy, or if the symptoms be very urgent, laryngotomy, the latter operation being more quickly and more easily accomplished. If the foreign body be noAv found in the larynx, it should be dislodged and extracted, the surgeon, if necessary, dividing the thyroid cartilage in the median line (thyrotomy), or this and the cricoid as well (crico-thyrotomy). If the foreign body be in the trachea or bronchi, it may be immediately expelled through the tracheal wound, or more rarely through the mouth—though in other cases it may not be ejected until several hours or days, or even a much longer period after the operation. There is some difference of opinion, among surgeons, as to the propriety of endeavoring to extract foreign bodies through the tracheal SURGICAL TREATMENT OF APN03A. 349 wound, by means of forceps. Mr. Durham's statistics sIioav, I think, con- clusively, that such attempts are not only justifiable, but eminently proper, 41 cases, in Avhich removal was effected by forceps, having given 39 recoAer- ies. and but 2 deaths, neither of Avhich appears to have been due to the use of the instrument. The best forceps for the purpose are those devised by Prof. Gross (Fig. 173), the blades of Avhich are five inches long, and Avhich, Fig. 173. Gross's tracheal forceps. being made of German silver, can be bent to suit any particular case, while they are so delicate as not materially to interfere Avith the passage of air dur- ing the necessary manipulations. After the exit of the foreign body, the Avound may usually be closed at once, but, if there be much laryngeal irritation, a tube may be introduced for a few days, until this has subsided. Subhyoidean pharyngotomy (see Chapter XXXVIII.) may in some cases be preferred to either laryngotomy or tracheotomy, and has been successfully resorted to in a case of foreign body impacted in the larynx, by Lefferts. Surgical Treatment of Apxcea. Apnoea, or as it is more commonly called, Asphyxia, may arise from various causes, such as droAvning, inhalations of chloroform or of poisonous gases, spasm or oedema of the larynx, or the presence of false membrane, of a morbid groAvth, or of a foreign body in any portion of the air-passages. The surgical operations employed in the treatment of apnoea, are, artificial respi- ration and the various procedures which are included under the general term of bronchotomy. Bronchotomy is applicable to cases in which the air-passages themselves are in any way obstructed; Artificial Respiration to cases in Avhich the air-passages are free, or in which apnoea continues after the per- formance of bronchotomy. Artificial Respiration___This may be effected in several Avays:— 1. Mouth to Mouth Inflation, though objectionable as furnishing air wliich has already been expired, is occasionally the only method Avhich can be em- ployed in an emergency, and may be resorted to, in any case, while more efficient means are being procured. 2. Inflation with Bellows, provided with a suitable mouth or nose piece, may be efficiently used, provided that care be taken to secure expiration by manual compression, and that the instrument be Avorked gently, and not more than ten or twelve times in the minute. 3. Inflation with Oxygen Gas might be tried in extreme cases, or Avhen other means had failed : the gas might conveniently be administered from a bladder, fitted Avith a mouth-piece. 4. Artificial respiration may readily be practised by alternately Compress- ing the Chest and Abdomen with the Hands, to imitate expiration, and then allowing the natural resiliency of the thoracic walls to produce expansion, 350 INJURIES OF THE FACE AND NECK. and thus imitate inspiration. This method is very easily applied, and is par- ticukry suitable in cases of apparent death from chloroform. 5. Silvester's Method, which is that adopted by the Royal Humane Society, of England, consists in placing the patient in a supine position, with the head and shoulders slightly elevated, then grasping the arms above the elboAvs, drawing them gently but steadily upwards till they meet above the head, keep- ing them thus for two seconds, and, finally, bringing them doAvmvards, and pressing them for two seconds more against the sides of the chest. This mani- pulation is to be repeated, fifteen times in the minute, until natural respira- tion is established, or until a sufficient time has elapsed to show that further efforts are useless. 6. Dr. B. Howard's " Direct Method," for cases of apparent death from droAvn- ing, consists in turning the patient downwards with a roll of clothing under the chest and abdomen, and making pressure on the back so as to force the water out of the lungs and stomach ; then reversing the patient's position, putting the roll of clothing under the back, placing his hands together above his head which is kept low, and practising artificial respiration by compressing the lower part of the chest, and letting go with a jerk so as to alloAV the parts to expand by their natural resiliency. 7. Marshall Hall's "Ready Method."—This mode of treatment, which is, upon the whole, probably the best yet suggested, is thus described by its dis- tinguished author, under the name of " Prone and Postural Respiration :"— " (1.) Treat the patient instantly, on the spot, in the open air, exposing the face and chest to the breeze (except in severe weather). "I. To Clear the Throat. " (2.) Place the patient gently on the face, with one wrist under the forehead. [All fluids, and the tongue itself, then fall forwards, leaving the entrance into the windpipe free.} If there be breathing, wait and watch ; if not, or if it fail— "II. To Excite Respiration. " (3.) Turn the patient Avell and instantly on his side, and " (4.) Excite the nostrils with snuff, the throat with a feather, etc., and dash cold water on the face previously rubbed Avarm. If there be no success, lose not a moment, but instantly— "III. To Imitate Respiration. " (5.) Replace the patient on his face, raising and supporting the chest and abdo- men well on a folded coat or other article of dress. " (6.) Turn the body very gently on the side and a little beyond, and then briskly on the face, alternately; repeating these measures deliberately, efficiently, and per- severingly fifteen times in the minute, occasionally varying the side. [When the patient reposes on the chest, this cavity is compressed by the weight of the body, and expiration takes place; when he is turned on the side, this pressure is removed, and inspiration occurs.] " (7.) When the prone position is resumed, make equable but efficient pressure, with brisk movement, along the back of the chest, removing it immediately before rotation on the side. [The first measure augments the expiration, the second com- mences inspiration.] "The result is respiration ; and, if not too late, life ! "IV. To Induce Circulation and Warmth. " (8.) Rub the limbs upwards, with firm grasping pressure and with energy, using handkerchiefs, etc. [By this measure, the blood is propelled along the veins towards the heart.] " (9.) Let the limbs be thus dried and warmed, and then clothed, the bystanders supplying coats, etc. '* (10.) Avoid the continuous warm bath, and the position on or inclined to the back." LARYNGOTOMY AND TRACHEOTOMY. 351 Whatever mode of treatment be adopted, should be perseveringly continued for three or four hours, unless sooner successful; if secondary apnoea come on after apparent recovery, artificial respiration should be again resorted to, together with the application of electricity to the base of the brain and upper part of the spinal cord. Bronchotomy__Under this name are embraced the operations of Laryn- gotomy and Tracheotomy, together with their modifications, Thyrotomy, Crico-thyrotomy, and Laryngo-tracheotomy', the names of which sufficiently express their nature. 1. Laryngotomy__In this operation the windpipe is opened through the crico-thyroid membrane. The larynx being steadied between the thumb and fingers of the left hand, the surgeon makes a longitudinal incision of about an inch, in the median line, over the lower half of the thyroid cartilage, the crico-thyroid space, and the cricoid cartilage. The sterno-hyoid muscles being now separated, and the intervening fascia and connective tissue divided to the full extent of the cutaneous Avound, the knife is at once thrust, Avith its edge upwards, through the crico-thyroid membrane and its mucous lining, into the larynx. The opening is then enlarged transversely as much as may be required, and the tube introduced. The only vessel likely to be cut is the crico-thyroid artery, Avhich should, as a rule, be secured before opening the larynx. This operation, which is by no means difficult, may be performed either Avith or without the aid of anaesthesia, the patient being in a recum- bent position, with the head throAvn backAvards, and the neck rendered promi- nent by means of a pillow beneath the nucha. 2. Tracheotomy__In this operation tAvo or more of the tracheal rings are divided, or an elliptical portion of their anterior face cut away. The patient being in the position already described, and preferably under the in- Fig. 174. Tracheotomy. (Liston.) fluence of an anaesthetic, the surgeon, standing at his left side, or, which I prefer, at his head, makes a longitudinal median incision, extending from the bottom of the cricoid cartilage to an inch and a half or more below, according to the length of the neck. The subcutaneous fat and areolar tissue are simi- larly divided, care being taken to avoid any superficial veins; the sterno- 352 INJURIES OF THE FACE AND NECK. hyoid and sterno-thyroid muscles being then cautiously separated Avith the handle of the knife, or Avith the director, the trachea, crossed by the isthmus of the thyroid gland, is exposed. The trachea may be opened above, through, or below the thyroid isthmus, the first being, in the case of children espe- cially, the point to be preferred ; if it be necessary to cut through the isthmus, a ligature must be first applied on either side of the point of division. Hemoi- rhage having been arrested, the surgeon draAvs fonvards the trachea with a single or double tenaculum, and thrusting in his knife, edge upAvards, divides the necessary number of rings. The tube is then at once introduced, and, when the respiration has become tranquil, the surgeon may, if it be thought proper, temporarily remove it, and proceed to cut away an elliptical portion of the front wall of the trachea ; this step, though not, I think, in itself objec- tionable, is, hoAvever, seldom necessary. The above description presupposes that the surgeon has time to make a careful dissection of the superincumbent parts, before opening the windpipe— and, in the immense majority of instances, enough time is afforded for this purpose. I believe, however, Avith Mr. Durham, that cases are occasionally met with, in which it is very important to hasten the steps of the operation ; and, in such an emergency, would recommend a plan described by that author, and which he assures us he has advantageously employed in nineteen instances. In this method the operator (standing on the patient's right side) places the forefinger of the left hand on the left side of the trachea, and the thumb on the right, pressing steadily backwards until he feels the pulsation of both carotid arteries. By slightly approximating the finger and thumb, he feels that the trachea is firmly and securely held between them, and knows that the safety of the great vessels is insured, Avhile the tissues over the wind- pipe are rendered tense. The finger and thumb thus placed are not to be moved until the trachea is reached. By a succession of careful incisions, the surgeon noAV cuts boldly down on the Avindpipe, the finger and thumb on either side helping him to judge of the position of the median line (from which the knife must not deviate), and, by their pressure, causing the wound to gape, and the trachea to advance. The forefinger of the right hand is passed from time to time into the Avound, to make sure that no important ves- sel is in the Avay, and Avhen the trachea is reached the knife is introduced (guarded by the right forefinger), or the windpipe may be seized with a tenaculum and opened as in the ordinary operation. The chief danger from tracheotomy is from hemorrhage; instances are on record in Avhich the carotid, or even the innominate, artery has been wounded, Avhile fatal bleeding has not unfrequently occurred from the division of large veins. Arterial hemorrhage should, of course, be checked before opening the trachea, and bleeding veins should also be secured, provided that death from suffocation be not likely to occur Avhile this is being done. It must be remem- bered, however, that the venous congestion is due, in great measure, to the obstruction of the patient's breathing, and will be lessened as soon as free respiration is established ; hence the surgeon should not fear, if necessary, to open the windpipe even Avhile venous bleeding continues, introducing the canula, as has been forcibly said, " even through a very pool of blood." In order to avoid the risk of hemorrhage, Verneuil, Bourdon, and FoAAder, of Brooklyn, recommend the use of a knife heated by the galvanic cautery,1 and report several cases in Avhich tracheotomy has been thus bloodlessly per- 1 Amussat had previously employed the galvanic cautery, dividing the trachea from within outwards with a platinum wire previously introduced by means of a curved needle. Paquelin's thermo-cautery has been recently employed in trache- otomy by Poinsot, of Bordeaux. AFTER-TREATMENT OF CASES OF BRONCHOTOMY. 353 formed. I cannot but doubt, Iioavca er, Avhether this mode of treatment Avill ever supersede the ordinary operation with the simple scalpel. Laryngo-tracheotomy is, as its name implies, a combination of laryngotomy, with tracheotomy above the thyroid axis. Its mode of performance requires no special description. After-treatment of Cases of Bronchotomy__In almost all cases, except those of foreign body in the air-passages, it is necessary to introduce a tracheal canula or tube, Avhich must be worn until the poAver of breathing through the larynx Fig. 175. is restored. The tube should be made of silver, with a curve of rather less than a quarter of a circle, double, so that the inner canula may be removed and cleansed, Avhile the outer retains its position, the tAvo being secured by means of a button attached to the neck-plate of the outer one. The neck-plate itself should be so ar- ranged as to alloAv the canula to move freely with the motions of the trachea, and the inner tube should project beyond the outer one for about a quarter of an inch, at either extremity. Tracheal tube. The canula should be from tAvo to three inches in length, and, as advised by Mr. Howse, as large as can be conA'eniently in- troduced into the trachea. For use after laryngotomy the canula mav be a little flattened, the transverse being someAvhat greater than the antero-pos- terior diameter of its section. The canula above described, which embraces the improvements of both Obre and Roger, is, I think, preferable to either the ordinary double tube, or the bivalve canula of Fuller. Mr. Durham has suggested a still further modification, by which the length of the tube can be regulated, by means of a screw, to meet the emergencies of any particular case. To facilitate the introduction of the tube, the edges of the wound may be held apart Avith two- or three-bkded dilating forceps, or, which is better, a blunt-pointed pilot trocar, as suggested by Dr. Gairdner, or a fenestrated tubular trocar, as employed by M. Pean, may be thrust in Avith the canula, to be withdrawn, of course, as soon as the latter is in place. Mr. Durham employs a " lobster- tailed" trocar, constructed on the same principle as Squire's " vertebrated" catheter. Flexible tubes are used by Mr. Morrant Baker. The canula being introduced, is held in position by tapes, attached to the neck-plate, and fastened around the neck. During the whole course of after- treatment, the atmosphere of the room should be kept moist and warm (about >So° Fahr.) ; the inner tube should be frequently removed and cleansed, and if the operation have been done for pseudo-membranous croup or diphtheria, lime-water or dilute carbolic acid may. from time to time, be vaporized through the tube Avith an atomizer. The expectorated matters should be constantly wiped aAvay, and accumulations of mucus or false membrane re- moved Avith a camel's-hair brush, feather, or " elbow-forceps." As soon as the canula can be safely dispensed Avith, it may be removed, but this should not be done permanently until, by leaving it out for several hours at a time, it has been proved that the function of the larynx has been restored. If it be necessary to perform bronchotomy in an emergency, and when a tracheal canula cannot be obtained, the surgeon must have recourse to excis- ing an elliptical portion of the tracheal Avail, and keeping the edges of the wound apart with retractors made of bent Avire (the hooks of ordinary large '* hooks and eyes" Avill answer), secured by an elastic band passing behind 23 354 INJURIES OF THE FACE AND NECK. the neck. If apnoea persist after a free opening has been made into the Avind- pipe, the surgeon must at once resort to one or other of the methods of prac- tising artificial respiration already described. Dr. Beverley Robinson, of NeAV York, has devised an ingenious " insufflator," by means of Avhich the surgeon can directly inflate the patient's chest through the tracheal tube, without incurring any risk from contact with the secretions of the part. This instrument or a double-acting belloAvs, as recommended by Dr. B. W. Rich- ardson, should be employed in case suffocation is threatened by false mem- brane accumulating beloAV the opening in the trachea; or, if neither of these be at hand, an ordinary hand-ball syringe (reversed) may be used, as sug- gested by Dr. Green, of Brooklyn. Choice of Operation__The relative advantages of laryngotomy and tracheotomy are still a matter of dispute among practical surgeons. Trache- otomy is preferred in all cases by Mr. Marsh, and laryngotomy, or laryngo- tracheotomy, by Mr. Holmes, especially among children. Mr. Erichsen recommends laryngotomy for adults, and tracheotomy, above the thyroid isthmus, for children ; Avhile Mr. Durham considers that the advantages of opening the trachea below the isthmus, as compared Avith its risks and diffi- culties, are greater than those afforded by making the opening higher up. While I do not believe that any rule of universal application can be safely laid down upon this question, I would advise, in general terms, that trache- otomy above the isthmus should be preferred, in all cases in Avhich time is afforded for a careful and deliberate operation, but that if great haste is essen- tial, laryngotomy, which may readily be converted subsequently into laryngo- tracheotomy, should be performed instead. When the operation is required by the presence of a foreign body in the windpipe, a more definite rule may be given. If the offending substance be lodged in the larynx, that part itself must usually be opened, though Dr. Lefferts, of Xew York, has under these circumstances successfully employed Malgaigne's and Langenbeck's operation of sub-hyoidean pharyngotomy (see Chap. XXXVIII.), but if the foreign body be in any other part of the air-passages, tracheotomy is the operation to be chosen. The risks of tracheotomy, per se, are not very great, death in fatal cases usually resulting from a continuance of the disease rather than from the operation. I have myself been so fortunate as to save three out of four cases. Injuries of the (Esophagus. Wounds.—These have already been alluded to in describing penetrating wounds of the neck, the treatment of Avhich injuries is complicated by the oesophageal wound, through the difficulty thence arising in administering the necessary amount of nutriment. A patient Avith wound of the gullet, may be fed through an elastic gum catheter, introduced through the mouth, or, if, with suicidal intent, he refuse to separate the jaws, through the nose. By this means a pint of beef-essence, or of " eggnog," may be introduced tAAro or three times a day, until the poAver of deglutition returns. If the Avound is above the position of the larynx, suffocation may occur from the superven- tion of oedema of the glottis—an accident which would call for the immediate performance of laryngotomy. Rupture of the (Esophagus is a rare form of injury of which Charles, of Belfast, has collected 15 cases; to these may be added one observed by Dr. William Hunter, and others recently reported by Dr. J. S. Bailey, of Albany, and Dr. G. 0. Allen, of Boston. The accident has usually occurred INJURIES OF THE OESOPHAGUS. 355 during the act of vomiting, and the symptoms are intense pain with collapse, followed by death in the course of a fe-Av hours. According to Fitz, the affection is still rarer than Avould be indicated by the above figures, many of the reported cases being, in the opinion of this author, really instances of post-mortem softening and perforation. Foreign Bodies in the Pharynx or (Esophagus.__Foreign bodies not unfrequently become impacted in some portion of the food-passage (usually, according to H. Allen, either at the position of the cricoid cartilage, or just above the crossing of the left bronchus), and produce not only great irritation and difficulty of swallowing, but may even induce suffocation by pressure on the Avindpipe. The symptoms vary Avith the nature, size, and position of the foreign body. A fish-bone, bristle, or pin may be caught betAveen the tonsil and half-arches of the palate, and give rise to much dis- comfort, with tickling cough, dysphagia, and nausea. A pointed body in this situation may even perforate an important vessel, and thus cause death by hemorrhage. A bolus of food, arrested at the summit of the oesophagus, may suffocate the patient by pressure on the larynx; or, again, a hard body, such as a bone or tooth-plate, may, if impacted, produce ulceration of the oesophageal Avails, and penetrate into the larynx, or other important structures in the neighborhood. The diagnosis is usually sufficiently evident from the sensations of the patient, but in any case of doubt, the surgeon, besides carefully inspecting the pharynx in a good light, should SAveep his finger around the part as far as he can reach, and cautiously explore the oesophagus Avith a well-oiled pro- bang. In some cases the laryngoscope may be used to facilitate the exami- nation of the upper portion of the gullet. Though the foreign body can thus usually be discovered, if present, a small substance, such as a fish-bone, may, from the peculiarity of its position, elude detection even after careful and repeated exploration ; on the other hand, the sensations of the patient may continue to indicate the impaction of a foreign body for a long period, Avhen none is really present, and cesophagotomy has actually been performed, on more than one occasion, Avithout any substance being found Avhich could account for the patient's symptoms. Fig. 176. Burge's oesophageal forceps. Treatment—If suffocation be threatened, unless the foreign body can at once be seized and removed, tracheotomy should be resorted to Avithout delay. In every case an effort should be made to extract the foreign body through the mouth, and this can usually be done, either by simply hookin°- it out Avith the finger (if lodged in the pharynx), or by the cautious use of oeso- phageal forceps, or of the horsehair, or SAvivel probang (Fig. 177). Dr. Lamm, a SAAredish surgeon, has succeeded in Avashing out a foreign body from the oesophagus by syringing through a flexible catheter. If the foreign body be of such a nature that it will not be likely to produce injurious con- sequences in the stomach and boAvels, as a lump of meat or even a small coin, it may, if its extraction prove difficult, be pushed onwards into the 356 INJURIES OF THE FACE AND NECK. Fig. 177. stomach, with a sponge or ivory-headed probang.1 If, as occasionally though rarely happens, a foreign body in the gullet can be neither extracted, nor other- wise disposed of, it should be removed through an external incision, by the operation known as pharyn- gotomy or oesophagotomy. (Esophagotomy__If the foreign body can be felt externally, the operation should be done on that side Avhich is the most prominent; otherwise the left side is to be chosen, as the oesophagus naturally inclines someAvhat in that direction. The patient should be anaesthetized, and placed in a supine posi- tion, Avith the head and shoulders a little raised, and the face someAvhat averted. An incision, four or five inches long, is made in the space betAveen the trachea and the sterno-mastoid muscle, beginning above, on a level Avith the top of the thyroid cartilage. This incision is cautiously deepened, the omo-hyoid mus- cle, and the outer fibres of the sterno-hyoid and sterno-thyroid, being divided if necessary ; the carotid sheath is carefully drawn outwards, and held with a blunt hook, the trachea and thyroid gland being similarly draAvn inwards. If the foreign body can noAv be felt, the oesophagus may be incised directly upon it; otherwise a sound or curved forceps should be introduced through the mouth, and made to pro- ject in the wound, thus affording a guide to the point at Avhich the gullet should be opened. The incision may be subsequently enlarged, either upwards or downwards, and the foreign body extracted Avith the finger or forceps. Special care must be taken, in this operation, not to Avound either the inferior thyroid artery, or the recurrent laryngeal nerve. The incision should be alloAved to heal by granulation, the patient being fed through a catheter, as after an accidental wound of the oesophagus. This operation is essentially that Avhich has been successfully performed by Syme, Cock, and Cheever, and seems to me in every Avay preferable to that by a median incision, Avhich is recommended mI°^rhairPr0bang'°r*a" b^ N61aton- The results of oesophagotomy for the removal of foreign bodies are quite encouraging, .'J3 cases to Avhich I have references having given 20 recoveries and only 7 deaths. 1 An English surgeon, Dr. SteAvart, has recorded a case inAvhich a live fish was thus successfully disposed of. CONTUSIONS OF THE CHEST. 357 CHAPTER XVIII. INJURIES OF THE CHEST. Contusions. Contusions of the Thoracic Parietes, Unaccompanied by Visceral Injury, are usually of but trifling importance ; if there be much pain attending the act of respiration, the surgeon should fix the injured side with broad strips of adhesive plaster, precisely as in a case of fractured ribs. An occasional consequence of severe contusion of the chest, is the formation of an abscess beneath the pectoral muscle ; suppuration in this situation may continue for a considerable time Avithout being recognized, pointing at last probably in the axilla. The local symptoms are necessarily obscure, con- sisting mainly in great pain, and general swelling of the whole pectoral region; should, however, these symptoms follow an injury, and coincide Avith the constitutional evidences of the existence of deep-seated suppuration, the proper treatment would be to cut doAvn in the direction of the muscular fibres, enlarging the exploratory incision subsequently, as much as might be necessary. Contusion, Accompanied by Rupture of the Thoracic Viscera, Avithout fracture, and without external wound, is a rare and dan- gerous accident, Avhich may result from the contact of a spent ball or piece of shell, from being run over, from falls from a height, etc. Rupture of the Lung has been occasionally obsened, under these circum- stances, and cases are recorded by Saussier, Gosselin, and Da Costa, in which, in spite of the severity of the injury, the patients recovered. The symptoms are those of Avounded lung—pneumothorax, Avith, perhaps, emphy- sema, haemothorax, haemoptysis, and, at a later period, pleurisy and pneumonk, Avith accumulation of pus or serum in the pleural cavity. The mechanism of the lesion in these cases is, doubtless, as pointed out by Gosselin, that, at the moment of injury, the lung is distended by inspiration, and the glottis spas- modically closed, thus preventing the lung from yielding to the sudden pres- sure. I have seen tAvo cases of this kind, one at the Pennsylvania Hospital, under the care of Drs. E. Hartshorne and C. C. Lee, in which the left lung was ruptured and which proved fatal on the third day, and another Avhich was under my oavii care at the Episcopal Hospital, in which the injury affected the right lung, death following on the fifth day. In the latter case the rupture Avas superficial, and there Avas no haemoptysis, though the symp- toms of haemothorax, pneumothorax, and pleurisy, Avere well marked. This rare form of injury is chiefly met Avith in young persons. It appears to be less fatal in military than in civil life; 21 cases which I have collected, and which resulted from various forms of violence other than gunshot injury, bavin a given only 7 recoveries, Avhile 2o cases recorded by Dr. Otis as having oc- curred during our late Avar gave 11 recoveries. The treatment of this form of injury is that vvhich will be presently described as appropriate to Avounds of the lung. Rupture of the Heart, under similar circumstances, is, I believe, inva- riably, though not ahvays instantly, fatal. Gamgee has collected 28 cases of 358 INJURIES OF THE CHEST. rupture of this viscus (including one observed by himself) in 9 of Avhich there was no fracture, and " either no bruise of the thoracic parietes or a very slight one." The pericardium Avas intact in at least half of the cases, and of 22, in which the precise seat of lesion Avas noted, the right ventricle Avas rup- tured in 8, the left in 3, the left auricle in 7, and the right in 4. The longest period during which any patient survived the injury Avas fourteen hours. Barth has collected 24 cases of spontaneous rupture of the heart (i. e., not traumatic), and in every instance the seat of the lesion Avas in the left ven- tricle;1 in some of these cases the cardiac Avail appears to have given Avay by repeated slight lacerations, death not having ensued in some instances for several (2-11) days after the first manifestation of serious symptoms. Concussion of the Lung.—Le Gros Clark has described as a "serious functional derangement Avithout organic lesion," a condition of the lung, resulting from external violence, and very analogous to concussion of the brain ; the symptoms are dulness on percussion, with diminished respiratory murmur, on the injured side, and puerile respiration on the other, attended with great dyspnoea, but Avithout cough or expectoration. The symptoms disappear in so short a time (forty-eight hours) as to forbid the idea of any very serious organic lesion. Other Complications, which are sometimes met Avith in connection with contusions of the chest, are Pleurisy and Pneumonia, Carditis and Pericarditis, Cerebral Congestion, from interference Avith the respiratory function, as when a man is partially buried beneath a falling bank of earth, and Inflammation and subsequent Suppuration in the Mediastina. It has been proposed to trephine the sternum, in order to evacuate an abscess in the anterior mediastinum, but the symptoms, Avhile suppuration was confined to the substernal region, could hardly be sufficiently distinct to Avarrant the operation, Avhile it would, of course, be unnecessary if the abscess pointed on either side. Wounds. Non-penetrating Wounds of the chest usually present no features of special interest. The surgeon should be very cautious in his examination of these injuries, lest he should unfortunately convert the Avound into one of the penetrating variety. Hence the finger should be used in preference to the probe, and if foreign bodies are to be removed, this should be done with the utmost gentleness. The diagnosis must be founded chiefly on the absence of those symptoms Avhich attend penetrating Avounds, though certain of these (as haemoptysis) may be present, Avithout the thoracic cavity being directly hwolved. It is said by Mr. Poland, and some other writers, that traumatic emphysema may accompany non-penetrating chest wounds, the air being, as it Avere, sucked into the subcutaneous areolar tissue, by the motion of the thoracic walls in respiration ; but Avhile I would not deny the possibility of such an occurrence, it must at least be extremely rare, and the presence of emphysema must certainly be considered as strong presumptive evidence that the pleural cavity is implicated. The treatment of these injuries must be conducted on those principles Avhich guide the surgeon in the management of similar wounds in any other part of the body; advantage may often be derived (especially in cases of oblique punctured or gunshot Avounds, burrow- ing subcutaneously for a considerable distance) from the use of broad adhe- 1 Spontaneous rupture has, however, been observed by Dr. Beckett in the right auricle and by Dr. Lansing in the right ventricle. WOUNDS OF THE PLEURA AND LUNG. 359 sive strips, to fix the chest, and thus lessen the chance of the formation of a fistulous track, the presence of Avhich would greatly delay recovery. Xon-penetrating Avounds of the chest may be attended with troublesome and even dangerous hemorrhage, from lesion of an intercostal, or of the internal mammary, artery, though these vessels are more frequently involved in cases of penetrating wound. The treatment Avould consist in the use of ligatures, or, if these could not be employed, in the application of a compress and firm bandage. Penetrating Wounds__These may be best studied by considering in succession—1. Wounds of the pleura and lung; 2. Those of the pericardium and heart; 3. Those of the aorta and vena cava; and 4. Those of the ante- rior mediastinum. 1. Wounds of the Pleura and Lung__The costal pleura alone may be Avounded, the pulmonary pleura and lung being uninjured. This is more apt to occur with incised wounds than with those of any other variety. There is no symptom, however, on Avhich the surgeon can rely, to distinguish these cases from those in which the pulmonary tissue itself is involved, and which are certainly of more frequent occurrence. A Avound of the lung may exist as a complication of fracture of the ribs, as was mentioned in a preAdous chapter; the injury in such a case, being of the nature of a subcutaneous lesion, is of a less serious character than a wound communicating Avith the external air. Symptoms___These are usually well marked. The shock is in most cases very decided, there is great dyspnoea (the respiration being chiefly diaphrag- matic), with jwtn'ra at the seat of injury, and a short, tickling cough which is very distressing to the patient. Haemoptysis is usually, but by no means invariably, present, the expectorated matter being frothy mucus mixed with blood, or more rarely pure blood in considerable amount. Emphysema and pneumothorax (the former consisting in the diffusion of air through the areolar tissue, and the latter in an accumulation of air in the pleural cavity) are very constant symptoms of lung wounds, though they may accompany wounds involving the pleural cavity only; emphysema, indeed, according to some Avriters, being met Avith in cases of non-penetrating Avound. Tromatopncea is, perhaps, more characteristic than any other single symptom of a Avound of the lung, though I have witnessed it in cases in Avhich there Avas every reason to believe that the pleura alone Avas injured, and it is said by Fraser to be occasionally present in Avounds in which even the pleural cavity is entirely unhurt; it consists, as its name implies, in air passing in and out of the wound during the act of respiration. External hemorrhage is of course present in greater or less amount in every case of penetrating Avound of the chest, but a more serious symptom is hemorrhage into the pleural cavity, giving rise to the complication knoAvn as hemothorax. Hernia of the lung, pneumocele, or pneumatocele is a rare sequence of penetrating wounds of the chest, and is more apt to occur after cicatrization of the external Avound, than as a primary phenomenon. Pneumonia and pleurisy, in the ordinary sense of these Avords, are very seldom metAvith, though inflammation, limited to the track of the wound, probably occurs in most cases of lung wound which are not rapidly fatal, effusion of serum and empyema being occasional and very grave complications of the later stages of the injury. Collapse of the lung is probably a less frequent occurrence in penetrating chest Avounds than Avas formerly supposed. It appears, when present, to depend upon the compression caused by pneumothorax, or by the various forms of liquid effusion. 360 INJURIES OF THE CHEST. Diagnosis—This can commonly be made without difficulty, by noting the presence or absence of the various symptoms above enumerated. It is to be observed, however, that no one of them is in itself pathognomonic, and the warning cannot be too often repeated, that no exploration Avith a probe or finger should be made in any case of doubt. Prognosis.—The prognosis in any case of wound of the lung should be very guarded, at least during the first three days, though in a person of healthy constitution, with care and judicious treatment, recovery may often be obtained. Of the different Aarieties of Avound, the incised or punctured are less dangerous than the lacerated and contused, and, of gunshot Avounds, those which are perforating, or through and through, give more favorable results than those Avhich are merely penetrating, the missile or other foreign body lodging in some part of the thoracic cavity. The mortality after gun- shot Avounds of the chest, accompanied by lesions of the thoracic viscera, Avas, in our army during the late war, nearly 63 per cent. Wrounds of the root of the lung are much more fatal than those of the surface. Treatment.—Under this head I shall first describe the treatment applicable to lung Avounds in general, considering afterwards such modifications as may be required by those conditions which are sufficiently important to be regarded as complications. The Local Treatment \raries according to the nature of the wound. If it be incised or punctured, the external opening should be, as a rule, immediately closed Avith sutures, and covered Avith a compress and bandage, Avhich should not be removed for at least five or six days. By this time, in a favorable case, the visceral lesion will have been repaired, and, if the external wound itself have not united, it Avill have been converted into a comparatively superficial injury. In the case of a gunshot wound, as the part will necessarily slough, the surgeon should content himself Avith removing all foreign bodies that can be discovered without dangerous interference, then applying a light dressing, of wet lint, or some similar substance. Dr. B. IloAvard, reviving an old suggestion, has proposed, under the name of " her- metically sealing" chest wounds, to pare the edges, thus converting the external opening into an incised AA'ound, and then to bring the edges together with sutures and collodion. The records of the Surgeon-General's Office, however, sIioav that, though ingenious in theory, this method is unsuccessful in practice, 42 out of the 69 cases in which it Avas tried during our late war, having certainly pro\red fatal, and but 3 of the remaining 27 being looked upon by Dr. Otis as authentic instances of complete and permanent recovery. Whatever be the nature of the wound, great comfort may often be afforded the patient by fixing the injured side of the thorax Avith broad strips of adhesive plaster, an opening being of course left opposite the wound. If haemoptysis be present, ice should be freely applied to the chest. With regard to the Constitutional Treatment appropriate to cases of wound of the lung, considerable difference of opinion at present exists among practical surgeons. Until within a few years it Avas customary to advise venesection in almost all cases, both to arrest haemoptysis and as a prophylactic against subsequent pneumonia. Absolute diet was invariably directed, and antimony or mercurials administered on the first suspicion of inflammatory action. The credit of the first formal protest against the common practice of venesection in these cases is due, I believe, to Dr. Patrick Fraser, avIio gave the results of extended personal observation during the Crimean Avar, in an interesting monograph, published in 1859. The correctness of the views Avhich Dr. Fraser advanced have been amply confirmed by the experience of military surgeons since that time, and, for my oavu part, I can testify that, in civil practice, I have found no reason to adopt a different mode of treatment from that Avhich has proved successful in the surgery of Avar. " In the treatment WOUNDS OF THE PLEURA AND LUNG. 361 of penetrating Avounds of the chest," says the author of Circular No. 6, "• venesection appears to have been abandoned altogether. Hemorrhage Avas treated by the application of cold, perfect rest, and the administration of opium. These measures seem to have proved adequate generally, and no instances are reported of the performance of paracentesis or of the enlarge- ment of wounds for the evacuation of effused blood." Still more emphatic language is used by Confederate Surgeons :— "Equally unphilosophical and more injurious, in our opinion, than even the use of the last class of sedatives [antimonials], is the time-honored absurdity of venesection. It comes to us embalmed in the dicta of 'the highest authority,' and consecrated by the owlish wisdom of ' the ancients,' and, until recently, the precept has met with sub- missiA-e and unquestioning acquiescence. We are gratitied to find that in all the cases of arterial hemorrhage collected in the office of the inspector, not one is reported Avherein the expedient was practised by a surgeon of the Confederate States.......For traumatic pulmonary hemorrhage the measure appears to us not only hazardous, but actually injurious."1 The constitutional treatment Avhich I would recommend, in any case of wound of the lung, Avhether from gunshot or other form of injury, consists in the adoption of those measures which are adapted to facilitate the work of nature in the reparative process. Profound quiet and rest, both physical and mental, should be rigidly insisted upon. The diet should consist of such sub- stances as are most easy of digestion, and which are yet sufficiently nutri- tious. Milk is probably here, as in other severe injuries, the most generally suitable article of food. Opium should be freely administered in almost all cases, its constipating effect being obviated by the occasional use of mild laxatives or simple enemata. Diaphoretics may be employed if there be marked febrile reaction, and if pneumonia or pleurisy occur, they may be treated as if idiopathic affections, it being remembered that the inflammation in these cases is usually limited to the immediate neighborhood of the seat of injury, and is indeed a part of the natural process by Avhich the existing lesion is to be-repaired. Beef-tea and even brandy Avill, according to my experience, be more often required in cases of lung Avound than calomel or antimony. Complications___The complications of Avounds of the lung which require special consideration, are (1) hemorrhage (which may be external or into the pleural sac), (2) pneumothorax and emphysema, (3) hernia of the lung tissue, and (4) serous or purulent accumulations in the cavity of the pleura. (1.) Hemorrhage may arise from a Avound of the lung itself, or of an inter- costal, or the internal mammary, artery: if from a lesion of an intercostal artery, the surgeon should enlarge the external Avound, and, if possible, secure the injured vessel Avith double ligatures ; if this be impracticable, compres- sion must be employed, either by means of Desault's compress, or serrefines, or, if these will not suffice, by means of manual pressure. Desault's com- press, Avhich is Avell spoken of by Otis, consists of a piece of strong linen or muslin, pressed through the Avound, stuffed Avith lint or charpie, and then draAvn outAvards against the rib. It has been proposed to facilitate ligation of an intercostal artery by first excising a portion of the adjacent rib, but unless a fracture or other injury of the rib itself rendered such an operation necessary (p. 242), I should scarcely think the surgeon justified in its per- formance. Hemorrhage from the internal mammary artery should be treated by ligation of that vessel, Avhich in the upper intercostal spaces may be reached by an oblique incision, from ^ to \ an inch from the border of the 1 A Manual of Military Surgery, prepared for the use of the Confederate States Army, page 97. Richmond, 1863. 362 INJURIES OF THE CHEST. sternum, the costal cartilages being, if necessary, divided so as more fully to expose the artery. If hemorrhage proceed from a wound of the lung itself, the blood may escape at the cutaneous orifice, may be coughed up through the air-passages, or may accumulate in the cavity of the pleura, giving rise to the condition knoAvn as hemothorax. This condition may also arise, though more rarely, from wounds of the intercostal or internal mammary arteries. The rational symptoms of hemothorax are those Avhich character- ize loss of blood in general, such as faintness, dizziness, and pallor, with dis- turbance of the respiratory function, dyspnoea, restlessness, etc. None of these are, however, in any degree pathognomonic, and death from hamiothorax may take place, Avithout the previous occurrence of any symptom certainly indi- cative of Avound of the lung. The physical signs, when present, are more trustAVorthy; they consist of enlargement of the injured side of the chest, with bulging of the intercostal spaces ; absence of respiratory murmur, and dulness on percussion—gradually increasing in extent, and the line of dulness varying with the posture of the patient; the sensation of a Avave of fluid, or of splashing, felt by the patient, or transmitted to the hand of the surgeon on succussion ; and finally, according to Valentin and Larrey, oedema and ecchymosis in the lumbar region. All of these signs, except the last (Avhich is by no means constant, and is, indeed, looked upon by Fraser and Otis as somewhat apocryphal), may be equally present in cases of serous, or of puru- lent accumulation, and hence it is only by their appearance immediately after the injury, and in coincidence with other signs of hemorrhage, that the surgeon can satisfy himself as to the nature of the case. The treatment of hemorrhage, from wound of the lung, Avould consist in closing the external Avound by means of a firm compress, in the application of ice, and in the administration of opium and ergot, with perhaps digitalis or veratrum viride ; by these means, in a favorable case, coagulation of the effused blood, and sub- sequent occlusion of the bleeding vessels, may be obtained, the clot being gradually absorbed, and the patient recovering without further trouble ; if, however, the bleeding continue into the pleural sac, as marked by increased dulness on percussion, with dyspnoea, and the other symptoms of hemothorax above enumerated, the original wound must be reopened, or, if it have already healed, paracentesis must be performed, as in a case of empyema. (2.) Pneumothorax and Emphysema usually coexist in the same case, though either may be present without the other. By the act of inspiration the air is sucked into the pleural cavity, either through a cutaneous wound or from the ruptured air-vesicles of the lung, Avhile in expiration, the orifice by which the air entered being closed by the valve-like action of the sur- rounding structures, it is pumped into the areolar tissue, pneumothorax thus usually preceding emphysema. If, however, there be old pleural adhesions, or if the external wound correspond exactly with that in the lung, the air may pass directly in and out (tromatopnosa), without invading either the pleural sac or the planes of connective tissue. Pneumothorax alone may result from rupture of the lung, without injury of the costal pleura, while emphysema alone may result from puncture of the lung through an old pleural adhesion, from rupture of an air-cell or bronchus into the posterior medias- tinum (according to Hilton), or possibly, as taught by Poland and others, from a non-penetrating wound of the chest. Pneumothorax is marked by great resonance on percussion, with absence of the respiratory murmur, by amphoric respiration, and occasionally by metallic tinkling; if excessive, it produces much dyspnoea. Emphysema is characterized by a diffuse, puffy, colorless, perfectly elastic swelling, crackling under pressure; it can scarcely be mistaken for any other condition. It is very seldom that either of these complications requires special treatment. Pneumothorax, if existing on both WOUNDS OF THE PLEURA AND LUNG. 363 sides, might threaten suffocation, and the proper treatment in such a case would be to evacuate the contained air by puncturing the chest Avith an aspirator or A*ery small trocar, closing the wound immediately afterAvards with a strip of adhesive plaster. Emphysema, if very extensive, might require the application of a bandage, or even scarification of the most distended parts. (3.) Hernia of the Lung—This rare form of accident, of Avhich Desfosses has collected twenty examples, six occurring spontaneously and fourteen con- secutively, or as the result of injury, may occur as a subcutaneous lesion, the result of crushing violence to the chest, or even, it is said, of straining efforts during parturition. It may also occur in the site of a cicatrix, as in an instance mentioned by Velpeau. The tumor under these circumstances is soft, someAvhat circumscribed, elastic, compressible, increasing in expiration and diminishing in inspiration, communicating a distinct impulse on coughing, crepitating Avhen handled, and measurably disappearing Avhen the patient holds his breath ; the tumor is resonant on percussion, and the seat of a loud respiratory murmur; the limits of the aperture through which it has escaped, may often be distin- guished by palpation. The treatment consists in effecting and maintaining reduction, by means of a compress and bandage, if this be possible, and if not, in the application of a concave pad, so as to protect the part from injury, and prevent further protrusion. Hernia of the lung sometimes takes place through an open wound, usually in the neighborhood of the nipple: if the projecting lung tissue be healthy, it may be cautiously pushed back, the ori- fice through Avhich it escaped being slightly enlarged if necessary; if gan- grene have occurred, however, the protrusion should not be interfered with, the part being left to be removed by sloughing. (4.) Hydrothorax and Empyema, the former term denoting a collection of serum, and the latter one of pus, in the pleural sac, are occasional complica- tions of the later stages of Avounds of this part. The symptoms are those of chronic pleuritic effusion, from Avhatever cause (the physical signs being the same as those Avhich Avere mentioned in speaking of hamiothorax), and the diagnosis is to be made, principally, by observing the later period of occur- rence and the more gradual increase of the symptoms, and, in the case of empyema, the tendency which is sometimes manifested to the formation of an external opening. Empyema, according to the elder Pepper and other au- thors, is particularly marked by bulging of the loAver intercostal spaces, and dilatation of the superficial veins ; but BoAvditch doubts the possibility of more than suspecting the nature of pleuritic effusions, before operation, and founds even this suspicion, mainly, on the previous history of the case. Ac- cording to Baccelli, of Rome, and CheAv, of Baltimore, feebleness or absence of the vocal and respiratory sounds is indicate of the presence of pus, dense fluids transmitting vibrations less readily than others. It is doubtful if any advantage is to be obtained, in the treatment of these cases, from the use ot medicines designed to promote absorption, such as are employed in the cases of chronic pleuritic effusion Avhich come under the observation of the phy- sician ; hence, in any case in Avhich the accumulation is so great as to give manifest tokens of its presence, the surgeon should have recourse to the ope- ration of Paracentesis, Avhich should be performed before the lung has become so bound down by adhesions, as to have lost the poAver of expanding when the source of pressure is removed. Paracentesis Thoracis___Before resorting to this operation, the surgeon should confirm his diagnosis by the use of an exploring trocar and canula, or, Avhich is perhaps better, an aspirator or a long-nozzled hypodermic syringe, by Avhich a small portion of the accumulated fluid may readily be obtained for examination. The particular operation to be chosen depends someAvhat upon the nature of the effusion; if this be serous, the opening should be a small 364 INJURIES OF THE CHEST. one, and it is here important to guard against the admission of air, by using the suction trocar proposed by Dr. Wyman and modified by Dr. Bowditch, the aspirator of Dieukfoy, Kasmussen, or Potain, or, if none of these be at hand, a trocar fitted with a stopcock and gum-elastic bag, or with a flexible tube so arranged as to evacuate the fluid under water. For the evacuation of an empyema the same precautions need not be taken, and it is here better to use a full-sized trocar, leaving the canula or an elastic catheter in the wound, or, which is better, introducing a drainage tube, one end of Avhich projects at the point of tapping, the other being brought out through a coun- ter-opening at the loAvest part of the cavity. Drainage tubes (introduced by Chassaignac) consist of pieces of India-rubber tubing, about one-sixth of an inch in diameter, with numerous lateral apertures, made by notching the tube Avith scissors. Roser and Peltavy recommend that, instead of using a drain- age tube, a free opening should be secured by resecting a portion of a rib—a plan Avhich is said to have been successfully resorted to by the late Warren Stone and by T. G. Richardson, of New Orleans. The point at Avhich para- centesis should be performed is a matter of dispute ; that usually recommended is betAveen the fifth and sixth, or sixth and seventh, ribs, in a line nearly cor- responding to the insertion of the serratus magnus muscle. Dr. BoAvditch usually taps betAveen the ninth and tenth ribs, while others go as high as the fourth intercostal space; I have usually chosen the sixth or seventh, finding that at a lower point pain may be caused by the diaphragm rising against the instrument, while, if the puncture be made higher, it is difficult to secure full evacuation of the cavity. Whatever point be chosen, the intercostal space should be, if not bulging, at least not contracted; the skin should be incised with a bistoury or lancet, and the trocar thrust in at the upper edge of the loAver rib, so as to guard against Avounding the intercostal artery—an accident which proved fatal in a case recorded by Gallard. If an ordinary trocar be used (in a case of hydrothorax), the admission of air may be further guarded against by drawing the cutaneous incision to one side before introducing the trocar, thus making a kind of valvular opening ; but the calibre of the suction- trocar is so small that, if it be employed, this precaution is unnecessary. The patient, at the beginning of the operation, should be in a sitting posture, and as the fluid is Avithdrawn should be gently lowered into a supine position, and slightly turned on the affected side; an assistant should steadily compress the loAver part of the chest, to prevent syncope, and further to guard against the entrance of air. The after-treatment (as far as the operation is concerned) consists simply in closing the wound Avith a piece of lint and an adhesive strip. If it be determined (in a case of empyema) to employ a drainage tube, this is intro- duced as follows: a steel eyed-probe, bent like a sound, is passed through the Avound of tapping, and made to project at the lowest accessible intercostal space ; upon this, as a guide, a counter-opening is made, and the eye of the probe threaded Avith a strong ligature carrying the tube, which is thus readily brought into place when the probe is Avithdrawn; the ends of the tube are then fastened together, and the Avounds covered Avith wet lint, or other simple dressing. The cavity should be thoroughly washed out at least once a day with a dilute solution of iodine or carbolic acid, so as to prevent putrefaction of the contained pus and consequent septicaemia. Dr. Hutchinson exhibited to the College of Physicians, of this city, a patient in Avhose case this plan had been systematically carried out with complete success, the punctures healing readily Avhen the tube was removed, and recovery following without the oc- currence of any reaccumuktion. The statistical results of the operation of tapping the chest are quite satisfactory; of o2G terminated cases collected by WOUNDS OF THE PERICARDIUM AND HEART. 365 G. H. EAans, no less than 373 ended in recovery, while only two of the 153 deaths were attributable to the operation itself. In a case of Empyema following a Gunshot Wound, in Avhich there was reason to suspect the presence of a foreign body, the surgeon should carefully explore the cavity Avith a probe, after evacuating the contained fluid, Avhen, if a ball, or other foreign body, should be discovered, it should be removed with suitable forceps, as Avas successfully done by Larrey. 2. Wounds of the Pericardium and Heart___Wound of the Pericardium alone Avould not appear to be as fatal an injury as Avould natu- rally be supposed; at least 51 cases collected by Fischer gave only 29 deaths, and as many as 22 recoveries, the diagnosis in three of the latter being sub- sequently confirmed by post-mortem inspection, Avhen the patients died from other causes. Wounds of the Heart are usually, though not necessarily, fatal; 401 cases, collected by Fisher, afforded as many as 50 recoveries, the diagnosis in 33 of the latter being eventually confirmed by means of an autopsy. The symp- toms of these injuries are not very definite; if the Avound be large, there is, of course, profuse hemorrhage, Avhich may prove almost instantly fatal; punctured Avounds are, however, often attended Avith little or no bleeding, OAving chiefly to a peculiar arrangement of the muscular fibres of the heart, described by PettigreAv, by Avhich a Avound Avhich is transverse to one layer of fibres is in the direction of another layer, and therefore, to a certain extent, necessarily valvular. Syncope is often observed in cases of heart Avound, occurring not unfrequently at the moment of injury. Pain, Avhen present, is, according to Fisher, due to the pericardial lesion. If effusion of blood, or serum, take place into the cavity of the pericardium, the sounds of the heart and the cardiac impulse are diminished in intensity. A systolic bellows sound is the most usual abnormal murmur observed in cases of heart wound. Precordial anxiety, dyspnoea, and other symptoms are not distinctive, and, indeed, are occasionally entirely Avanting. The diagnosis, Avhich, as may be inferred from Avhat has been said, is often obscure, may be additionally com- plicated by the coexistence of a wound of the lung, as happened in a case which I observed some years ago. The prognosis should, of course, be very guarded. RecoArery, hoAvever, may occasionally folloAv, and instances have been recorded by Ferrus, Latour, Fournier, Randall, Carnochan, Balch, Hamilton, Hopkins, Gallard, Tillaux, Conner, and others, in which patients have survived heart Avounds for considerable periods, even though Avith foreign bodies lodged in the substance of the organ. Callender has recorded a remarkable case in which he successfully removed a needle which Avas fixed in the substance of the heart. The treatment of a suspected Avound of the heart Avould consist in keeping the patient at absolute rest, and in the appli- cation of cold, the administration of opium, digitalis, veratrum viride, etc., and, if death Avere threatened by pericardial effusion, perhaps the performance of paracentesis. Paracentesis Pericardii may be performed in the fourth or fifth intercostal interspace, with the same precautions that Avere recommended for the operation of tapping the pleural sac. Of 41 cases collected by Dr. Roberts, of this city, 22 proved fatal, but mostly from causes unconnected with the operation. 3. Wounds of the Aorta and Vena Cava are almost invariably fatal. Cases are, hoAveAer, recorded by Pelletan, Heil, and Legouest, in which patients survived wounds of the aorta for from tAvo months to several years. 366 INJURIES OF THE ABDOMEN AND PELVIS. 4. Wounds of the Anterior Mediastinum are less serious than any other penetrating Avounds of the chest: the symptoms are often rather obscure, being indeed in many instances chiefly negative, and the diagnosis depends on the absence of those signs Avhich characterize Avounds of the lung. Some of these signs may, hoAve\Ter, be present; thus, emphysema, and, according to Fraser, even tromatopnea, may accompany.Avounds of the mediastinum which do not invoh-e the lung or pleura. The chief dangers of these injuries are hemorrhage (from the internal mammary artery), diffuse inflammation, and suppuration. Death may result from pressure of the accumulated pus on the heart or lungs, or from pyaemia. The treatment of a Avound of the mediastinum is that which has been directed for other pene- trating Avounds of the chest: if suppuration occur, the matter should be evacuated where the abscess tends to point, at one or the other side of the sternum. Injuries of the Diaphragm. The diaphragm may be ruptured by external violence, as by a fall on the chest or abdomen, by violent squeezing, as in railway accidents, or (as in a case referred to by Mr. Pollock) by spasmodic contraction of the part itself. The usual seat of laceration, in these cases, is the left side, in the fleshy por- tion of the muscle. If the injury be uncomplicated by lesion of abdominal or thoracic A'iscera, the prognosis is not so unfavorable as might be supposed: unless, however, the laceration be very limited in extent, protrusion of the stomach or other abdominal viscera into the cavity of the chest will almost inevitably occur, constituting the condition known as Diaphragmatic Hernia. Wounds of the diaphragm, resulting from stabs, gunshot injuries, etc., are usually complicated with other serious lesions, and it is from these, rather than from the wound of the diaphragm itself, that the danger in these cases chiefly arises. The symptoms of a Avound of the diaphragm are very obscure ; in most instances there is great dyspnoea, breathing being principally carried on by the subsidiary muscles of respiration. Dr. C. T. Hunter has, howeATer, recorded a case of gunshot Avound, in Avhich the ball, after perforating the stomach, boAvels, and diaphragm, lodged in the thoracic cavity, but in which there Avas no difficulty of breathing until shortly before death, the dyspnoea even then evidently resulting mechanically, from gaseous distension of the intestines. The treatment of a Avound of the diaphragm is essentially the same as that recommended for penetrating Avounds of the chest. CHAPTEE XIX. INJURIES OF THE ABDOMEN AND PELVIS. Contusions of the Abdomen. Contusions of the Abdomen, unattended by Lesions of the contained Viscera, are rarely attended with much risk. It is popularly believed that sudden death not unfrequently results from a blow on the epi- gastrium, no morbid appearance being discoverable on post-mortem inspec- tion ; the possibility of such an occurrence has, however, been shoAvn, by Mr. Pollock's researches, to be at least doubtful, though there can be no question CONTUSIONS OF THE ABDOMEN. 367 that rapid death may follow these injuries, either from concomitant shock, or from a condition of the solar plexus analogous to cerebral concussion. In either case, hoAvever, there Avould probably be physical lesions Avhich could be recognized after death. Fig. 178. Rupture of the Abdominal Muscles may occur Avithout the existence of any external Avound : these ruptures have usually been observed in the recti muscles, though they may occur in any portion of the abdominal parietes. The accident is very apt to be folloAved by a form of ventral hernia, -which may sometimes attain a ATery large size, as in the patient Avhose case is represented in the annexed figure, and avIio received his injuries by being run over by the Avheel of a cart. The treatment of such a case con- sists in the application of a truss with a broad and somewhat concave pad, to re- strain the protrusion. There is little risk of strangulation, on account of the large size and yielding character of the hernial aperture. I haA~e several times seen, in soldiers, a ventral hernia in the median line, resulting from separation of the ten- dinous fibres in the linea alba, and caused, apparently, by the fatigue of long marches and the Aveight of the knapsack. The treatment consists in the application of a pad and elastic bandage. Ventral hernia, following rupture of the abdominal muscles. (From a patient in the Episcopal Hospital.) Abscess of the Abdominal Pa- rietes occasionally follows contusion of the part, and may cause great destruction of tissue by extending betAveen the mus- cular planes. The treatment consists in early evacuation of the pus, by means of free incisions so arranged as to permit drainage. Contusions of the Abdomen, attended -with Lacerations of the Abdominal Viscera, are very grave injuries. Rupture of the liver, spleen, kidney, omentum, or mesentery, or of any of the large vessels, may prove rapidly fatal from internal hemorrhage; Avhile lacerations of the hollow viscera, as the stomach, bowel, or gall-bladder, or of the parietal peritoneum, are principally dangerous on account of the peritonitis wliich almost inevi- tably results. Intestinal obstruction occasionally folloAvs apparently slight contusion of the abdomen, doubtless from injury to the peritoneum covering the affected portion of bowel. Encysted dropsy resulted in a case recorded by Duplay. The degree of risk attending laceration of the solid viscera de- pends entirely upon the extent of the lesion : thus a superficial laceration of the liver may cause merely localized peritonitis, from Avhich the patient may recover ; injuries of the spleen are more dangerous, on account of the profuse bleeding which attends even slight lesions of this organ, and death usually results, if not from hemorrhage, yet at a later period, from the supervention of diffuse inflammation and suppuration. Laceration of the kidneys offers a comparatively favorable prognosis : as was mentioned in Chap. XVI., slight lacerations of these organs are not infrequent in cases of spinal injury, and do not appear necessarily to entail any serious consequences. Ruptures of the 368 INJURIES OF THE ABDOMEN AND PELVIS. stomach or bowel are almost invariably fatal: if the seat of laceration should be such that extravasation of the contents of these viscera should take place elsewhere than into the peritoneal cavity (as betAveen the layers of the mesentery, in the case of the boAvel), it would be just possible that the resulting inflammation might terminate in an abscess Avhich would point externally, and that recovery might thus folloAV ; hut it may be given as a general rule, that ruptures of the stomach or boAvel are fatal injuries. Rup- ture of the gall-bladder is almost ahvays followed by death, bile being found in the peritoneal cavity on post-mortem examination : that recovery is at least possible, would, hoAvever, appear from a case recorded by Dr. Fergus, in Avhich the patient was considered conATalescent, and Avas AAalking about, Avhen, on the seventh day, peritonitis Avas suddenly developed, and proved fatal two days subsequently. Rupture of the ureter is a very rare injury: Mr. Poland has collected four cases, one of Avhich recovered, after the evacu- ation by puncture, at intervals, of about two gallons of fluid resembling urine, the other cases terminating in death, during the first, fourth, and tenth Aveeks respectiAely. In none of the cases does it appear that peritonitis was present, the urinary extravasation having occurred into the cellular tissue behind the peritoneum. Ruptures of the abdominal bloodvessels, without other injuries, are seldom met with. Legouest has recorded a case of laceration of the aorta; and Dr. Otis has collected five cases of a similar lesion of the vena cava. I have myself seen death follow an unrecognized rupture of the external iliac artery (see Fig. 80). Symptoms___The symptoms of these various forms of injury are rather obscure. There is usually marked shock, Avith pain, and a sensation of impending dissolution—but not more than is often observed in cases of abdominal contusion unaccompanied by visceral lesion : the persistence of collapse, however, with other evidences of internal hemorrhage, will give reason to suspect rupture of a solid viscus, or of a portion of the peritoneum which contains large vessels ; while the immediate development of peritonitis would indicate rupture of one of the hollow viscera. Pain in the right hypo- chondrium, with increased hepatic dulness, and, at a later period, bilious \-omiting, clay-colored stools, and the presence of sugar in the urine, would afford evidence of laceration of the liver; hematuria would indicate lesion of the kidney, though its absence Avould, by no means, prove that this organ had escaped; hsematemesis would be a symptom of ruptured stomach, and bloody stools of ruptured intestine—a lesion, the existence of Avhich might also be suspected, if the abdominal wall Avere the seat of emphysema, the diagnosis of wliich from emphysema due to thoracic injury, and from gaseous putrefaction, might be made by observing the history of the case, and the coincident symp- toms. The history may also serve, sometimes, to distinguish between gastric and intestinal laceration, rupture of the stomach rarely occcurring except when that organ is distended by a recent meal. Treatment—As these injuries are in the majority of instances necessarily fatal, their treatment must, of course, be often merely euthanasial. As far as any curative influence can be exerted by remedies, it must be (as Sir Thomas Watson puts it) in obviating the tendency to death. Hence the surgeon's first efforts must be directed to arresting the internal hemorrhage which is the source of immediate danger, and at a later period to combating the peritonitis which is the common cause of death in those cases Avhich survive the early periods of the injury. The patient should be put to bed, and kept profoundly quiet; if the symptoms of shock be very prominent, cautious efforts may be made to induce reaction, preferably by the application of external Avarmth, for it must be remembered that internal stimulation might increase the risk of hemorrhage. Opium may be freely administered, both to relieve the suffer- TRAUMATIC PERITONITIS. 369 ings of the patient, and as an anti-hemorrhagic remedy; to increase its effi- ciency in the latter respect, it may be advantageously combined Avith acetate of lead. The older writers recommended venesection in these cases, on the same principle on which it Avas employed in the treatment of penetrating wounds of the chest; but I imagine that there are feAv surgeons at the present day, who Avould employ bleeding under these circumstances. The local treatment should consist (at this stage) in the application of cold to the abdomen—dry cold applied by means of an ice bag or box (see page 5f>), or, if these be not at hand, cloths Avrung out of cold water and frequently renewed. The diet should be mild and unirritating, and if there be reason to suspect laceration of the stomach or bowel, the patient should be exclu- sively fed by means of nutritive enemata. If great suffering should he caused by gaseous distension, the surgeon would be justified in puncturing the bowel with a fine trocar, tlirough the linea alba, as recommended by T. Smith. It does not appear that this little operation is in itself attended'with any parti- cular risk,1 and it Avould certainly be permissible as an euthanasial measure. Retention of urine should be obviated by the use of the catheter. An ex- ploratory operation, to seek for the laceration and close it by sutures, has been suggested in these cases, but it seems to me, Avould but add to the patient's danger. Traumatic Peritonitis—It is probable that slight and circumscribed peritonitis occurs in almost every case of severe abdominal injury Avhich re- covers, but it is the existence of diffuse peritoneal inflammation, attended with the effusion of turbid serum, or Avith suppuration, that constitutes the chief danger to be apprehended in the later stages of these injuries. The symptoms of traumatic peritonitis do not differ from those of the idiopathic variety of the affection, and for their description I Avould therefore refer the reader to Avorks on the Practice of Medicine. The course of traumatic peri- tonitis is very rapid, death from this cause sometimes occurring in less than twenty-four hours from the time of reception of the injury. The treatment varies with the general condition of the patient, and the supposed nature of the internal lesion. I have never had occasion to employ general bleeding in these cases, but I have applied leeches or cups (in cases occurring amono- those of robust health and vigorous constitution), and, I am sure, with advan- tage. The amount of blood drawn may vary from 8 to 12 ounces, and the immediate mechanical relief thus afforded to the inflamed peritoneum, is suf- ficient, I think, to compensate for the evils Avhich ineAitably attend all forms of bloodletting. In an old or feeble person, however, or in a young child, I should consider even local bleeding highly improper. The application of a large blister is usually recommended in these cases, and I have myself em- ployed it. I am not sure, however, that a jacket-poultice, enveloping the Avhole abdomen, might not be equally efficient, as it would be probably more agreeable to the patient. 1 have found advantage from the use of the vera- trum viride, in doses of 3 or 4 drops of the tincture, every three hours, simply as a means of reducing the rapidity of the heart's action, and the force of the circulation ; the remedy is, hoAvever, a dangerous one, and its effects should be carefully watched, its administration being suspended as soon as the pulse falls to the normal average. Opium is an invaluable remedy in cases of trau- matic peritonitis, and may be freely given in every instance. Dr. Alonzo Clark's rule is to give two grains, more or less, every tAvo hours until the 1 Fonssagrives has collected 84 cases of puncture of the bowel for tympanites, show- ing that the operation is not particularly dangerous, but his views are contravened by Piorry and Frantzel, who regard the procedure as one Avhich is full of peril. 370 INJURIES OF THE ABDOMEN AND PELVIS. patient's respiration has been reduced to twelve in the minute. Unless lace- ration of some part of the alimentary canal be suspected, this drug may be suitably combined with small doses of calomel; but in cases of intestinal rup- ture, the effect of the latter substance would be to increase the risk of fecal extravasation, and in such a case, if mercury be used at all, it should be em- ployed by inunction. Milk diet is that Avhich is best adapted to cases of traumatic peritonitis, Avine or brandy being added if necessary. If the stomach or boAvel be lacerated, nutritiAre enemata, of beef-tea, egg-nogg, etc., must be substituted. If serous effusion persist after the subsidence of acute symptoms, an attempt may be made to promote absorption by the use of blisters, and by the administration of iodide of potassium. Retro-peritoneal Suppuration, resulting from rupture of the intes- tine between the layers of the mesentery, might possibly require incisions to evacuate the pus ; and similar treatment Avould be indicated in the eA'ent of Urinary Extravasation occurring from laceration of the kidney or ureter. AVounds of the Abdomen. Non-Penetrating Wounds of the abdominal parietes present few peculiarities requiring special mention. Foreign bodies are to be removed, and the Avound cleansed, as in other localities. Hemorrhage in these cases cannot safely be controlled by pressure, simply because there is no surface to furnish counter-pressure, while closure of the external wound will not suffice, because it would alloAV interstitial bleeding to continue, and thus dissect up the inter-muscular spaces; therefore, if, in any case, the hemorrhage be greater than mere oozing, the part must be freely exposed (the Avound, if necessary, being enlarged for this purpose), and the bleeding vessel secured by ligature, torsion, or acupressure. These wounds are apt to gape, and, hence, if extensive, require the use of sutures, muscular relaxation being secured by position. Ventral Hernia may occur after cicatrization, and would require the application of a truss or bandage. Penetrating Wounds__These may be divided into—1. Those Avith- out protrusion or wound of the abdominal viscera; 2. Those without protru- sion, but with Avound of such viscera ; 3. Those with protrusion of unwounded viscera; and 4. Those Avith protrusion and wound of viscera. 1. Penetrating Wounds of the Abdomen, without Protrusion or Wound of the Contained Viscera, may result from stabs, bayonet thrusts, or gunshot injuries. The diagnosis from non-penetrating wounds is often difficult, and any exploration with a probe would be manifestly improper. The escape of bloody serum may be taken to indicate penetration of the peritoneum, and the diagnosis Avill be confirmed should peritonitis subsequently occur. The treat- ment, in such a case, would be the same as in one of non-penetrating Avound, visceral complications being managed on the principles already laid down in speaking of visceral rupture Avithout external wound. 2. Penetrating Wounds, with Wound of the Abdominal Viscera, but with- out Protrusion—The diagnosis of these cases from those of the last cate- gory, can usually be made only by observing the flow of the visceral contents through the external wound, or by noting a very rapid development of peri- tonitis, which, when resulting from extravasation of the visceral contents, occurs more quickly than under other circumstances. In a remarkable case of gunshot Avound of the stomach, recorded by Culbertson, of Ohio, the diagnosis was however rendered clear by the detection of several shot in the matter vomited by the patient immediately after the reception of the injury. PENETRATING WOUNDS. 371 The treatment of a case of this kind Avould consist in placing the patient in such a position as to alloAv any matter that might be extravasated to escape externally, in the free administration of opium, and in the adoption of such measures generally as would tend to moderate the peritonitis, Avhich would almost inevitably ensue. It is recommended, in such a case, by Legouest, Otis, Dugas, and other high authorities, to enlarge the external opening, search for the source of extravasation, and apply sutures to the wounded vis- cus; but the prospective benefits of such a proceeding would, it seems to me, be extremely questionable, while the additional risks that it Avould entail are manifest. AVhen the patient recovers, after an injury of this kind, it is usually with a gastric, biliary, urinary, or fecal fistula, according to the part which has been wounded. 3. Penetrating Wounds, with Protrusion of Unwounded Viscera___Por- tions of almost any of the abdominal organs may protrude, if the wound be a large one, and instances are not wanting in which recovery has followed the protrusion, under such circumstances, of parts of the stomach, liver, spleen, or other viscera. In these cases, the wound being large, there is commonly not much difficulty in reduction, which should ahvays be practised in the case of such organs as have been mentioned. If the bladder protrude, reduction may be much facilitated by the use of the catheter. If, as occa- sionally happens, a portion of a solid viscus, such as the liver, spleen, or pancreas, be strangulated and already gangrenous when first seen by the sur- geon, a strong ligature should be applied, Avhen the sloughing mass may be either cut away or allowed to separate spontaneously. Recoveries under these circumstances haA*e been reported by several surgeons, and Dr. Otis has collected a number of such cases in the second volume of the Surgical History of the War. The parts which are liable to protrude through small wounds are the bowels, mesentery, and omentum. The treatment of such cases would depend upon the condition of the extruded viscera. If Bowel protrude, and be found healthy, or only moderately congested, it should be at once returned. This may sometimes be effected by drawing doAvn a further portion of the gut, and gently pressing upwards the fecal contents, so as to diminish the tension of the protruded mass. In other cases it may be necessary to enlarge the wound—just as in the analogous case of operation for strangulated hernia. This debridement, as it is called, should be made in an upward direction, and should be eonfined, if possible, to the skin and muscular tissues, the peri- toneal aperture usually yielding Avithout incision. If reduction he rendered impossible by gaseous distension of the protruded boAvel, the surgeon would be justified in puncturing the part Avith a grooA'ed needle, as has been suc- cessfully done by Mr. Tatum and others. Dr. Storrs, of Hartford, Conn., recommends that the lips of the wound should be draAvn upAvards and sepa- rated by means of blunt hooks or ligatures, previously introduced. Reduction should be aided by placing the patient in such a position as will insure re- laxation of the abdominal AATalls, and the portion of bowel Avhich has last descended must he first returned. The surgeon must take care that reduction is really accomplished, and that the protruding part is not merely thrust up betAveen the planes of the abdominal parietes. If the protruded boAvel be gangrenous, it would not be safe to attempt reduction, and, in such a case, the part should be freely incised, and the patient allowed to recover, if pos- sible, Avith a fecal fistula. AVhat course should be adopted, if the bowel, though not absolutely gangrenous, be intensely inflamed ? It is usually ad- vised, under these circumstances, to effect reduction and close the wound, but I am not sure that it might not sometimes be better to alloAv the part to re- main in situ, after dividing any constricting bands that might threaten 372 INJURIES OF THE ABDOMEN AND PELVIS. strangulation. The risk of peritonitis would, at least, not be increased by this plan, Avhile, if the boAvel should subsequently give Avay, there would be less danger of fecal extravasation. The course to be pursued in case of Omental Protrusion likeAvise depends upon the state of the part; if this be healthy, it should be at once returned, but if violently inflamed, or if gan- grenous, it should be excised—the part immediately above being first trans- fixed and tied Avith a double ligature, to prevent hemorrhage, and the stump being secured in the deeper portion of the wound, by fastening the ligatures, Avith adhesive strips, to the abdominal wall. The treatment to be pursued after reduction, consists in accurately closing the Avound Avith numerous sutures (Avhich should embrace the Avhole thick- ness of the abdominal wall, except the peritoneum), and in adopting means to moderate the peritonitis Avhich may be expected to occur. If omentum baAe been excised, the cutaneous wound should be closed over the ligated stump, the ligatures being brought out betAveen the points of suture. If boAvel have been left in the Avound, with anticipation that a fecal fistula will follow, the part should be lightly dressed, with oiled lint or some similar substance, so as to exclude the air, and keep the Avound from dust. 4. Penetrating Wounds, with Protrusion and Wound of Viscera.—If a solid viscus be affected, the treatment Avould consist in reduction, or (in the case of the omentum) perhaps in partial excision, according to the rules above laid doAvn. Hemorrhage from a mesenteric artery should be arrested by torsion or ligature. Wounds of the stomach or boAvel require the applica- tion of sutures, the part being subsequently returned into the abdominal cavity, and the after-treatment being conducted as in cases of the previous category. The suture employed should, in case of a large Avound, be the continued or glover's suture (Fig. 69), applied through all the coats except the mucous, or, which is preferable if the Avound be transverse, Lembert's or Gely's modification. These have for their object the inversion of the edges of the wound, and the consequent coaptation of the serous surfaces (Figs. 17!», 180), and seem to me, upon the Avhole, quite as satisfactory as the more com- plicated methods of Vezien, Louisson, and Beren- ger-Feraud. The suture being applied, both ends are to be cut short, and the Avhole replaced in the abdominal cavity. The suture (which should be of silk or thread) gradually finds its way into the interior of the bowel, and is eventually discharged per a nam. For small longitudinal wounds the common interrupted suture may suffice, while a mere puncture may be closed by simply throwing around it a ligature, the AArounded point being raised for the purpose Avith tenaculum or artery forceps. If, on the other hand, a transverse wound involve the whole calibre of the bowel, it is probably better to secure the edges of each extremity of the gut to the exter- nal Avound, and allow the formation of a fecal fistula. This course Avould, I think, be safer, under such circumstances, than an attempt to restore the continuity of the boAvel by means of sutures. In the after-treatment of all these cases the free administration of opium is of the highest importance. The patient must be kept perfectly quiet, pur- gatives strictly interdicted, and food given as much as possible in the form of nutritive enemata. Fie. 179 180. Lembsrt's suture. Gely's suture. Gastric Fistula is a condition by no means incompatible Avith long life and comfort. If small, an attempt may be made to promote contraction and FECAL OR INTESTINAL FISTULA. 373 cicatrization by occasional cauterization of the edges ; but if large, the sur- geon should ordinarily content himself Avith applying a suitable compress, or obturator. Billroth, howeA-er, has successfully resorted to gastroraphy, split- ting the edges of the fistula and closing the gastric opening with sutures, and then covering the external wound with a flap taken from the neighboring integument. Biliary Fistula, of Avhich I have seen but one example, scarcely admits of any treatment, except keeping the parts clean and removing any gall- stones that may become impacted. Urinary Fistula, folloAving a Avound of the ureter inflicted in ovariotomy, has been successfully treated by Gussenbauer by a process of ureteroplasty, Avhich consisted in dilating the sinus and then establishing an artificial passage betAveen the cut ureter and the bladder. Fecal or Intestinal Fistula (usually called Artificial Anus) is more frequently met with after strangulated hernia than after a Avound, but the treatment in either case is the same, and I shall, therefore, consider it here. If the opening into the boAvel be but small, the greater portion of the fecal mass being eA-acuated in the natural way, it may be sufficient to keep the parts clean, and to apply a firm compress, wliich, with occasionally touching the edges with nitrate of silver, will sometimes effect a cure. If, however, the opening be larger, and still more if the whole calibre of the gut be in- volved, the condition is different. In such a case the ends of the bowel adhere by their serous surfaces, their position at the bottom of the external Avound having been not inaptly compared to that of the tubes of a double-barrelled gun. The loAver end of the bowel, being unused, undergoes contraction, while the upper extremity is frequently abnormally dilated. The mesenteric portion becomes prolonged between the ends of the gut into a kind of spur, Avhich acts as a valve in further occluding the lower opening. In some cases, the junction of the tAvo ends of bowel is at a considerable depth from the sur- face, the fecal contents finding their way to the external wound through a long and perhaps sinuous canal. The treatment consists, if Desault's plan of continuous compression fails, in dividing the "eperon," or spur-like projection betAA^een the intestinal extre- mities, so as to restore the continuity of the boAvel, and in subsequently freshening the edges of the external Avound, Avhich is then closed Avith harelip pins—or in performing a plastic operation, if the simpler procedure fail. The division of the spur may be accomplished in several ways, the best probably being by means of the enterotome devised by Dupuytren. The enterotome consists of two serrated blades (Fig. 181, a, b), which are introduced, one into each end of the bowel, and Avhich are then approximated, and fixed by means of a screw. This screAV is tightened day by day, so as to cause the adhesion of the adjoining surfaces of the bowel, and the removal of the septum by sloughing ; if this be done too quickly, the peritoneal sac will be opened, and death will probably occur from fecal extravasation. Another risk is the possibility of pinching a knuckle of healthy intestine between the blades. The tightening of the screAvmust be very gradually effected, the time required for safe division of the septum being at least a week. In a case in Avhich the loAver end of the boAvel could not be found, Laugier opened the large intestine at another part, and, introducing one blade of a modified Dupuytren's entero- tome through each Avound, succeeded in this manner in restoring the con- tinuity of the gut. To avoid the risk of premature perforation, Dr. David Prince has recently suggested the use of a Avire loop and pin, by Avhich the 374 INJURIES OF THE ABDOMEN AND PELVIS. sides of the septum are invaginated, while the necessary pressure is afforded by an elastic cord which connects the pin and loop outside of the body. Per- foration being effected, the little instrument is made to cut its Avay out through the septum by means of another elastic cord, attached to a miniature " der- Fig. 181. Fig. 182. D ipuytren's enterotome. Enterotome applied. (Erichsen.) rick" which is fixed upon the surface of the abdomen. Other plans are Physick's, Avhich consists in bringing together the sides of the septum with a ligature, and in subsequently dividing the part below; and Schmakhalden's, Avhich consists in transfixing the septum Avith a ligature, which is then forcibly tied, and alloAved to cut its Avay out. Various modifications of Dupuytren's method have been proposed by Liotard, Delpech, Gross, and others. During the application of the enterotome, the patient should be kept fully under the influence of opium. As soon as the continuity of the boAvel has been restored, the edges of the external wound may be pared and brought together Avith the twisted suture, or, as suggested by Duncan, the edges may be split, the mucous surfaces being invaginated and secured with catgut sutures, Avhile the external Avound is closed with silver Avire ; or, if simpler measures fail, an attempt may be made to close the opening by means of a plastic operation. Foreign Bodies, such as coins, pins, buttons, or artificial teeth, are not unfrequently swalloAved, and may lodge in the stomach or bowels. The domestic treatment of such cases is usually the administration of a purgative— a remedy Avhich is, hoAvever, really unsuitable, as the object should rather be to delay peristaltic action, and to alloAv the foreign body to become enveloped in a mass of fecal matter, so that it may produce less irritation in its omvard passage. If the foreign body cannot be extracted through the mouth, as has been successfully done in one instance by L. S. Little, and is of such a nature (as a table knife, or fork) that it cannot probably be either dissolved by the gastric and intestinal juices, or naturally evacuated, the surgeon Avould, I think, he justified, provided its position could be ascertained by external pal- pation, in attempting its removal by operation. Gastrotomy has, including Labbe's case, been successfully performed under these circumstances, in at least seven instances;1 and, as death Avould be, sooner or later, almost inevit- ' Dr. Otis has collected 12 cases, not including Labbe's ; the histories of 5 are more or less open to question, and, of the remaining 7, one terminated fatally. INJURIES OF THE PELVIC ORGANS. 375 able without operation, the attempt Avould be at least permissible.1 The incisions, in such a case, should he regulated by the size and shape of the body to be removed, and the after-treatment should be the same as for an incised wound accidentally inflicted. Enterotomy might be similarly resorted to, if the foreign body, having reached the boAvel, should cause complete intestinal obstruction. (See Chap. XLII.) Injuries of the Pelvic Organs. Injuries of the Bladder__The bladder may be ruptured (without external AA^ound) by violence, as a kick, applied to the abdomen. This acci- dent is only likely to happen if the organ be distended with urine, as Avhen empty it sinks beneath the pubic arch, and is thus measurably protected from external injury. The rupture usually occurs in the posterior Avail of the bladder, involving the peritoneal as Avell as the other coats of the organ, and allowing urinary extravasation into the peritoneal cavity, an event which is almost inevitably fatal. More rarely the rent is confined to the anterior wall of the bladder, urine then escaping into the pelvic areolar tissue, and inducing a condition Avhich, though very grave, is not so uniformly fatal as the one previously referred to. The symptoms, in the former case, consist of intense epigastric pain, collapse, urgent but fruitless efforts to urinate, and in a short time the ordinary signs of peritonitis ; the introduction of the catheter serves to eAacuate either none or a very small quantity of bloody urine. If the peritoneum be not inAxuVed, the symptoms are less urgent, the patient being, in these cases, gradually worn out by diffuse inflammation and slough- ing of the areolar tissue. Among 78 cases collected by Dr. Stephen Smith in 18."> 1, there Avere but five recoveries. The treatment consists in the intro- duction of a large flexible catheter, which (as a general rule) should be secured in place, the urine being alloAved to run off constantly, by means of an attached India-rubber tube, into any comenient receptacle. The patient should be got as soon as possible under the influence of opium, a warm poul- tice may be placed over his epigastrium, and concentrated food or stimulants administered, if indicated by his general condition. Diaphoresis should be encouraged by external applications, it being an obvious indication to pro- mote the vicarious action of the skin, and thus diminish the amount of urine secreted. It has been suggested to perform cystotomy (as in the median or lateral operation for stone), in these cases, and if it Avere found impossible to keep the bladder empty by means of a catheter, the operation, which has been successfully resorted to, under these circumstances, by Walker, of Mas- sachusetts, and by Parker and Mason, of New York, would be certainly proper, and Avould, I think, be preferable to opening the bladder either through the rectum or aboA^e the pubes, though the latter procedure also has been successfully employed by a New York surgeon, Dr. Williams. Holmes suggests that it might be justifiable to open the abdomen and close the vesical Avound with sutures, but a case in which Willett tried the operation terminated fatally. A similar operation Avas suggested some years ago by Prof. Gross, and is said to have been successfully resorted to by Dr. "Walter, of Pittsburg. Free incisions should be made on the first outAvard manifestation of urinary infiltration having occurred. A feAV instances are on record, in which the bladder has been ruptured by the accumulation of its OAvn secretion ; such an accident, hoAvever, is very rare, the urethra usually giving way, in such cases, rather than the bladder. 1 See, however, this question discussed by Poland (who considers the operation unnecessary) in Guy's Hosp. Reports, 3d s., vol. ix. 376 INJURIES OF THE ABDOMEN AND PELVIS. Wounds of the Bladder are amongst the most serious complications of fractures of the pelvis. The bladder may also be Avounded by gunshot pro- jectiles, by pointed instruments, by the horns of infuriated animals, etc. When the wound is in that part of the organ which is covered with perito- neum, these injuries are usually fatal, but there are numerous instances of recovery from Avounds of the bladder inflicted in the perineal region. The treatment of these cases is essentially that Avhich has been described in the preceding paragraph ; any foreign body that may have lodged in the bladder should be removed, as its continued presence would produce great irritation, and probably cause the formation of a calculus. If the wound be through the rectum or vagina, a troublesome fistula may result, requiring, perhaps, the performance of a plastic operation. Foreign Bodies, such as slate pencils, pins, etc., may be introduced into the bladder, through the urethra, through an external wound, or, more rarely (by the process of ulceration), from another viscus—as in a remarkable case recorded by Dr. Kingdon, in which a pin, having been swallowed, lodged in the appendix vermiformis, from Avhich it subsequently made its Avay into the bladder, where it formed the nucleus of a calculus ; the ulceration by which this process was attended, gave rise to the formation of an intestino-A esical fistula, through Avhich no less than six round worms entered the bladder, and were at different times discharged from the urethra. Foreign bodies may occasionally be spontaneously expelled from the bladder—or may be extracted Avith urethral forceps, or a small lithotrite, if the surgeon succeed in catching them in the direction of their long axis. In the male, however, it is usually necessary to resort to lithotrity (if the nature of the body admit of its being crushed), or to lithotomy, the median being in such a case the preferable ope- ration. From the female bladder, foreign bodies may be conveniently removed, in most cases, by dilating the urethra with two- or three-bladed forceps, or Avith graduated bougies, until the forefinger can be introduced, Avhen it is very easy Avith forceps to seize and extract the foreign body, the finger serving to adjust it into a favorable position for removal. It occasion- ally happens that, in using the female catheter, the instrument slips from the fingers, and is sucked into the bladder. In the event of such an unfortunate occurrence, the surgeon should at once dilate the urethra and remo\e the foreign body. I have known fatal ulceration to result under these circum- stances, from the delay of only a few days. Injuries of the Rectum— Wounds of the rectum, provided that they are uncomplicated, usually heal without much difficulty, as is seen after the operation for fistula, or when the boAvel is accidentally wounded in lithotomy. If the lesion involve the bladder or vagina, recto-vesical or recto-vaginal fistula will probably result, and may require the performance of a plastic ope- ration. Death may follow perforation of the rectum (from the peritoneum being opened), as has occasionally happened from the incautious use of syringes, or of rectal bougies. Foreign Bodies are occasionally found in the rectum, and must be removed with scoop or forceps, as the ingenuity of the surgeon, and the exigencies of each particular case, may suggest. The removal of masses of impacted feces, of seeds or fruit-stones, etc., may often be accomplished simply by the repeated use of Avarm enemata. A fish-bone, or similar article, may be caught in one of the pouches of the rectum, and, by the resulting ulceration, give rise to a fistula in ano. Injuries of the Penis and Male Urethra.— Wounds of the Penis, if limited to the skin, are not attended with any particular risk ; they always INJURIES OF THE PENIS AND MALE URETHRA. 377 require the use of sutures, on account of the retractile tendency of the part. In deeper Avounds there may be profuse hemorrhage, which may require a ligature, if it proceed from any recognizable artery, but Avhich, if of the nature of general oozing, may be checked by cold and pressure, the latter being best applied by introducing a full-sized catheter, and then compressing the organ upon this Avith adhesive strips. Contusion, or Partial Rupture, of the corpora cavernosa, is folloAved by interstitial extravasation of blood, attended by marked induration, and sometimes by priapism, Avhich may per- sist for several days. Such an injury is best treated by the continued appli- cation of evaporating lotions. Strangulation of a portion of the penis is sometimes produced in children by tying a string round the part, or, in adults, by the introduction of the organ into a metallic ring, the neck of a bottle, etc. If gangrene has not been induced, the symptoms will usually quickly subside upon the removal of the source of constriction. Nekton, Heyenberg, and Moldenhauer have reported remarkable cases of luxation of the penis, the organ being completely separated from its cutaneous covering, and buried in the adjoining tissues. In Nelaton's case reduction Avas effected by the use of forceps. The Urethra may be Wounded by cutting instruments, or gunshot projec- tiles, or may be Lacerated by falls or bloAvs upon the perineum or penis, by injuries receiATed during coitus, or even by violent straining efforts at mictu- rition, in cases of stricture. It may also be Avounded in rude attempts at cathe- terization, giving rise to the formation of " false passages." The symptoms of laceration of the urethra are pain, considerable sAvelling from interstitial bleeding, hemorrhage from the meatus, and inability to urinate. If the pa- tient, by straining, succeed in passing Avater, Urinary Extravasation will usually occur, giving rise to extensiA-e destruction of tissue, and the formation of perineal fistulas. This is less likely to happen in cases of " false passage" than in those of other varieties of urethral laceration, because in the former the direction of the passage is away from the course of the urine. The treat- ment consists in the immediate introduction of a full-sized catheter (flexible, if possible), which must be retained for several days, until the subsidence of pain and SAvelling renders it probable that the laceration has healed; the catheter should not be plugged, lest the accumulating urine find its Avay by the side of the instrument. If it be impossible to introduce a catheter, the surgeon must at once open the urethra in the perineum, Avhen, if the instru- ment still cannot be passed, a flexible tube may be introduced through the wound into the bladder. This I believe to be safer, in these cases, than puncture through the rectum or prostate, or above the pubes. If extrava- sation of urine have occurred, free incisions mitst be made in the perineum, scrotum, and inside of the thighs, or AvhereA-er the urine may have reached, to permit the escape of the irritating fluid, and facilitate the separation of sloughs. Laceration of the urethra, according to its extent, will probably result in an intractable form of stricture, or even in complete obliteration of a portion of the tube, Avith the persistence of an incurable perineal fistula. Foreign Bodies in the urethra may be extracted through the meatus, Avith urethral scoop or forceps (or, in some cases, as suggested by Keyes, of New York, Avith a Thompson's stricture expander) or through an incision in the median line. If this incision be in the perineum, the wound maybe allowed to heal by granulation, a full-sized catheter, or bougie, being passed every other day; but if in the penile portion of the urethra, sutures will be required, and in this case a flexible catheter should be retained until union has oc- curred. When the foreign body is long and soft (as a bit of catheter), an ingenious plan of removal, suggested by Van Buren and Keyes, may be adopted: this consists in transfixing the foreign body with a stout needle 378 INJURIES OF THE ABDOMEN AND PELVIS. passed through the floor of the urethra, and pushing back the canal as far as possible, like a glove over a finger, then AvithdraAving the needle and transfix- ing again, and so gradually coaxing the foreign body forwards until it can be seized at the meatus. Injuries of the Scrotum and Testes—Wounds of the Scrotum require the application of sutures ; if the Avound be extensive, the testis may be extruded, owing to the great contractility of the dartos muscle. In order to effect relaxation of the part, Mr. Birkett advises the use of Avarm fomenta- tions before the application of stitches, cold lotions being afterwards substi- tuted to produce contraction and prevent bagging. Confusion of these parts is followed by great swelling and ecchymosis, and often results in the forma- tion of a hydrocele, or hauuatocele. Wounds of the Testis usually heal readily, the tunica vaginalis, in such cases, commonly becoming obliterated by inflammation. Atrophy of the organ is said to occasionally folloAv these injuries. Injuries of the Prostate___Incised Avounds of the prostate heal Avith- out trouble, as is seen in cases of lithotomy. The prostate is sometimes Avounded in rude attempts at catheterization, causing retention of urine, and urethral hemorrhage ; the treatment consists in introducing a large flexible catheter, or, if this be impossible, in tapping the bladder through the rectum or above the pubes. Injuries of the Spermatic Cord and Vas Deferens__Wounds of the Spermatic Cord require the use of the ligature, or other means of checking hemorrhage, and the divided segments of the cord should be brought together with a stitch, in hope of procuring union. Mr. Hilton has met Avith several cases of Rupture of the Vas Deferens, marked by arterial hemorrhage from the urethra, with great pain and fever, and followed by atrophy of the corresponding testis. The treatment is that which is appropriate for ordinary deep-seated inflammation. Injuries of the Uterus.—Injuries of the Unimpregnated Uterus are verv rare, and could scarcely occur except in combination Avith other more serious lesions. Injuries of the Pregnant Uterus, beside the risks of hemor- rhage and peritonitis, are extremely apt to terminate in abortion. The treat- ment of such cases must be conducted upon the principles which have been laid down for the management of cases of severe injury to the abdominal viscera in general. If the foetus be partially or completely extruded from the Avomb, it must be removed, per vias naturales, or through the external Avound, if there be one, according to the particular circumstances of the case. Rupture of the Womb, Occurring during Parturition, is not a subject prop- erly Avithin the scope of this work. Laceration of the Cervix Uteri is an accident of not unfrequent occurrence during labor, and may require an operation, which consists essen- tially in freshening the edges of the rent Avith suitably curved scissors, and fixing them -with metallic sutures which are alloAved to remain for about ten days. Injuries of the Vulva and Vagina__Contusions and Wounds of these parts are to be treated on the principles Avhich guide the surgeon in the management of similar injuries in other regions of the body. Women are sometimes seriously wounded, Avhile in the act of micturition, by the breaking INJURIES OF THE PERINEUM. 379 183. under them of chamber utensils, and fatal hemorrhage has occasionally re- sulted, under these circumstances, from a Avound of the internal pudic artery. The treatment would consist in plugging the wound Avith lint, dipped in a solution of the persulphate or perchloride of iron, and in the application of a compress and firm bandage. Foreign Bodies occasionally become impacted in the vagina, or may be thrust through its Avails into the bladder, rectum, or peritoneal cavity. The treatment consists in the removal of the offending substance, by such means as the ingenuity of the surgeon may suggest, and in the subsequent adoption of measures to combat the resulting inflammation. Injuries of any portion of the " genital zone," received during pregnancy, are, as pointed out by Gueniot, apt to be followed by abortion. Injuries of the Perineum__Wounds of the Male Perineum, not in- A'olving the urethra, commonly heal Avithout much difficulty. Lacerations of the Female Perineum occasionally occur during labor, and, if at all extensive, usually require an operation for their cure. If the case be seen within twelve hours after the occurrence of the laceration, it Avill probably be sufficient to approximate the parts with deep and superficial sutures, maintaining the thighs in apposition until union has occurred, and insuring cleanliness by frequent syringing with a solution of permanganate of potassium. At a later period, it will be necessary, aJter emptying the bowel by means of an enema, to draw aAvay the anterior Avail of the vagina Avith a duck- billed speculum, and freshen the edges of the opening (making a raAv surface at least an inch in depth, and extending the Avhole length of the fissure), then accu- rately adjusting the parts with the quilled suture, as recommended by BroAvn, or simply Avith the interrupted suture, as done by Sims, Emmet, and AgneAv. In either operation, two sets of sutures may be properly employed ; a deep set—enter- ing an inch from the cut edge, passing as deep as the denudation extends, and com- ing out an inch from the cut edge on the opposite side—and a superficial set to in- sure more accurate adjustment of the cu- taneous surfaces. When the sphincter is involved, care should be taken in passing the hindmost suture to let the needle enter and come out far back towards the coc- cyx, so as to insure the close approxima- tion of the separated muscular fibres, and thus guard against fecal incontinence. This precaution is particularly insisted upon by Emmet, avIio finds that its neglect frequently allows the persistence of a recto-vaginal fistula. If the Avhole recto-vaginal septum be torn, it will be necessary to close this by numerous interrupted sutures passed from the vagi- nal surface, and, in these cases, it may be desirable to divide the sphincter ani on either side, as recommended by BroAvn. If there he great tension upon the deep sutures, a curved incision may be made on either side of the perineum, as recommended by Diefi'enbach and T. Smith ; Parker, of NeAV York, employs lateral incisions through the bottom of which he passes sutures Surface denuded in complete perineal rupture, and first two sutures in position. (Thomas.) 380 DISEASES RESULTING FROM INFLAMMATION. of doubled wire, secured over bits of catheter. If the quilled suture be em- ployed, either strong whip-cord or flexible Avire may be used. The best ma- terial for the interrupted sutures, both superficial and deep, is strong silver wire. The deep sutures are most conveniently introduced by means of a needle fixed in a handle. In the after-treatment, constipation should be maintained by the administration of opium, for about two Aveeks, and the catheter should be used at regular intervals. Sims and Emmet advise the employment of a short rectal tube, to allow the escape of flatus. The deep sutures may be removed from the sixth to the eighth day, and the superficial set a few days later. Catgut sutures are recommended by Dr. Brickell, of New Orleans, avIio further modifies the operation by tying the deep sutures over metallic stays placed between the sides of the wound. Dr. Hodgen, of St. Louis, instead of merely freshening the edges of the laceration, dissects triangular flaps from both buttocks, and turns them inwards with their cuta- neous surfaces towards the vagina, thus increasing the size of the raAv surfaces to be approximated, and furnishing an apron Avhich prevents the vaginal dis- charges and urine from irritating the Avound. A similar plan is adopted by Parker and by Stimson, of New York, and is by the latter surgeon attributed to Langenbeck. CHAPTER XX. DISEASES RESULTING FROM INFLAMMATION. Abscess. An abscess is a collection of pus, surrounded by a Avail or layer ofi%lymph.' Pus, existing in a serous cavity (as in empyema), or in a joint, does not strictly constitute an abscess (though often so called), any more than pus Avidely diffused through the cellular tissue, or covering the granulations of an ulcerated surface. Several varieties of abscess are described by surgical writers, as the acute or phlegmonous; the chronic ; the cold, lymphatic, con- gestive, or scrofulous; the diffused (a contradiction in terms) ; the emphy- sematous ; the metastatic or pyamiic ; and the residual. The division Avhich I shall adopt, and which seems to me to be the simplest, is into (1) the acute or phlegmonous abscess, which may be considered the typical form ; (2) the chronic or cold abscess; and (3) the residual abscess. Diffused Suppura- tion (Avhich, according to the definition above given, does not constitute an abscess) will be described in a separate place, and the so-called Metastatic Abscess in the chapter on Pyaemia. The presence of gas in an abscess (con- stituting the Emphysematous variety) is a mere coincidence, depending on the locality of the affection, or on the occurrence of putrefaction. Acute or Phlegmonous Abscess__When a part that has been inflamed becomes more swollen, the dull pain changing to one of a throbbing or pulsatile character, the skin assuming a deeper hue, and presenting a shining and glazed appearance, the surgeon knows that suppuration is im- pending, and that an abscess will probably be formed. If the seat of pus- formation be deep-seated, the superincumbent tissues become braAvny and edematous, from infiltration of lymph and effusion of serum, and, as the pus gradually approaches the surface (Avhich it has an almost invariable tendency to do), the overlying tissue becomes softened, the thinnest part bulges for- ACUTE OR PHLEGMONOUS ABSCESS. 381 wards, the cuticle often desquamates, fluctuation (wliich was at first obscure) becomes manifest, and pointing of the abscess is said, to have occurred. A small circular slough is then formed at the thinnest part, and detached by the outAvard pressure of the pus, Avhen the abscess discharges its contents, its Avails contract by their own elasticity, the cavity is filled by the process of granulation, the remaining superficial ulcer cicatrizes, and the part returns gradually to its normal condition—the scar and loss of substance, however, sometimes persisting for a very long time. The mechanism of pointing has never been explained in a perfectly satisfactory manner. The tissue Avhich intervenes between the abscess and the surface upon Avhich it is to break, is usually said to yield by a combined process of absorption and disintegration : it seems more probable, hoAvever, that under the influence of the inflamma- tory process, rapid cell-proliferation occurs in the abscess Avail, with liquefac- tion of the intercellular substance, thus forming fresh pus-cells, the number of which is probably still further increased by the direct transit of white blood corpuscles tlirough the parietes of the capillary vessels. The final step con- sists, as has been mentioned, in a small disc of skin becoming deprived of its vitality, and being then thrown off as a minute circular slough. Though an abscess usually tends towards the cutaneous surface, it may, under other cir- cumstances, break into a mucous canal, into a joint, or even into one of the large serous cavities of the body. A happy provision of nature in the case of abscesses of internal organs (as of the liver), pointing externally, is that local- ized inflammation and adhesion may open the Avay for the escape of the pus upon the cutaneous surface, Avithout the intervening serous cavity becoming involved. Diagnosis.—The diagnosis of phlegmonous or acute abscess can usually be made without difficulty, by attending to the history of the case, by observ- ing the disposition to point, by noting the presence of fluctuation and the other local signs above described, and lastly, if necessary, by using the ex- ploring needle or trocar. Fluctuation, which is the sensation communicated to the surgeon's hands by a wave of fluid, can best be recognized by placing one or tAvo fingers of each hand on the suspected SAvelling, and making alter- nate pressure, first Avith one hand, and then Avith the other. The fingers should be placed longitudinally as regards the direction of the muscular fibres of the part, and it must be observed that in any region in Avhich the muscular and connective tissue is abundant, as in the thigh or nates, or bound doAvn by dense fasciae or ligaments, as in the temporal region or the back of the hand, a very slight increase of tension from inflammation or effusion Avill give a deceptive feeling closely analogous to fluctuation. Again, certain tumors, as the cystic, fatty, glandular, or encephaloid, are often attended with fluctuation, and have been frequently mistaken for abscesses. Finally, a partially consolidated aneurism may give the sensation of deep-seated fluc- tuation, and thus lead the surgeon into error. Hence, in any case of doubt, more especially if the suspected swelling be in the neighborhood of a large artery or other important part, the surgeon should, by all means, confirm his diagnosis by using the exploring-needle, before making a free incision. A better instrument, in some cases, than the ordinary exploring-needle, is the aspirator, or even the common hypodermic syringe. Prognosis___An acute abscess, unless very large, is usually a comparatively trivial affection. In certain situations, however, even a small abscess may not only, by pressure on nerves or other important structures, cause great pain and discomfort, but may even seriously endanger life. An abscess of the prostate or perineum may cause retention of urine ; one of the fauces or throat, dyspnoea and even death ; or one of the parotid or a cervical gland, fatal bleeding from the carotid artery or internal jugular vein. The drain 382 DISEASES RESULTING FROM INFLAMMATION. from a very large abscess, or from numerous abscesses, may cause death by exhaustion, Avith or Avithout the development of hectic fever, or by inducing the peculiar form of visceral disease which has received the name of amyloid or albuminoid degeneration. Treatment—This may be divided into the Prophylactic, and the Curative treatment. The formation of pus, in acute phlegmonous inflammation, may be prevented: more than this, pus after formation may be absorbed. I have myself seen this in several instances, and a number of cases Avere collected in the Medical Times and Gazette, for 18;">8, Avhich proved the possibility, at least, of this occurrence. Nor can this be considered at all unreasonable, if we accept the views of Cohnheim and his folloAArers, who have pretty much proved the identity of the pus cell with the Avhite blood corpuscle, and have actually seen the latter migrating through the capillary Avails. Be this as it may, abscesses unquestionably disappear under treatment, though in many cases it is probably the fiuid matter only which is absorbed, the solid remain- ing as a caseous residue, or undergoing cretaceous degeneration. The old humoralistic doctrine looked upon suppuration and abscess as efforts of nature to rid the system of some peccant matter, and hence taught the propriety of promoting and hastening, rather than of endeavoring to prevent suppuration. I suppose, however, that there are feAv surgeons at the present day avIio would not consider the prophylactic treatment of abscess at least permissible. The remedies to be employed for this purpose, have been already referred to, in the chapter on the Treatment of Inflammation : they are such as tend to pro- mote resolution. Sedative and anodyne applications, are usually most appro- priate ; dry cold, or evaporating lotions, are often useful, the former, especially, in cases in which the integrity of a joint is threatened. Warm and emollient fomentations, on the other hand, sometimes ansAver a better purpose than cold applications; gentle friction with laudanum and olive oil, and the use of cata- plasms, will be found most efficient in the prevention of mammary abscess. Finally, it is sometimes possible, as it Avere, to stimulate aAvay an abscess: I have more than once succeeded in dispersing a bubo by the use of a blister, even after pointing had occurred. Curative Treatment___The length of time during Avhich abortive measures, if not rapidly successful, may be persevered in, should depend a good deal upon the feelings of the patient. If the pain and febrile disturbance which accompany the formation of an abscess be very great, it will usually be Avise to desist from such measures, and strive merely to relieve the patient's suffer- ings. I am not quite sure that Ave can often materially hasten the pointing of an abscess by treatment, but Ave can certainly make the patient more com- fortable while the pus is approaching the surface, and the best application for this purpose, in the immense majority of cases, is an emollient poultice. Though an abscess will eventually burst of itself, it is usually better to evacuate its contents artificially—this little operation giving great relief to the patient, and rendering the resulting scar less conspicuous. The time at which an abscess should be opened depends on the circumstances of the case; if the pus be deep-seated and bound down by tense fascia\ the pain being great, an early incision, at the most dependent point, should be practised, and will be found to afford the greatest comfort to the patient; if, on the other hand, the abscess be comparatively superficial, and the pain and constitutional disturbance not very intense, it is, I think, better to wait until decided point- ing has occurred. The reason for this is that, if the incision be made pre- maturely in another locality, pointing and spontaneous opening may still take place, the surgeon's interference in such a case being afterAvards thought by the patient, and not unreasonably, to have been uncalled for. An acute abscess should only be opened by incision, and this is best ac- CHRONIC OR COLD ABSCESS. 383 Fis. 184. complished, I think, with a straight, narroAv, sharp-pointed bistoury. The surgeon, holding the knife in his right hand as a pen, but almost perpendicu- larly to the surface, with the edge towards himself, fixes the abscess Avith the thumb and fingers of the left hand, and resting the ring and little finger of the right hand upon the skin, quickly plunges the point of the knife into the cavity of the abscess, and rapidly draAving the blade toAvards himself, enlarges the puncture to the requisite extent as he Avithdraws the instrument. The depth to which the knife is to penetrate having been mentally determined beforehand, the instrument is prevented from going too far by the pressure of the fourth and fifth fingers on the cutaneous surface. The incision should be made in a longitudinal direction as regards the part affected. Local an- aesthesia has been sometimes used in these cases, but the freezing process is in itself not devoid of pain, while it renders the skin much more difficult of penetration. If the abscess be situated very deeply, there might be some risk of Avounding a large vessel in making the opening as above directed, and in such a case it Avould be better to adopt Hilton's plan, incising the skin and fascia, and then pushing a grooved director through the OAerlying mus- cles into the abscess, the opening being dilated by separating the blades of a pair of forceps introduced along the groove of the instrument. A free aper- ture having been made, the abscess may be alloAved to evacuate its.contents by the elastic contraction of its OAvn Avails; the surgeon may, if necessary, make Arery gentle pressure with soft sponges on either side of the incision, but all rude handling or squeezing should be strictly ayToided. Hemorrhage into the cavity of an opened abscess may occur from a vessel accidentally divided, or Avhich subsequently gives way from the relief of pres- sure upon its Avails. The treatment consists in exposure to the air, cold, pressure, or ligation, as in other cases of hemorrhage. After the eA'acuation of an abscess, poultices may be con- tinued for a few days, until the surrounding inflammation has subsided, when cerate or other simple dressing should be applied to the wound, and the Avails of the cavity compressed by means of a bandage or adhesive strips. If, from the size or situation of the abscess, or from any other circumstance, there be a tendency to bag- ging of matter, a drainage-tube may be em- ployed, being either simply introduced into the incision by means of a forked probe, or carried seton-like through the cavity, and brought out by a counter-opening. Instead of the ordinary drainage-tube, a flexible metallic probe may be substituted (the pus escaping by its side), or a coil of Avire, as recommended by Mr. R. Ellis. The hygienic and constitutional treatment of abscess, and of suppuration generally, has already been considered in the chapter on the Treatment of Inflammation. Drainage-tube and forked prob" Chronic or Cold Abscess.—The term chronic abscess is open to objection, as referring etymologically only to time, and being of course merely comparative. A phlegmonous abscess, if deeply seated, may be of sloAver development than a chronic or cold abscess, Avhich is superficial. The term cold abscess is borroAved from the Germans, and is significant, as referring to a prominent symptom in these cases, viz., the absence, in greater or less 384 DISEASES RESULTING FROM INFLAMMATION. degree, of the increased temperature and other common signs of inflammation. These abscesses are chiefly met with in connection Avith diseases of the bones or joints, or of the lymphatic system. They are not attended with much pain, have little or no disposition to point, and sometimes extend widely beneath the skin, or among the planes of muscular tissue. Their development is sometimes very slow, resembling that of phlegmonous abscesses, only with less local and constitutional disturbance, the investing layer of lymph being occasionally so dense as to obscure fluctuation, and give the appearance of a solid tumor; at other times, the patient suddenly discovers in the groin or axilla a large fluctuating swelling, no symptom having been previously mani- fested to call attention to the part. These abscesses may persist, Avithout undergoing any marked change, for months or even years. The diagnosis must be made with the precautions already pointed out, and often requires the use of the exploring-needle. The pus in these abscesses is usually thin and ill-formed, containing a larger proportion of granules and oil globules, and feAver pus corpuscles, than ordinary "laudable" pus. The treatment of these cases is somewhat different from that appropriate to those of the phlegmonous variety. If the abscess be quite small, it may be simply opened, healing of the cavity being subsequently promoted by the use of some stimulating application, such as the diluted tincture of iodine. In dealing Avith a larger abscess, it is better to wait until the skin threatens to give way, unless, from the situation of the abscess, it may be necessary to relieve adjacent organs from pressure. With regard to very large abscesses, particularly those Avhich are connected with disease of the spine or bony pelvis, I am decidedly of opinion that it is better, as a rule, to leave them unopened ; a patient may carry a psoas or iliac abscess for years Avith com- paratively little annoyance, and maintaining very tolerable health, and yet sink in a very short time after such an abscess has been imprudently evacu- ated. Besides, there is ahvays the hope that complete or partial absorption may occur, Avhen the patient may remain Avell, if not permanently, at least for a very long period. If it be determined to open a large chronic or cold abscess, this may be done Avith the aspirator, or, if preferred, by means of a valvular incision made Avith antiseptic precautions in the manner recom- mended by Prof. Lister. If an abscess have been freely opened and Avill not heal, stimulating injections of iodine may be tried, or a seton of oakum or tarred rope may be used (as recommended by Dr. Sayre, in cases of caries), a method Avhich has the additional advantage of insuring drainage of the suppurating cavity, Callender advises hyperdistension of the abscess-sac with carbolized water. In all cases of chronic abscess it is necessary to pay great attention to the state of the general health, maintaining the patient's strength by the administration of nutritious food and tonics. Residual Abscess__This term has been introduced by Sir James Paget, who proposes to include under it " all abscesses formed in or about the residues of former inflammations." They may occur in the site of pre- vious abscesses which have been partially absorbed, or in the indurations and adhesions left by old inflammation, Avhich had not reached the suppurative stage. Residual abscesses are chiefly met Avith in connection with diseases of the spine, of the bones and joints, and of the lymphatic glands. The prognosis is more favorable than that of ordinary chronic abscess, the heal- ing after evacuation being, according to Paget, quicker, and attended with less constitutional disturbance, than that of a primary abscess, of the same size, and in a similar situation. The treatment is that already described as appropriate to chronic abscess arising under other circumstances. ULCERS. 385 Sinus and Fistula___These are narrow, and often tortuous, suppurating canals or tubes, left by the incomplete healing of abscesses, or resulting from wounds Avhich have united imperfectly. The term fistula is also applied to abnormal communications between external and internal parts (as gastric, aerial, or urethral fistula), or between adjacent mucous canals or cavities (as recto-vesical, or A'esico-vaginal fistula). When applied to the condition re- sulting from an abscess, or ordinary wound, the term fistula should be reserved for those cases in Avhich there are two openings (as in a fistula in ano), the more general term, sinus, embracing all those tortuous suppurating tracks, which have but one orifice. Sinuses may be kept from healing by the presence of a foreign body or a spicula of bone, by the passage of secretions, as of saliva or urine, or by the action of adjacent muscles. The treatment consists in re- moving all irritating substances, and in placing the part at rest, by position, bandaging, etc. In a recent case, healing may be promoted by keeping the walls of the sinus in contact by means of compression, Avhile, if the Avails of the sinus be callous and indurated, they may be stimulated to greater activity by means of irritating or caustic injections, the tarred seton, or the galvanic cautery. Finally, it may be necessary to freely lay open the sinus through its entire length, by introducing a grooved director and slitting up the super- incumbent tissues ; the sinus may then be dressed as an open ulcer, and made to heal from the-bottom. This mode of treatment is especially indicated Avhen healing is prevented by the action of neighboring muscles, as in cases of fistula in ano, or in the troublesome sinuses Avhich are met with in the groin, in con- nection with suppurating buboes. It is often a good plan, after laying open a sinus, to Avipe its Avhole track out Avith the solid stick of nitrate of silver, thus making a superficial slough, and preA'enting premature reunion of the cut edges. Diffused Suppuration, though ordinarily occurring in that form of diffuse inflammation of the areolar tissue which is closely analogous to, if not identical with, erysipelas, may, I believe, occur as a sequel of ordinary inflam- mation, in persons in a Ioav state of health, and whose vital powers have been from any circumstance much reduced. It may result from an accidental or other Avound, or from the irritation of extravasated urine, but may also occur without any apparent exciting cause. The surface in these cases is but slightly red, the SAvelling is ill-defined, and rapidly spreads in various direc- tions ; there is a feeling of bogginess, rather than of fluctuation, and there is sometimes emphysematous crepitation, caused by the gases developed by the putrefactive process ; the patient does not suffer very great pain, but is in a profoundly typhoid condition. The treatment consists in making numerous punctures, or small or even large incisions (to relieve tension, and facilitate the exit of pus and sloughs), and in the free administration of stimulants and quinia. Ulcers. The process of ulceration and the mode in which ulcers heal, by granula- tion and cicatrization, have been considered in a previous chapter, and need not be again referred to. Ulcers have been variously classified by systematic Avriters, either according to the appearance of the ulcer itself, or according to the constitutional condition of the patient. Thus, we read of healthy, irrita- ble, indolent, weak, inflamed, exuberant, sloughing, varicose, and hemor- rhagic ulcers; and, again, of eczematous, cold, senile, strumous, scorbutic, gouty, syphilitic, lupous, and cancerous ulcers. It is easy to understand that in a person disposed to eczema, an ulcer may be seriously complicated by an 25 386 DISEASES RESULTING FROM INFLAMMATION. attack of that disease, and that any treatment, to be successful, must have regard to the eczematous condition, as Avell as to the ulcer itself. So in a strumous subject, such remedies as iodine and cod-liver oil may be more im- portant than any local treatment. Scorbutic and gouty ulcers require medi- cines adapted to the scorbutic and gouty diatheses ; Avhile it is quite idle to attempt to heal the ulcerated surface of a cancer, as long as the cancerous mass itself is alloAved to remain. For practical purposes, the classification usually adopted (which has reference to the appearances of the ulcers them- selves, when occurring in persons of ordinary good health, and not the sub- jects of any special morbid diathesis), is convenient and sufficiently satisfactory, it being remembered that there is no specific or essential difference between these various forms of ulcer, but that the ulcerative process is identical in nature, under all circumstances. Simple or Healthy Ulcer.—This may be considered the type of all the other varieties, and that to which they must be brought, in order to effect a cure : it is such an ulcer as is seen in a healing burn, or in a superficial Avound which is closing by the second intention. The natural tendency of such an ulcer being towards a cure, the only treatment necessary is to keep the part from being injured. Water dressing, or a greased rag, Avith an elevated position of the part, is all that is usually required ; if the granula- tions become exuberant, they should be touched with bluestone or lunar caustic ; while if too small and closely set, the resin, or carbolic acid, cerate may be substituted for the milder applications commonly employed. This variety of ulcer may be met with in any part of the body ; those to be next described are most frequently seen in the leg. Inflamed or Phlegmonous Ulcer___This variety is usually met Avith in those of full habit, and may arise from accidental irritation of a simple ulcer. One of the worst cases of this kind that I have ever seen, was in a gentleman Avho, having a slight excoriation of the tibial region, rode for seve- ral hours on horseback, with the stirrup-leather constantly rubbing and chafing the injured part; as a consequence, the whole leg Avas attacked with phleg- monous inflammation, which obliged the patient to stay in the house, with the foot elevated, for a considerable period. The treatment of an inflamed ulcer consists in enforcing rest, with elevation of the part, in the use of soothing applications, either cold or warm as most agreeable to the patient, and in the administration of laxatives, diaphoretics, etc., as may be indicated by his general condition. Sloughing Ulcer__This may be considered as an aggravated form of the last variety, and is usually met with in cachectic or ill-nourished indivi- duals. The treatment consists in the administration of opium and of concen- trated nutriment, with stimulus if required, and in the local application of anodyne fomentations, such as diluted laudanum. If there be much tendency to spread, the ulcer should be treated as a case of sloughing phagedama, or hospital gangrene. The " electric bath" is recommended by AVeisflog. Weak or (Edematous Ulcer__In this variety the granulations are large, pale, flabby, and apparently distended with serum. They are not un- frequently detached in large masses by sloughing. This form of ulcer may be induced by long-continued application of poultices, or of Avater dressing. I have frequently seen it in cases of neglected gunshot Avound. The treatment consists in improving the general tone of the patient, and in the local use of INDOLENT OR CALLOUS ULCER. 387 stimulating and astringent dressings, such as a solution of sulphate of zinc, or of sulphate of copper, zinc cerate, etc., with moderate support by means of a bandage. Roche, an East Indian surgeon, speaks very highly of applications of the bark of the acacia catechu, so as fairly to tan the ulcer and surrounding skin. Neuralgic or Irritable Ulcer__This variety is characterized by the intense pain and hyperaesthesia Avhich accompany it. It usually occurs about the malleoli, or anterior edge of the tibia, and is most frequent in Avomen past the middle age, and avIio are in a depressed state of health, though I have seen it in young, and otherwise healthy, laboring men. The treatment consists in the use of anodyne fomentations, with the occasional application of a solution of nitrate of silver (gr. iv-x ad f 3j), as recommended by Skey for painful burns. The general health must at the same time be improved by the administration of tonics, especially quinia, nux vomica, etc. If the pain can be traced to any special nerve, this may be resected, as advised by Mr. Hilton. Indolent or Callous Ulcer.—This is by far the most common form of ulcer; it occurs usually in those of middle life, and is situated in the loAver half of the leg, and more often on the fibular than on the tibial surface. The floor of the ulcer is someAvhat concave, Avith flattened granulations, furnishing a thin and scanty pus. The ulcer is surrounded by an elevated ring of very dense and indurated tissue, which seems to be a provision of nature to prevent the spread of the disease, acting, indeed, as a kind of natural splint to keep the ulcerated surface at rest. As long as this hard ring remains, however, healing will not occur, and, hence to depress the edges, is the first step in the treatment of an indolent ulcer. If the patient can remain in bed, with the foot elevated, a poultice may be applied for tAvo or three days, to soften and relax the tissues, pressure being then applied by means of a few adhesive strips, the positions of Avhich are varied at each dressing, Avhile the edges of the ulcer are stimulated with the solid stick of nitrate of silver. A very good plan of hastening the disappearance of the indurated ring, is to make across it numerous radiating incisions, extending about a quarter of an inch into sound tissue, as recommended by Mr. Gay. Sappey's and Syme's method, which consists in the application of a blister, to the Avhole ulcerated surface and a zone of the surrounding healthy skin, is occasionally very efficient. Finally, the indurated edges may be trimmed away with the knife, a pro- ceeding which, though apparently heroic, is almost painless, on account of the indolent nature of the sore. As soon as the ulcer has by these means lost its peculiar excavated appearance, it may be dressed with resin cerate, or some similar article, cicatrization being assisted by moderate compression with adhesive strips and bandage. The sulphuret of carbon has recently been recommended as a dressing in these cases by Guillaumet and other French surgeons. In case the skin is very irritable, the disease approaching in character to Avhat is called the eczematous ulcer, wet strips of Bandage may be advantageously substituted for those of adhesive plaster. It often happens that patients Avith indolent ulcers find it impossible to lie by, as above recom- mended, and, under such circumstances, I know of no better mode of treat- ment than that introduced by Baynton and Critchett, which consists in closely strapping the part, or even the Avhole limb, Avith strips of adhesive plaster laid on in an imbricated manner, a firm bandage being then applied over all (Fig. 185); or an India-rubber bandage maybe used, as advised by H. Mar- tin. The only constitutional treatment usually required in these cases, is such 388 DISEASES RESULTING FROM INFLAMMATION. Fig. 18"). as mav be indicated by the pa- tient's general condition. Mr. Skey recommends the adminis- tration of opium, Avhich may be given in doses of one grain, night and morning. In the eczema- tous cases, I have derived advan- tage from the persistent use of small doses of FoAvler's solution. In some cases an ulcer Avill heal readily up to a certain point, and there will stop, in spite of the most careful dressing—the tension upon the part appearing to be so great that further con- traction cannot take place. Un- der such circumstances a longi- tudinal incision, as advised by strapping an ulcer. (Liston.) Faure, may be made through the healthy skin on each side of the ulcer, the gaping of the incisions permitting the resumption of the healing process; or circular incisions, surrounding the ulcer, as originally suggested by Dolbeau and recently recommended by Niissbaum, may be substituted. Plastic operations have been occasionally practised for the cure of obstinate ulcers of the leg, but, in my experience, have not proved very successful. It has been suggested by a French surgeon, M. Reverdin, to treat ulcers by the Transplantation of Cuticle. The operation consists in applying shav- ings of the epidermis, or of this with a thin layer of the cutis—the latter plan has been most commonly adopted—to various points of the granulating surface, binding these grafts in position by means of adhesive strips. The grafts may at first seem to disappear, but in a few days become converted into isolated cicatrices, from which, a.s from centres, the healing process rapidly spreads. It is essential for the success of the experiment, that the granula- tions should be in a healthy condition, that no fat should be transplanted Avith Fig. 186. Scissors for skin-grafting. the skin, and that the graft should be closely and accurately applied to the granulating surface. This mode of treating ulcers has excited a good deal of attention, and has been tried with more or less successful results at numerous English and American hospitals. The transplantation of hairs has been suggested as a substitute by Dr. ScliAveninger, a German surgeon. In some situations, as on the back, betAveen the shoulder-blades, it is very difficult to apply equable pressure by the methods ordinarily employed. Here the application of a zinc plate, or disc of sheet-lead, cut to fit the ulcer, will ULCERS OCCURRING ON MUCOUS MEMBRANES. 389 often be attended by the happiest results—not, I believe, by the development of any galvanic current, as has been supposed, but simply by acting as an efficient means of applying mechanical compression. The use of a gahanic current is, liOAveA'er, recommended by Spencer AYells, Golding-Bird and other writers. The virtues of sheet-lead have been recently extolled by Dr. Aran Blaeven, a Belgian surgeon, avIio claims by its use to have effected the restoration of parts carried aAvay by sabre-strokes, etc. Hemorrhagic and Varicose Ulcers__Other varieties of ulcer, de- scribed by systematic Avriters, are the hemorrhagic and the varicose. The Hemorrhagic Ulcer is one that bleeds from time to time, occasionally existing in connection with the hemorrhagic diathesis, but more often serving as a channel for \-icarious menstruation. The treatment, in the latter case, con- sists in endeavoring to restore the normal Aoav, by means of the remedies ordinarily used for amenorrhoea. The Varicose Ulcer is merely an ulcer co- existing Avith varicose veins. It is commonly taught that the varicose disease precedes and causes the ulcer, and obliteration of the veins is accordingly proposed as the only rational mode of cure. It has been shoAvn, hoAvever, I think, by Mr. Gay's researches, that the varicose condition is rather a conse- quence than a cause of the ulceration, and that hence less actiAe measures will commonly suffice. The treatment should vary according to the condition of the ulcer, Avhether inflamed, irritable, or indolent. Hemorrhage from the bursting of a A'ein, may be checked by position and pressure, or may occa- sionally require obliteration of the vessel, by the method Avhich will be described Avhen we come to speak of varicose veins in general. After the cicatrization of an ulcer is completed, a great deal may be done by care and attention to prevent the scar from again giving Avay. The part should be kept scrupulously clean, and should be protected as much as pos- sible from external injury. If the ulcer be situated on the leg, the patient may ad\-antageously wear an elastic bandage or stocking, to counteract the tendency to gravitation of blood Avhich necessarily exists in that part. Amputation for Ulcer__It sometimes happens that an ulcer proves utterly incurable, either from extending completely around the limb, or from deeply inA'olving a subjacent bone or neighboring joint (as in the perforating ulcer which sometimes folloAvs a bunion). In such cases the question of amputation may arise, and the operation under such circumstances would be occasionally justifiable. It must be remembered, hoAvever, that amputation, in the loAver extremity, is in itself attended with very great risk to life, and that the disease, in the instances mentioned, is often more a source of dis- comfort than of danger or even positiA'e suffering. Hence the surgeon should hesitate before proposing an operation which is not imperatively required, and which may be folloAved by the gravest consequences. When amputation is resorted to, it should he done at such a height as to insure the possibility of forming the flaps from perfectly healthy tissues. Ulcers occurring on Mucous Membranes present the ordinary characters of healthy, Aveak, or irritable ulcers, as met with in the cutaneous structures. They usually require the free use of stimulating or caustic appli- cations, the best being, probably, the nitrate of silver, Avhich may be employed either in substance or in solution. 390 DISEASES RESULTING FROM INFLAMMATION. Gangrene and Gangrenous Diseases. The nature and treatment of the ordinary forms of gangrene have already been considered in the chapters on Inflammation, on AVounds in General, on Injuries of Bloodvessels, and on Amputation. There remain to be described certain forms of Spontaneous Gangrene, and those affections which are com- monly classed together as Gangrenous Diseases. Spontaneous Gangrene may occur at any age, and is due to arrest of the circulation, caused either by disease of the arteries themselves, or by a morbid condition of the circulating fluid. Lnfiammation of the arterial coats may cause gangrene, as may arterial thrombosis without inflammation, or embolism from the detachment of fibrinous concretions from the valves of the heart; the latter is, I believe, a more frequent occurrence than is usually supposed. Finally, the use of certain articles of food, as of spurred rye, has been followed by spontaneous gangrene. This form of gangrene is usually of the dry variety, though moist gangrene may occur after embolism, when the main trunks which furnish blood to the part are suddenly occluded—the dif- ference probably depending, as remarked by Coote, upon the rapidity with Avhich the death of the part takes place. Senile Gangrene (which, as ordi- narily seen, may be considered the type of the dry variety of the affection, or mummification) is dependent upon calcification of the arterial coats, together with the general loss of tone and enfeebled nutrition which accom- pany old age. In certain cases, the exciting cause of the disease is some slight irritation, such as the chafing of a shoe, and, under such circumstances, the gangrene approaches somewhat to the ordinary inflammatory form of mor- tification. More often the disease begins, Avithout apparent cause, as a dark purple or blackish spot, surrounded by a dusky red areola, which spreads with the gangrene and is the seat of intense burning pain, the latter, how- ever, subsiding when the gangrene is complete. The seat of the gangrene is commonly the inner side of the foot, and especially of the great toe, though I have seen a precisely similar condition of affairs in the scrotum, in a patient worn out by a low fever; the fact that this form of gangrene occurs, under such circumstances, among comparatively young persons, sIioavs that the term senile gangrene, though significant, is not strictly accurate. AAkrning is some- times given of the approach of this form of gangrene, by the existence of signs of defective circulation, such as numbness, coldness, tingling, and cramps in the calves of the legs. The course of senile gangrene is usually chronic, lasting sometimes for more than a year, and recovery occasionally follows after the separation of the affected part. Treatment___This consists in maintaining the general health of the patient, by the use of tonics, and by the judicious administration of food and stimu- lants. Among drugs, opium is particularly useful, and may be given in grain doses three or four times in the twenty-four hours. Antispasmodics also may be advantageously used in these cases, especially chloroform (internally) and camphor. The local treatment consists chiefly in keeping the part warm, by wrapping it in cotton-wadding or wool; if there be much fetor, charcoal poultices may be substituted, or cloths wet with a solution of permanganate of potassium. The question of amputation in senile gangrene has already been referred to, at page 91. Bed-sores.—These may occur in any case in \Arhich a patient is confined to bed for a considerable period, simply from the long-continued pressure— GANGRENOUS STOMATITIS. 391 just as similar excoriations and sloughs may result from the use of a badly- padded splint. The Avorst forms of bed-sore are, however, seen in patients whose general powers of nutrition are impaired by previous illness (as in typhoid fever), or who, from spinal injury, are totally unable to vary their position. In such cases, it is not infrequent for the slough to extend so deeply as to involve the sacrum, or any other bone that is exposed to pressure, or even, in some instances, to lay open the vertebral canal. The pain attending bed-sores is usually very great, though, in cases of spinal injury, the patient may be unaAvare of their existence. The formation of bed-sores may com- monly be prevented by the use of a water-mattress, or of soft pilloAvs, the parts being kept scrupulously clean, frequently bathed Avith stimulating and astringent lotions, and protected by the application of collodion, soap-plaster, or adhesive plaster; Prof. Brown-Sequard recommends the alternate appli- cation of ice and hot poultices. If a bed-sore have actually formed, the sepa- ration of the slough may be hastened by the use of yeast or porter poultices, the ulcer Avhich is left being subsequently dressed with resin cerate, or some similar application ; the part must be entirely freed from pressure, and the patient's general health improved by the administration of concentrated food, tonics, and stimulants. In obstinate cases, healing may sometimes be pro- moted by the application of the galvanic current, as suggested by Crussel, of St. Petersburg, and recommended by Spencer AArells and by Hammond, of New York. Bed-sores may occasionally prove fatal, by involving important structures (as the membranes of the spinal cord), by leading to hemorrhage, by gradually exhausting the patient, or by the induction of pyasmia. Gangrenous Stomatitis, also called Gangraena Oris, Cancrum Oris, and Noma, is an affection of childhood, coming on after the A'arious eruptive J**4^t3*:~~^ fevers, especially measles—a someAvhat similar affection sometimes occurring 0*~e*^T*"j\ in adults after typhus. Gangrenous stomatitis has been attributed to the ^ abuse of mercury, and this drug, if improperly exhibited, may of course be one source of depression, in addition to the debilitating effects of illness, deprivation of food, etc. That there is, hoAvever, any direct causal connec- tion betAveen the use of mercury and this disease, is, I think, at least not proved. The first symptom of gangrenous stomatitis is usually a dusky red SAvelling of the cheek, which becomes stiff and shining. Careful examination will now show a sloughing ulcer on the inside of the cheek, extending to the adjacent gum, and discharging fetid, ill-formed pus, Avhich, mingled with saliva, constantly dribbles from the mouth. As the disease progresses, a gangrenous spot appears on the cheek, the whole thickness of the part being finally involved, and perforation of the cheek, with denudation and perhaps necrosis of the alveoli, resulting. The constitutional symptoms are of a typhoid character, coma sometimes supervening before death, which may occur at almost any period of the disease. The treatment consists in evert- ing the cheek (the patient being anaesthetized), and thoroughly cauterizing the Avhole ulcerated surface with strong nitric acid. One thorough cauteriza- tion is usually sufficient, though the case must be watched, and a second or third application made if necessary. The mouth should be frequently syringed Avith detergent and disinfectant Avashes, such as a solution of the permanganate or chlorate of potassium, or of borax, and the general health sustained by the frequent administration of concentrated food and stimulus. The application of tincture of iodine is recommended by Dr. Miller, of Kansas City, while Popper, of Pesth, advises that the slough should be scraped away, and the parts dressed Avith creasote. The deformity left after cicatrization may subsequently require a plastic operation for its cure. 392 DISEASES RESULTING FROM INFLAMMATION. Noma Pudendi—This grave affection, which seems to be confined to female children, is very analogous to the preceding, and usually attacks the mucous or submucous tissues of the generative organs, though, according to Holmes, it sometimes begins in the fold of the groin. The treatment consists in early and thorough cauterization, and in the adoption of measures to sus- tain the patient's strength. Parrot speaks favorably of the local use of iodo- form. Death sometimes occurs very suddenly, after the apparent establish- ment of convalescence. Hospital Gangrene___This affection, which has received a great variety of names, such as Sloughing Phagedena, Pulpy Gangrene, Putrid Degeneration, Traumatic Typhus, Pourriture d'Hopital, etc., is occasionally met with as a sporadic disease, but has attracted most attention when pre- vailing epidemically or endemically in hospitals, especially where large num- bers of wounded men are crowded together, as in military hospitals in the neighborhood of a battle-field. It has been studied by a great many Avriters, among whom may be particularly mentioned, Pouteau, La Motte, Ollivier, Delpech, Legouest, Rollo. Blackadder, Boggie, Hennen, Ballingall, Thomson, Guthrie, and Maeleod. It has also been ably investigated by many Ameri- can surgeons, who had ample opportunities for its study during the late Avar, and an elaborate monograph on the subject has been contributed by Prof. Joseph Jones, of New Orleans, to the Memoirs of the U. S. Sanitary Commis- sion. The characters of hospital gangrene vary in different epidemics. The majority of observers have found the local to precede the constitutional symp- toms, and hence have regarded the disease as a strictly local affection ; Avhile in other instances, equally careful observers have found constitutional disturb- ance, headache, furred tongue, etc., to precede the local changes intheAvound by an interval of from one to three days. Hospital gangrene is undoubtedly contagious,1 having been developed by indirect inoculation, as well as through the medium of instruments and sponges ; the exceptional cases, in which one of two contiguous Avounds, in the same patient, suffered from the disease, Avhile the other escaped, merely prove that in those instances the affection was not auto-inocukble. AY bile, however, hospital gangrene is usually transmitted by contagion, it may probably also originate de novo, as the result of overcrowding, bad ventilation, etc. Two forms of hospital gangrene may be recognized, but the difference be- tween them is one of degree rather than of kind. For the development of either, the presence of a Avound is probably necessary, though this Avound may be of the most trivial character, as the sting of an insect, the prick of a 1 Dr. W. Thomson examined microscopically the discbarges, in several cases of hospital gangrene which occurred at Douglas Hospital during the late war, with a view of determining the presence or absence of fungi, which it was supposed might be tbe source of contagion. " No fungi Avere found. The discharge consisted of fluid, granular matter, and debris. The connective tissue seemed to have been broken down into unrecognizable granular material. The fibrous tissue was softened and easily teased out, and in the muscular tissue the striated appearance was lost before the fibrous. No evidence of textural growth was found in the discharges, although the ' piled-up' and thickened margins of the ulcers would probably reveal, on exami- nation, a multiplication of the connective tissue corpuscles, as reported in a similar group of cases at Annapolis, Md., by Assistant Surgeon Woodward, U. S. A." {Am. journ. of Med. Sciences, April, 1864, p. 393.) By microscopic examination, Prof. Joseph Jones has discovered numerous animalcules, as well as vegetable organisms, in the gangrenous matter of hospital gangrene, but has been unable to establish any relation between the cause of tbe disease and the nature and character of these or- ganisms, which have been absent in the most extensive gangrene, when excluded from the atmosphere by sound skin. (See U. S. Sanitary Commission Memoirs (Surgi- cal), vol. ii. p. 266.) HOSPITAL GANGRENE. 393 lancet, or even the scratch of a finger-nail. A depressed or depraved state of the system does not appear to be at all essential for the development of the disease, though it may very probably aggravate the intensity of the affection when it occurs. The following description, taken from Guthrie, gives a vivid picture of the worst form of hospital gangrene. The wound thus attacked "presents a horrible aspect after the first forty-eight hours. The Avhole sur- face has become of a dark-red color, of a ragged appearance, Avith blood partly coagulated, and apparently half putrid, adhering at every point. The edges are everted, the cuticle separating from half to three-quarters of an inch around, with a concentric circle of inflammation extending an inch or two beyond it; the limb is usually swollen for some distance, of a shining white color, and not peculiarly sensible except in spots, the Avhole of it being per- haps oedematous or pasty. The pain is burning, and unbearable in the part itself, while the extension of the disease, generally in a circular direction, may be marked from hour to hour; so that in from another twenty-four to forty-eight hours, nearly the whole of the calf of the leg, or the muscles of the buttock, or even of the Avail of the abdomen, may disappear, leaving a deep, great IioIIoav, or hiatus, of the most destructive character, exhaling a peculiar stench, which can never be mistaken, and spreading with a rapidity quite aAvful to contemplate. The great nerves and arteries appear to resist its influence longer than the muscular structures, but these at last yield ; the largest nerves are destroyed, and the arteries give Avay, frequently closing the scene, after repeated hemorrhages, by one Avhich proves the last solace of the unfortunate sufferer. . . . The extension of this disease is, in the first in- stance, through the medium of the cellular structure of the body. The skin is undermined and falls in; or a painful red, and soon black, patch, or spot, is perceived at some distance from the original mischief, preparatory to the whole becoming one mass of putridity, Avhile the sufferings of the patient are extreme." This worst form of hospital gangrene is, happily, comparatively rare at the present day. In the milder form, the whole course of the affec- tion is more chronic, causing less destruction of tissue, and accompanied Avith comparatively little constitutional disturbance. The general characters of the wound are the same, especially the circular shape, and cup-like excavation or scooped-out appearance of the ulcer. There is less eversion and under- mining of the skin, less oedema and pain, and the surface of the wound is covered with a pulpy, ash-colored slough, instead of the putrid clots described in Guthrie's vivid account. -The constitutional symptoms of hospital gan- grene may at first present a someAvhat sthenic type, but rapidly change into those of a profoundly typhoid and adynamic condition, the patient indeed presenting much the appearance of one suffering from typhus fever. The mortality from hospital gangrene has varied in different epidemics. During the Peninsular campaign, the death-rate, according to Guthrie, avus 20 to 40 per cent., the general average being about 1 death in 3 cases at- tacked. In the Crimean war, the mortality in uncomplicated cases was much less, Avhile in the experience of our OAvn surgeons, during the late war, the number of deaths was comparatively very small. The causes of death, ac- cording to Prof. Jones, may be classified as (1) progressive exhaustion, (2) hemorrhage, (3) entrance of air into veins, (4) opening of large joints, (5) formation of bed-sores which subsequently become gangrenous, (6) diarrhoea, (7) subcutaneous disorganization of tissues around the original Avound, (8) mortification of internal organs, (9) direct implication of vital parts, (10) pyemia, (11) phlebitis, (12) profuse suppuration, necrosis, etc. In the treatment of hospital gangrene, it is very important to secure good ventilation and to enforce the utmost cleanliness. Affected patients should be at once segregated (if possible) from others, and, if it were practicable, it 394 DISEASES RESULTING FROM INFLAMMATION. would be better that each person attacked should be placed in a sepaiate apartment or tent. It is, indeed, probable that a certain number of the milder cases would get well under simple hygienic treatment, and the risks of exposure are much less than those of overcroAvding; as a German surgeon (Prof. Jiingken) has somewhat quaintly put it, " It is, after all, better that the patient should shiver a little in a cold but pure air, than that he should die in a warm but poisoned atmosphere." As it is certain that the disease may be communicated by means of sponges, etc., the greatest precautions should be taken in Avashing and in dressing Avounds. The ward carriage (Fig. 10), or some similar contriA'ance for using a stream of running water, will, in these cases, be found of great service. The adoption of Lister's anti- septic method is recommended as a prophylactic measure by Nussbaum, of Munich. The Local Treatment of hospital gangrene, is now, I believe, almost uni- versally regarded as of the highest importance ; many different applications have been employed, varying in severity from the actual cautery down to simple syrup, or buttermilk, and each remedy has proved occasionally suc- cessful. The oil of turpentine is highly recommended by Prof. Bartholow, and poAvdered camphor by Netter and other French writers. Most surgeons are noAV agreed as to the propriety of thoroughly cauterizing the entire sur- face of the wound once, or oftener if necessary ; and to insure thorough cau- terization, it is necessary first to remove all the adherent slough Avith forceps and scissors, followed by rough sponging. The varieties of caustic most to be relied upon are, I think, nitric acid, bromine, and a strong solution of the permanganate of potassium. The latter article is that which I ha\re myself employed, in the proportion of 5j to f^j of AArater, and I have never, as yet, been disappointed in its effect; it is but just, however, to say that 1 have not had occasion to try it in any cases of the worst form, such as are described by Guthrie. The permanganate has been favorably reported upon by Prof. Jackson, Dr. Hinkle, Dr. Leavitt, and others. Nitric acid seems to be generally preferred by British surgeons, and is recommended by Prof. Jones, and by the authors of the " Manual of Military Surgery, prepared for the use of the Confederate States Army," Avhile the hot iron seems to be preferred by the French ; the latter application Avould probably be the best in cases attended with hemorrhage. Ileiberg, of Christiana, from an extended ex- perience during the Franco-German Avar, gives a preference to the chloride of zinc. Bromine, the merits of Avhich were first announced, during our Avar, by Dr. Goldsmith, has been most favorably reported upon by Drs. Post, Moses, AV. Thomson, Herr, and many others, and seems, from the published testimony in its favor, to be, upon the Avhole, the best caustic which has yet been proposed for these cases. The Avound haATing been previously cleansed, the bromine may be applied undiluted, or in solution Avith bromide of potas- sium, by means of a camel's-hair brush, or a sponge or mop, attached to a stick, or by means of a glass pipette or syringe; as the application is very painful, the patient should be first brought under the influence of ether or chloroform. Bromine has also been used in the form of vapor (the surface to be acted upon being protected Avith dry lint, upon Avhich is placed a cloth dipped in pure bromine, and the whole covered with oiled silk), and by means of hypodermic injection at the circumference of the sore. (See Dr. Brinton's Report to Surgeon-General, in Am. Journ. of Med. Sciences, July, 1863, p. 279.) The bromine acts by producing an eschar, upon the separation of which the Avound will usually be found healthy and disposed to heal. Until the slough separates, the wound may be dressed with dilute liq. sodae chlori- natis, with the permanganate of potassium (3j-Qj)» or simply Avith Avater dress- ing ; the resulting ulcer is, of course, to be treated on general principles. FURUNCLE OR BOIL. 395 The Constitutional Treatment, if less important than the local, is still not to he neglected. Almost all surgeons, with the exception of Boggie, have agreed in recommending a tonic and stimulant, rather than a depletory, course of treatment. The milder cases require scarcely any medication, attention to the state of the secretions being all that is necessary in many instances. When the typhous condition is more marked, the mineral acids may be used Avith adA-antage ; the muriatic acid of the U. S. Pharmacopoeia, may be given in five-drop doses, with opium and oil of turpentine, every three or four hours, as is done in cases of tA-phoid and typhus fever. Opium is, of all single remedies, the most useful in this affection : it may be given quite freely, and a case is reported by Pick, in which gradually increasing quanti- ties of laudanum Avere administered for fifteen days, the patient taking at the last nearly half an ounce in the tAventy-four hours. Quinia and iron (es- pecially in the form of the muriated tincture), are particularly valuable in the later, though they may be required in the earlier, stages of the disease. The diet should consist of nutritious but easily digestible articles of food, such as milk and beef-essence, and on the first manifestation of adynamic symptoms, alcoholic stimulants should be freely administered. Amputation may be occasionally rendered necessary by the occurrence of uncontrollable hemorrhage, from a Avound which has been attacked by hos- pital gangrene, or the same measure may be required at a later period, on account of the extensi\-e destruction of tissue, involving, perhaps, bones and joints, as Avell as the more superficial structures of the part. It is said that hospital gangrene may occur as an idiopathic affection, upon an unbroken surface, the disease then beginning as a vesicle surrounded by a dusky areola, the vesicle ultimately breaking, and leaving a slough upon the separation of which the characteristic appearances of the affection are mani- fested : these idiopathic cases are, however, at least, extremely rare, and in those which have been reported, it may be fairly doubted Avhether some excoriation may not in fact have existed, though so slight as to have escaped obserAation. Furuncle or Boil___This very common affection consists of a localized inflammation of the skin and subcutaneous areolar tissue, almost invariably running on to suppuration, and attended by the formation of a small central slough, which is popularly called the core. Boils may occur at any age, and in any part of the body; they are, hoAvever, most common in youth, and are generally seen on the nucha, back, or gluteal region. They are often mul- tiple, frequently come out in successive crops, and occasionally occur epi- demically—those who are affected being usually in a depressed state of health. The affection, though very painful and annoying, is not commonly attended Avith danger. The treatment consists in improving the general health by attention to the state of the secretions, and by the administration of tonics, especially quinia, if the patient be debilitated. Yeast is a favorite domestic remedy. Arsenic is sometimes of benefit, given in small doses, and continued for a considerable period. The liq. potasse has been similarly used with advantage, and the celebrated John Hunter, Avho suffered much from boils, declared that he had cured himself by taking the carbonate of sodium. The local treatment should vary Avith the circumstances of the case. If the boil be not very painful, it should be left to open of itself, being poulticed, or simply protected by means of the ceratum saponis, spread upon a piece of soft buckskin or wash-leather. There is some reason to believe that boils are less apt to recur if left to themselves, than if too actively treated. If, however, the patient be in great pain, Avith much constitutional disturbance, the sur- geon should not hesitate to make a free single or crucial incision, the case 396 DISEASES RESULTING FROM INFLAMMATION. being afterwards treated as one of abscess. It may be sometimes possible to abort a boil by purging, and by the application of tincture of iodine, spirit of camphor (Simon), or mercurial ointment (Roth), or by touching the vesicle which usually marks the point of central slough Avith lunar caustic, a solution of corrosive sublimate, or the strong aqua ammoniae. Planat recommends the use of arnica, both as an internal remedy, and, locally, mixed with honey. Anthrax or Carbuncle__A carbuncle may be regarded as an aggra- vated form of boil. It usually begins as a \Tesicle, surrounded by an indurated dusky areola. The subcutaneous tissue sloughs at an early period, giving the part a peculiar boggy feel, before the skin itself giAres way. The skin may slough merely beneath the central A'esicle, but, if the carbuncle be large, numerous apertures Avill be formed, arranged in a cribriform manner. The carbuncle continues to spread, reaching its height in from three to eight days, and accompanied, while it is extending, with great pain and constitutional disturbance. The average diameter of carbuncles is tAvo or three inches, though in some instances they attain a very much larger size. Mr. Paget mentions a case in a man aged eighty, in Avhich the carbuncle measured four- teen by nine inches. Carbuncles are usually met Avith on the back of the neck or betAveen the shoulders, but may occur in any portion of the body. They are most frequent in the male sex and in persons in advanced life. The causes of carbuncle are obscure. The affection is usually met with in those who are enfeebled by age, or Avorn down by overwork or privation, and is sometimes associated Avith visceral disease, particularly affections of the kidneys, or diabetes. The prognosis should always be guarded; though the large majority of cases recover, the disease is always serious. Death may occur from the extension of inflammation to an important organ, as the brain or peritoneum, from visceral complication, from simple exhaustion, or from the development of erysipelas or pyaemia. Treatment___If the surgeon be called at an early stage, it may be possible to abort the disease, by opening the central vesicle and applying some caustic agent, such as the nitrate of silver, the A "ienna paste, or a strong solution of the permanganate of potassium; or the plan proposed by Dr. Physick might be resorted to, and a blister applied over the whole inflamed surface. It usually happens, however, that the case is first seen Avhen the bogginess and cribri- form ulceration sIioav that sloughing of the areolar tissue has already occurred. Under these circumstances, it is commonly advised to make crucial or radiat- ing incisions, deep and free, so as to include the healthy tissue beyond the utmost limits of the disease. Other surgeons make subcutaneous incisions; while others again rely upon the use of caustics, applying these either to the surface, to the incision Avounds (when these are made), or around the cir- cumference of the carbuncle, in the form of caustic arrows (cauterisation en fieches). It is not proved, however, that any of these methods are effective, either in limiting the extent of the carbuncle, or in shortening its duration. It is possible that incision may, in the early stage of the disease, give relief from pain, but it does so at the cost of considerable loss of blood ; while the healing of the incision wounds themselves, imposes an additional tax upon the already overAveighted powers of the patient. In most cases it will be found sufficient to cover the carbuncle with a piece of leather or thick kid, spread Avith lead plaster or soap cerate, a central aperture being left for the escape of the slough. Another plan, which I have found very useful, is to apply pressure, as suggested by O'Ferral, by means of strips of adhesive plaster, beginning at the circumference and kid on concentrically, until all except the central portion is covered. A poultice may be applied over all if there be much pain, or the ulcerated centre of the carbuncle may be simply dressed MALIGN.ANT PUSTULE. 397 with wet lint. The extrusion of the slough is much assisted by the concentric pressure (which is not at all painful), and may be further aided by the use of forceps and scissors. Dr. Leitner, of Georgia, accomplishes the same purpose by the application of a cupping-glass. AAThen the slough has come aAvay, the resulting ulcer should be treated upon general principles. The constitutional treatment is equally simple. In the milder cases a little opium may be required as an anodyne, and, if there be constipation, the boAvels should be relieved by a mild laxative. Should the tongue be dry and covered with a brownish fur, muriatic acid, in combination with laudanum and oil of turpentine, may be usefully administered. At a later period, quinia and the tinct. ferri chloridi will come into play, Avhile at any stage, if there be delirium or other nervous complication, camphor and ammonia may be given with advantage. The diet should, as a rule, be mild, but nutritious, consisting of such articles as milk, beef-essence, soft-boiled eggs, etc. Alco- holic stimulus, though not necessary in every case, Avill usually prove a ser- viceable adjunct to treatment, and is often imperatively demanded, especially in the later stages of the affection. Facial Carbuncle__Under this name is described, by British surgeons, a malignant carbunculous affection, Avhich attacks chiefly the lips, and which presents some analogous features to the disease known in France and in this country as malignant pustule.1 The affection is a very painful one, and fre- quently proves fatal, through the development of pyaemia. Of 4;"> cases col- lected by Dr. Lidell, of New York, only five terminated in recovery. The treatment consists in the administration of stimulants, and of large doses of quinia. Local measures are of but secondary importance, but an incision may be required to relieve tension and allow the exit of sloughs. Malignant Pustule (Pustule Maligne, Charbon)—This affec- tion is usually communicated by inoculation, from direct contact with the blood or other fluids derived from diseased animals, as from horned cattle affected Avith the murrain, or from septic material conveyed by flies, and is said to have occasionally resulted from eating the flesh of such animals, or even to have been transmitted through the medium of the atmosphere. The affection begins a day or tAvo after inoculation, as an itching red spot folloAved by a vesicle, which bursting leaves a dry brownish eschar. A fresh crop of vesicles next appears around the slough, and the subcutaneous tissue becomes involved, forming a hard SAvelling to Avhich the French give the name of Bouton or Tumeur Charbonneuse. The neighboring lymphatic glands often become secondarily inflamed. There is a good deal of fever, and of consti- tutional disturbance, the patient, in unfavorable cases, rapidly sinking into a typhoid state, and dying with the ordinary signs of blood-poisoning.2 The affection is said by Prof. Gross and other American writers, to be intensely painful, but Bourgeois (one of the latest French authorities on the subject) speaks of the absence of pain as a prominent characteristic. The disease may be distinguished from carbuncle, by the fact of its beginning in the skin and 1 M. Reverdin maintains, in an elaborate memoir published in the Archives Centrales de Medecine for June, July, and August, 1870, that the gravity of carbuncles of the face, and particularly of the lips, is solely due to the frequent occurrence of phlebitis, which may cause death by the inflammation spreading to the sinuses of the dura mater, or by the development of pysemia. He regards the affection as totally distinct from malignant pustule, and recommends early and free incisions. A similar view is held by Dr. Lidell, and has been recently acceded to by Sir James Paget. 2 Dr. Gerald Yeo and some others believe that the disease is identical Avith that known to European writers as Mycosis Intestinalis, and that the development of an external pustule is not an invariable occurrence. 398 ERYSIPELAS. only involving the subcutaneous tissues at a later period, and bv the almost complete absence of suppuration. The treatment consists in thorough cauter- ization with caustic potassa, either Avith or without previous scarification, according to the progress which the disease has made when first seen ; Prof. Gross recommends total excision. The constitutional treatment consists in the administration of concentrated food and stimulus, Avith tonics, especially quinia, and the mineral acids. Cezard recommends the use, both internally and externally, of iodine held in solution by means of iodide_of potassium, looking upon this drug as a positive antidote to the poison of the disease, while Estradere speaks very favorably of the use of carbolic acid both inter- nally and as a local application. Other Gangrenous Affections.—Various forms of gangrene are occasionally met Avith, which cannot be referred to any of the diseases above described. Under the name of White Gangrane of the Skin, is described by Quesnay, Brodie, and others, a form of dry gangrene, in which successive patches in various parts of the body, especially the neck, arms, and back, undergo mortification, preserving at first their Avhite color, but becoming subsequently horny and straAV-colored, and shoAving, in the form of red streaks, the capillaries filled Avith coagulated blood. After the separation of the sloughs, the ulcers heal Avithout difficulty. Quesnay states that this form of gangrene is due either to arterial obstruction, or to compression or paraly- sis of the nerves of the part. The treatment, according to Brodie, is rather unsatisfactory. In one case, in Avhich the disease Avas associated with irregu- lar menstruation, the sulphate of copper was given with advantage. Tonics would seem to be usually indicated, and Avhen, as in one of Brodie's cases, and in one quoted by Quesnay from De La Peyronie, the disease succeeds an affection of the skin, arsenic might probably be advantageously employed. A curious case came under my observation at Cuyler Hospital, in which a soldier, noticing a painful pimple or pustule on the back of his hand, applied to the "medical officer of the day," who ordered a flaxseed poultice ; the next day the man came to me in great alarm, Avith a black dry slough upon his hand, exactly the size and the shape of the cataplasm; the eschar, wliich Avas quite deep, separated in a feAv days, and the remaining ulcer healed rapidly under the use of tbe permanganate solution. CHAPTER XXI. ERYSIPELAS. lZv.JL*~-*^l t* *fry **d Erysipelas1 is an acute febrile disease, attended by a peculiar form of in- flammation, which affects the skin, areolar tissue, and mucous or serous mem- branes. It occurs as an idiopathic affection, or as a complication of a wound, being called in the latter case traumatic erysipelas. External erysipelas, or that which affects the skin and connective tissue, is much more common than the internal variety, or that which attacks the mucous and serous membranes. 1 The usual derivation given for this word is from the Greek ipuca (I draw) and ttOat (near) ; others, however, prefer to derive it from epvBpo; (red) and new* (skin). (See, upon this subject, a note to Mr. DeMorgan's paper in Holmes's Syst. of Surgery, vol. i., SYMPTOMS OF ERYSIPELAS. 399 External erysipelas may be divided into the simple or cutaneous, the phleg- monous or cellulo-cutaneous, and the cellular or areolar, which is often spoken of as diffuse inflammation of the areolar tissue. Causes of Erysipelas__These may be divided into the predisposing and the exciting. Of the Predisposing Causes, some relate to the patient's own condition, and others to the circumstances by which he may be sur- rounded. Among the former may be enumerated a depressed or debilitated state of the system, resulting from any source, such as chronic visceral dis- ease, especially of the kidneys or liver ; diabetes ; chronic diarrhoea or dysen- tery ; deprivation of food ; neglect of hygienic rules ; intemperate habits ; overwork, etc. Any sudden source of depression may act as a predisposing cause of erysipelas ; thus, in military hospitals, the disease is often seen to folloAv in the wake of secondary hemorrhage. Among the surrounding cir- cumstances Avhich predispose to erysipelas may be mentioned overcroAvding, bad, ventiktiqn and seAverage, and the season of the year and state of the atmosphere ; it is notorious that erysipelas is most apt to occur during the cold, damp Aveather which often prevails about and after the vernal and autumnal equinoxes. The principal Exciting Causes of erysipelas are epi- demic influence, contagion, and the presence of a wound. Symptoms of Erysipelas__1. Simple or Cutaneous Erysipelas.— Constitutional disturbance, consisting of rigors, headache, nausea, and fever, may precede the local manifestations for one or tAvo days, though in many instances the patient is not conscious of any marked indisposition, until the appearance of the rash or cutaneous inflammation. In traumatic erysipelas, the locality of the rash will be determined by the position of the Avound ; in the idiopathic variety, though the disease may appear on any part of the body, it is most frequently seen upon the face (especially about the nose, ears, and eyelids), next upon the legs, and more rarely upon the trunk. The eruption appears as a red spot, rapidly spreading into a large patch with pretty Avell defined margins ; somewhat elevated ; of a bright rosy hue, disappearing under pressure; with a smooth, glazed, shining surface, and attended with a tingling and burning sensation. Except in the mildest cases, vesicles appear on the affected part, containing serum, wliich at first is clear, but soon be- comes turbid, these vesicles eventually drying into brownish scabs. The eruption of simple erysipelas lasts (as a rule) but four days in the same part: it may, hoAvever, spread to adjacent parts, or may break out in an entirely different region of the body, the affection in these cases constituting respec- tively the erysipelas ambulans, and the erysipelas erraticum of the older writers. As the eruption fades, the SAvelling subsides, the margins lose their definition, and the skin assumes a dry and somewhat wrinkled appearance. The constitutional symptoms are rather aggravated than diminished by the appearance of the eruption, the period of defervescence usually coinciding with that of the decline of the local phenomena. 2. Phlegmonous, or Cellulo-cutaneous Erysipelas___In this form of the affection both the local and general symptoms are more marked. The inflam- mation involves the subcutaneous connectiAe tissue as well as the skin, the swelling being greater, the color darker, the vesications larger, and the pain more intense than in the simple variety. These signs continue gradually in- creasing up to the sixth or eighth day, Avhen resolution may commence, or, as is very apt to happen, suppuration and extensive sloughing of the areolar tissue take place ; the part, from being hard and tense, now becomes soft and boggy; the skin, at first deeply congested, becomes pale in spots, and then 400 ERYSIPELAS. black, and quickly falls into a state of moist gangrene. The constitutional symptoms, Avhich may appear in the beginning to be of a somewhat sthenic character, rapidly degenerate into those of a typhoid type, and death may occur from exhaustion, hectic, diarrhoea, or pya>mia. This form of erysipelas is that which most often occurs in connection -with Avounds, simply because in such cases the deeper planes of fascia are usually opened, and thus exposed to the influence of the disease. Under the name of ozdematous erysipelas is described a modification of the phlegmonous form of the disease, which is chiefly met Avith in the legs, and about the genital organs of old or feeble persons. Both the local and general symptoms are less marked than in ordinary phlegmonous erysipelas, but there is a considerable effusion of lymph and serum, solid oedema sometimes per- sisting, and giving the part the appearance of Scleroderma, or Elephantiasis of the Arabs. 3. Cellular Erysipelas (Diffuse Inflammation of the Areolar Tissue)___ The former name is preferable, as there may be a diffuse inflammation of the connective tissue unconnected with the erysipelatous influence (see page 38")). In this variety of the affection there is great swelling, tension, and pain, but comparatively little redness. The disease extends rapidly and Avidely, some- times from a wound, but at other times beginning at a distance from the point of injury. Suppuration, sometimes attended Avith emphysematous crackling, occurs about the fourth day, or even earlier, and the skin quickly falls into a state of gangrene. This affection may also attack the deep planes of connec- tive tissue, as in the pelvis or anterior mediastinum. The constitutional symptoms are of a profoundly typhoid type, death sometimes occurring on the second or third day of the disease. 4. Traumatic Erysipelas is attended Avith changes in the condition of the wound itself. The edges become flabby, and the neighboring tissues cedema- tous. A thin sanious fluid replaces the ordinary healthy pus, the granula- tions become pale and shining, and the healing process is arrested ; recent adhesions may even be broken doAvn and absorbed. A sensation of weight and heat, with great pain, may precede by several hours the development of the characteristic eruption. 5. Erysipelas of Mucous Membranes___The parts most usually affected are the fauces, pharynx, and larynx. Beginning in the fauces, which are swollen and deeply red, the uvula being markedly oedematous, the disease may spread to the larynx, giving rise to a croupy cough, dyspnoea, aphonia, and some- times death from oedema of the glottis. At a later period fatal consequences may result from extension of the disease to the bronchi or lungs, from slough- ing of the part, or from the development of pyaemia. This variety of erysi- pelas is considered peculiarly contagious. Dr. Goodhart believes certain cases of the affection known as " Surgical Kidney" to be really examples of erysipelas affecting the kidney and urinary tract. 6. Erysipelas of Serous Membranes___This is chiefly met Avith in the arachnoid and peritoneum, the former being secondarily affected in cases of erysipelas of the scalp, or of injuries in the cranial region, and the latter in cases of injury of the abdomen or pelvis, or after various operations, such as herniotomy, ovariotomy, etc. The symptoms are those of inflammation of the affected parts, with the general evidences of a profoundly typhoid con- dition. Diagnosis Of Erysipelas.—Simple erysipelas may be distinguished from erythema, by the fact that the latter occurs in patches of various size, which have no particular tendency to spread, are not elevated, and are unac- companied by the formation of vesicles. The marked constitutional disturb- TREATMENT. 401 ance also is%absent in erythema. From scarlet fever the diagnosis maybe made by observing the circumscribed character of the erysipelatous eruption, its well-defined margin, the tenseness and glazed appearance of the surface, and the presence of vesicles. There is a peculiar inflammation of the skin which results from contact with the poison sumach (Rhus radicans, Rhus toxicodendron), Avhich is almost identical in appearance Avith erysipelas; the diagnosis can only be made by the history, and by the invariably mild course of the former affection, Avhich, moreover, is not, I believe, contagious. Phleg- monous erysipelas may be distinguished from ordinary inflammation, by the greater extent of surface involved, by the absence of any tendency to point, by the rapidity of its course, and by the asthenic type of the constitutional symptoms. From phlebitis, it may be distinguished by the hard, cord-like condition of the vein, and the absence of general redness in that affection ; and from angeioleucitis, by the fact that in that disease the redness and pain are confined to the course of the lymphatics and their neighboring glands. Cellular erysipelas may he distinguished from common diffuse inflammation of the connective tissue, by the even greater rapidity of the course of the former disease, and by the more asthenic type of its general symptoms. Erysipelas of the fauces or larynx, may be distinguished from ordinary inflammation of those parts, by the dusky redness exhibited in the former affection, and by the generally typhoid condition of the patient. Moreover, the manifestation of erysipelas on the cutaneous surface avill usually throAV light upon the diag- nosis. From diphtheria, erysipelas of the throat may be distinguished by the greater degree of constitutional disturbance, and by the absence of exudation. Erysipelas of the arachnoid or peritoneum, can only be distinguished from common arachnitis or peritonitis, by the primarily typhoid character of the constitutional symptoms in the former affections. The presence of delirium is a very frequent accompaniment of erysipelas of any form which affects the scalp, and must not be considered as in itself any evidence of meningeal com- plication. Prognosis___The prognosis, in any case of erysipelas, depends chiefly upon the form Avhich the disease assumes, the locality of the part attacked, and the constitutional condition of the patient. Simple erysipelas is usually a mild affection, and, in the large majority of instances, terminates in recov- ery ; if, hoAvever, it involve the scalp, or the abdominal Avail, there is ahvays a risk of transference to the arachnoid or peritoneum; if the face be affected, it may spread to the fauces or larynx ; while, if there be serious visceral dis- ease, especially of the kidney, the slightest attack of erysipelas is likely to prove fatal. Phlegmonous and cellular erysipelas are always very serious affections. In the head, abdomen, and loAver extremities, they are par- ticularly apt to prove fatal, extensive sloughing in the latter situation some- times laying bare the bones and opening the articulations. Faucial and laryngeal erysipelas sometimes prevail in an epidemic form, and have occa- sionally, under the name of " black tongue," produced frightful ravages in certain regions of our country. Finally, erysipelas in any form is a serious disease in neAV-born children, in very old persons, and in women in the puer- peral state. Treatment.-—A great deal may be done to prevent the development and spread of erysipelas. For this purpose, hospital wards, or the apartments occupied by sick or Avounded persons, should be well ventilated and scrupu- lously clean. All excreta and soiled clothing should be promptly removed, and particular attention should be given to the sewerage; the presence of a foul drain has not seldom proved the starting-point of a local epidemic of ery- 402 ERYSIPELAS. sipelas. As the disease can he unquestionably propagated by direct inocu- lation, precautions should be taken against the transference of morbid material from one patient to another. The washing of wounds should, if possible, be effected with a stream of running water; if this be impracticable, each pa- tient should, at least, be provided with his OAvn basin and sponge; the dress- ings should be of such a nature that they can be frequently renewed; they should, therefore, be as simple and as inexpensive as possible. Disinfectants, such as the chlorine preparations, the permanganate of potassium, carbolic acid, or bromine, may be placed in various portions of the room, or may be employed in the dressings. Personal cleanliness on the part of nurses and dressers should be rigidly enforced, and the latter should not be allowed to come directly from the post-mortem or dissection rooms to engage in their ward duties. The surgeon himself should exercise similar precautions, and, as there is an undoubted connection between erysipelas and certain forms of puerperal fever, should, wliile attending cases of the former affection, if pos- sible, temporarily decline engaging in obstetric practice. On the first ap- pearance of a case of erysipelas in a surgical Avard, the affected patient should be isolated, and disinfectant measures resorted to, in order to prevent the further spread of the disease. The Curative Treatment of erysipelas maybe divided into the constitutional and the local treatment. 1. Constitutional Treatment___In simple or cutaneous erysipelas, very little medication is, as a rule, required. If the patient, as is usually the case, be constipated, with a furred tongue, a mercurial purge may be administered. Emetics are often recommended, but, unless it be known that the stomach contains some irritating material, they are, I believe, as unnecessary as they are disagreeable; their reputation is probably derived from their known effi- ciency in those cases of erythema which result directly from the use of certain articles of food. As a cathartic, two or three grains of blue mass may be given, to be folloAved, in the course of tAventy-four hours, by a dose of castor oil or a Seidlitz powder. If there be much heat of skin, neutral mixture may be given, combined with camphor-water if the nervous symptoms are at all prominent. Anorexia will usually indicate the propriety of abandoning solid food, for which milk with lime-AArater, and beef-essence, may be substituted, in small quantities and at frequent intervals. In most cases, at least as met with in hospitals, a small quantity of alcoholic stimulus may be serviceably directed, but there is seldom occasion to give large quantities, four or five fluidounces of wine, or Iavo or three of brandy, in the course of the day, being usually quite sufficient. Most cases of cutaneous erysipelas Avill run a satisfactory course under the above simple mode of treatment. If, however, the surgeon wish to do more, there can be no objection to giving the muri- ated tincture of iron, Avhich is a remedy of undoubted value in the phlegmo- nous form of the disease. The sulphites and hyposulphites have been rather extensively used in erysipelas, and have, Avith some surgeons, acquired a reputation, Avhich is, I believe, due more to the natural tendency of this form of the disease to spontaneous recovery, than to any curative virtue of the remedies themselves. In phlegmonous, and in cellular erysipelas, the pa- tient may be put at once, after attention to the state of his boAvels, upon the use of the muriated tincture of iron, which must be believed, from pub- lished experience, to exercise a controlling influence over the course of the disease. This remedy, Avhich was first brought prominently to the notice of the profession in 1851, by Dr. G. Hamilton Bell, of Edinburgh, may be given in large doses—as much as twenty or thirty minims—every three or four hours, or even every hour if the urgency of the case require it. Quinia is another drug which may be usefully employed, particularly in the later TREATMENT. 403 stages of the disease. Free stimulation may be employed in these cases from the very outset, and as the symptoms assume more and more a typhoid aspect, carbonate of ammonia and oil of turpentine may be properly added to the remedies previously employed. The complications Avhich demand spe- cial attention, are the supervention of arachnitis, of peritonitis, or of erysipe- latous laryngitis. In the case of arachnitis, benefit may be expected from free purgation and the use of turpentine enemata. If coma occur under these circumstances, Dr. Copland recommends a full dose of calomel and camphor, folioAved by an electuary of castor oil and oil of turpentine, placed upon the back of the tongue, and repeated from time to time until purging is begun. Enemata may then be used as adjuvants, and blisters applied to the nucha and thighs, as derivatives. In erysipelatous peritonitis, opium is the remedy most to be relied upon. If the disease attack the air-passages, the greatest risk is from oedema of the glottis ; here (beside the local measures which Avill be presently alluded to) a cautious trial may be given to anti- mony in combination with opium, the latter remedy serving to counteract the spasmodic tendency, which almost ahvays exists in laryngeal affections. If the dyspnoea, hoAvever, should increase, no time should be lost in resort- ing to laryngotomy; the oedema does not extend below the vocal cords in these cases, and hence this operation is preferable to that of opening the trachea. 2. Local Treatment—The local treatment of erysipelas is almost as im- portant as the constitutional. A'ery various applications have been used in these cases, and each, at least in simple erysipelas, often with apparent suc- cess. It must not be forgotten, however, that, as pointed out by Velpeau, the duration of the eruption in one spot is limited to four days, and that in many instances no other part may become affected. In this, as in many other diseases, a knowledge of the natural history of the affection may tend to shake our faith in the curative poAver of the remedies employed. AVith regard to local applications in erysipelas, a good general rule is given by Dr. Reynolds, viz., to avoid anything which shall expose the skin to variations of temperature, or which shall interrupt its natural function. Hence cold ap- plications and oily or unctuous substances should not be employed. In simple or cutaneous erysipelas, if the affected patch be small, it may be sufficient to keep itAvell dusted Avith rice flour, toilet poAvder, oxide of zinc, or even com- mon wheat flour. If the patch be large, particularly if a limb be the part affected, and generally in hospital practice, it will be better to cover the Avhole seat of eruption with carded cotton, loosely applied; the cotton ex- cludes the atmosphere and keeps the part in a kind of continuous vapor bath. In cases in Avhich the tension of the part is very great, and which approach, in character, to the phlegmonous form of the disease, Avarm fomentations, such as chamomile or hop poultices, may be substituted for the simpler appli- cations. Akrious other articles are recommended by surgical Avriters, par- ticularly collodion, sulphate of iron, tinctiire of iodine, nitrate of silver, and, recently, nitrate of lead. Bromine in the form of vapor, applied as described in speaking of hospital gangrene, was someAvhat extensively used during our late Avar, and Avith alleged advantage. The nitrate of silver, which was first recommended in this affection by Higginbottom, is used in the form of a very strong solution (one part to three), and is applied, after thoroughly cleansing the part, " two or three times on the inflamed surface and beyond it, on the healthy skin, to the extent of tAvo or three inches." Another plan, if an extremity is affected, is to apply the caustic in a broad band, entirely around the limb, a feAV inches above the seat of inflammation. The spread of the eruption certainly seems, in some cases, to be arrested by the caustic application thus made, but perhaps not oftener than it would have been spon 404 ERYSIPELAS. taneously arrested at the same point, had the treatment not been employed. In phlegmonous erysipelas more active measures are required. In the early stages benefit maybe derived from making numerous punctures with the point of a sharp lancet, as advised by Sir R. Dobson ; these may be frequently repeated, and act by relieving tension and promoting resolution. If these fail, or if the case be first seen at a later stage, when the braAvny feeling of the surface indicates impending suppuration of the subcutaneous areolar tissue, incisions, from one to two inches long, and tAvo or three inches apart, should be made over the inflamed surface, in the general direction of the sub- jacent muscular fibres. These incisions, which should extend through the superficial fascia, Avere first popularized by Copland Hutchison. They gape pretty widely, OAving to the great distension and SAvelling of the part, their edges presenting a gelatinous appearance from the infiltration of serum and lymph, and soon breaking down into pus mingled Avith shreds of disinte- grated tissue. If the hemorrhage from these incisions be troublesome, they should be stuffed with scraped lint until the bleeding has ceased. South advises that the incisions should be arranged in the form of a lozenge, thus I I , the greatest relief from tension being thus obtained Avith the least destruction of tissue. At a still later stage, when braAvniness has given place to bogginess, showing that sloughing of the subcutaneous tissues has already occurred, free and deep incisions, three or four inches long, may be required, in order to prevent gangrene of the skin, and to afford an exit for sloughs, the separation of which may be hastened by means of forceps and scissors. AVarm fomenta- tions should be constantly applied, and antiseptics may be freely used, not only in the dressings, but injected among the tissues by syringing. AYhen the suppuration is very profuse, the fomentation may be omitted, the part being simply covered Avith lint and charpie, tow, oakum, or carded cotton, the now relaxed tissues being supported by the gentle pressure of a bandage. The abscesses, sinuses, and ulcers which are left after phlegmonous erysipelas, are to be treated on the principles laid down in the last chapter. Cellular erysipelas requires the same local treatment as the phlegmonous form of the disease; the incisions should be made even earlier and more freely than in that variety, on account of the greater rapidity Avith which sloughing of the connective tissue occurs under these circumstances. In certain localities, as in the orbit, the scalp, and the scrotum, early incisions are particularly im- perative. In the orbit, the incisions are to be made by everting the lids, and pushing the blade of a lancet or bistoury, held flatwise, through the conjunc- tiva, betAveen the eyeball and orbital Avails ; in the scalp, crucial incisions are the most effective; while in the scrotum, a single free incision on either side of the raphe will usually be all that is necessary. Erysipelatous arachnitis should be met by the application of cold to the scalp—the only form of erysipelas, I believe, in Avhich the use of cold is desirable. In erysipelatous peritonitis, the Avhole abdomen should be covered Avith a Avarm hop poultice. If erysipelas attack the fauces, a strong solution of nitrate of silver, or the muriated tincture of iron, may be freely applied with a sponge or camel's-hair brush ; while in erysipelatous laryngitis, before resorting to laryngotomy, a trial should be given to free scarification of the glottis, and of as much of the larynx as can be reached, folloAved by the inhalation of steam, and the free application of a solution of nitrate of silver (3j-f3j)- The scarification may be effected with a probe-pointed curved bistoury Avrapped with adhesive plaster, or, more conveniently, with an ordinary hernia-knife. Should the patient survive the first risks of the disease, the inevitable sloughing Avill require the use of detergent gargles PYiEMIA. 405 (especially such as contain chlorine or bromine), to obviate the fetor and diminish the risk of secondary blood-poisoning. In a case of traumatic erysipelas, if the disease appear to originate directly from the Avound, it Avould be proper to apply to the latter some disinfectant, such as a solution of bromine Avith bromide of potassium, in hope that the disease might thereby be, if not arrested, at least favorably modified in its course. Ilirschberg, of Berlin, recommends in these cases hypodermic injec- tions of a tAvo per cent, solution of carbolic acid. CHAPTER XXII. PYiEMIA. Pyaemia (in the sense in Avhich the term is used in this Avork) is a peculiar morbid condition resulting from the absorption of septic material, and -pun ally accompanied by the formation of puriform collections in various tissues and organs of the body. A irehoAv, to whose labors Ave are greatly indebted for our knoAvledge of the pathology of this disease, distinguishes several forms of blood-poison- ing, which are usually classed together as pyasmia, and proposes the names Ichorrhemia, Septhemia, and Septicemia, for that variety Avhich results from the absorption of putrid material from Avounds, and is not accompanied by the development of those puriform collections Avhich the older surgeons called "metastatic abscesses," and the formation of Avhich he believes to be invariably due to plugging of the capillary vessels by fragments of disinte- grated venous coagula. A similar distinction is made by many of the most eminent French surgeons, avIio differentiate between what they call purulent and putrid infection, and Dr. Lidell, one of the more recent American authors on the subject, is disposed to limit the term Pyemia to those cases Avhich are connected with pre-existing suppuration, and to apply the term Septhemia to the forms of blood-poisoning Avhich occur in connection with traumatic and hospital gangrene, dissection Avounds, etc. Prof. Akn Buren, too, teaches that septhaemia is a distinct and well-defined malady, due to the absorption of a definite and peculiar poison. AAliile it is quite possible that further experience and more accurate investigation may, at some future time, enable us to separate and classify different varieties of septic poisoning, to recognize their seAeral sources, and to distinguish the courses which they severally pur- sue, I cannot but think, with Arerneuil, that in the present state of science, it is more practically useful, as it is certainly more convenient, not to aim at these theoretical refinements, but to use the word pyaemia (as has been done in the definition given above) as a generic term, embracing one or more morbid systemic conditions—and to study such condition or conditions as parts of one disease, considering successively its pathological, clinical, and therapeutical relations, with the light afforded by observation and .experience. Nomenclature___The fact has long been knoAvn that patients Avho have received injuries (especially of the head, or of the long bones), or avIio have undergone operations, may die from inflammation or suppuration in Avidely different parts of the body j1 and various names have been suggested by sur- 1 See Dr. AVilliam Thomson's " Historical Notices of the Occurrence of Inflamma- tory Affections of the Internal Organs after External Injuries and Surgical Operations" 406 PYEMIA. geons, expressh-e of the theories adopted to account for these phenomena. Pyemia or Pyohemia (meaning literally purulent blood) Avas the name pro- posed by Piorry, in the early part of this century, and has been used by the large majority of surgical Avriters ; though a misnomer, as far as any patho- logical significance is concerned, it is perhaps no more objectionable than any other term, and is adopted in this work simply from motives of conveni- ence. Among the other names that have been employed may be specially mentioned, Phlebitis, Purulent Infection, Purulent Absorption, Purulent or Pyogenic Diathesis, Multiple or Metastatic Abscess, Thrombosis, Surgical Fever, Pyogenic Fever, Suppurative Fever, and Surgical Typhus. These are all more or less objectionable, either as implying an untenable theory, or as referring to some mere incident of the disease. Surgical Fever (the name used by the late Sir James Y. Simpson) is perhaps the least objectionable name—even less so than Pyemia—but is not adopted here because it is usu- ally recognized as a synonym for Inflammatory Fever, Avhich is quite a dif- ferent condition. : Pathology__Akrious pathological theories have been ad\~anced upon the subject of pyaemia, Avhich, though affording an interesting field for study, cannot be entered into within the limits of this Avork. I shall merely refer very briefly to the views Avhich have most advocates at the present day, and Avhich are—1. The theory Avhich makes pyasmia dependent upon the existence of pus in the blood ; 2. That Avhich makes it dependent upon thrombosis (the formation of venous clots or thrombi), and subsequent embolism,1 or plugging of the capillary vessels with fragments broken off from these clots and called embola; and 3. That which makes it dependent on the introduction of a septic material into the blood, and Avhich looks upon the processes of throm- bosis and embolism as subsidiary and not absolutely necessary. This seems to me in the present state of our knowledge to be the most plausible theory, and it is that which is here adopted. The theory which accounts for the phe- nomena of pyaemia by assuming the existence of a morbid diathesis, merely puts the difficulty one step further back; it is as hard to account for the dia- thesis as for the disease Avhich it is supposed to produce. The theory Avhich looks upon the symptoms of pyaemia as reflex phenomena brought about through the agency of the nervous system, is someAvhat plausible, but must be rejected as ignoring the facts which have been obtained by clinical obser- vation and dissection, as well as by experiments upon the lower animals. 1. Pus in the Blood—The existence of pus, in the blood of pyaemic pa- tients, has been affirmed by a very large number of observers, but strenuously denied by A'irchow and others, avIio declare the supposed pus cells to be merely the Avhite corpuscles of the blood, in increased numbers, and the con- dition of the blood in these cases to be one of leucocytosis, as in the disease called by ArirchoAV, Leukemia, and by Bennett, Leucocythemia. Sedillot indeed pointed out certain diagnostic marks as to size, color, etc., by which he believed that the pus cell could be distinguished from the Avhite blood cor- puscle, but it is now generally conceded that they are undistinguishable. It may be added that, if Cohnheim's observations are correct—if the white corpuscles and pus cells are really identical, and capable, by means of their amoebiform movements, of Avandering through the unbroken capillary Avails— the whole question of pus in the blood will have lost much of its significance. (reprinted from Edinburgh Med. and Surg. Journal), Philada., 1840: T. Rose's "Obser- vations, etc.," in Med.-Chir. Transactions, vol. xiv.; Dr. G. AV. Norris's edition of Fergusson's Surgery; BraidAvood, "On Pyaemia, etc.," chap, i., London, 1868; and Blum's Memoir, in Archives Ginerales de Midecine, Nov. 1809, pp. 534-.354. 1 From two Greek words, iv (in) andSaK\»; (I throAV or cast). PATHOLOGY. 407 The entrance of pus into the blood has been accounted for in two ways, viz., by the previous existence of suppurative phlebitis, and by the occurrence of direct absorption.1 Phlebitis Avas supposed to be the cause of pyaemia by Hunter, Abernethy, Guthrie, Arnott, Cruveilhier, and Liston, and this view has been and perhaps still is adopted by the majority of practical surgeons. The pus is supposed to be formed from the lining membrane of the vein, and thus to enter the circulation, either directly, or by the breaking down of the limiting clot. The objection to this view is that in many cases of pyaemia the veins are not in- flamed at all, and that Avhen inflammation does exist, it is secondary and does not involve the lining membrane of the vessel, being Avhat is called by Virchow a meso-phlebitis or peri-phlebitis. Even when the inner coat is involved in phlebitis, the entrance of inflammatory products into the general circulation Avould be preA'ented by the coagulum Avhich in these cases fills the vein. The theory of absorption of pus, has received support from the well-attested fact that pyaemia is particularly apt to occur after injuries or operations in parts in which open veins are, from mechanical causes, unable to collapse when cut, or to contract at a subsequent period, as veins ordinarily do, upon the shrinking of their contained clots. On the other hand, it has been repeatedly shown by experiment that (1) the effect of applying healthy pus to blood is simply to induce coagulation ; (2) that injection of pus into the blood of healthy animals is not usually folioAved by fatal results, though repeated injections may produce death ; (3) that the injection of the fiuid part of pus is of itself followed by no evil result; (4) that injections of small quantities of pus act just as injections of various other substances, such as mercury, oil, powdered oxide of zinc, etc., by producing local obstructions (infarctus) in the first set of capillaries; and that (f>) these obstructions may, in healthy animals, spontaneously disappear, the subjects of the experiments eventually recovering. Hence it is sIioavii that if pus be absorbed into the blood, its action can be only mechanical, and it is very reasonably argued that the pus corpuscle, being at least no larger than the Avhite corpuscle of the blood, is no more likely to produce the obstruction Avhich results in the for- mation of the "pyaemic patch" or "metastatic abscess," than the white corpuscle itself.2 Finally, as already remarked, if Cohnheim's vieAVS be cor- rect, this whole question will have lost much of its importance. 2. Thrombosis and Embolism—Thrombosis, or the coagulation of blood in the vessels during life, may depend upon a variety of causes, as (1) quies- cence or simple retardation of the circulation, (2) the contact of a rough surface, and (3) an alteration of the blood itself, consisting probably in an increase in the proportion of fibrine.3 Thrombi form in the veins in almost every case of injury, or of inflammation of the surrounding tissues, as well as 1 Piorry's idea that the blood itself could become tbe seat of inflammation and sup- puration, may, in the present state of science, be looked upon as purely chimerical; while the theory which supposes pus to enter the circulation by absorption through the lymphatic system, must be rejected on anatomical grounds, the lymphatic glands acting as filters, to prevent the passage of solid particles much smaller than the pus corpuscles. (See Virchow's Cellular Pathology {Chance's edit.), pp. 184-185.) 2 It is, however, possible, as remarked by Bristowe, that aggregated masses of pus cells may enter the circulation as pellets or flakes, and prove a mechanical source of embolism. 3 See Moxon, in Guy's Hosp. Reports, 3d s., vol. xiv. p. 101. According to Schmidt, of Dorpat, fibrine (as such) does not exist in the circulating blood, but is produced by the union of two substances which he calls fibrinogen, mulfibrinoplaslin, and coagu- lation is due to the action of a ferment produced by the disintegration of the white corpuscles. 408 PYiEMIA. Fig. 187. in cases of phlebitis. These venous thrombi or clots increase by aggregation, until they reach the points at which the veins in which they are seated anas- tomose Avith their parent trunk ; if the force of the circulation in this be suffi- ciently strong, it may prevent the further increase of the thrombi, but if not, these Avill continue to enlarge till they project into the main trunk, as shown in the annexed diagram taken from Callender (Fig. 187). A fragment of the projecting part of a thrombus may be broken off and SAvept into the circu- lation, passing through the heart and plugging an artery, producing embolism, and, if the vessel be of sufficient size, perhaps leading to gangrene ; just as we have seen in a previous chapter that gangrene may be induced by em- bolism, from the breaking up of a clot formed in the heart. Under certain circumstances, probably OAving to an unhealthy condition of the fibrine, a venous coagulum or thrombus softens and undergoes general disintegration; a large number of small fragments are thus carried into the circulation, and, passing through the heart, plug the first set of capillaries (which, if the seat of thrombosis be in the systemic circulation, will of course be the pul- monary), causing thus capillary embolism. A feAV em- bola may slip through the first, to plug other sets of capillaries, or each point of obstruction may cause fresh thrombosis, and a repetition of the Avhole process. In the same way capillary embolism may be due to disinte- gration of cardiac coagula, and to cases of this kind Dr. AYilks has applied the name "Arterial Pyemia." The secondary effects of capillary embolism consist essentially in the development of congestion and inflammation in the part deprived of its vascular supply, Avhich often, though not always, goes on to the occurrence of suppura- tion and gangrene—the embok themselves, in the latter case, breaking doAvn and mingling their debris Avith the products resulting from the disintegration of surrounding tissue. It is probably to this process of thrombosis and capillary embolism, that is due the formation of the large majority of secondary deposits, or " metastatic abscesses," in cases of pyaemia; but that this process is not neces- sarily present in every case, is shoAvn by the facts that (1) precisely the same set of changes may result from capillary stagnation, produced by the introduction into the circulation of putrid fluids,1 (2) that the secondary deposits are sometimes absent from the lungs, though present in other viscera (which Avould be unaccountable on the supposition that they Avere due solely to mechanical obstruction by solid par- ticles, as in that case these particles, or embola, would necessarily block the first set of capillaries),2 and (3) that in cases of capillary embolism from car- diac disease (arterialpyemia),z the course of the affection is Aery much less acute than is seen in the immense majority of cases of ordinary venous pyaemia, as met Avith in surgical practice, showing that in the latter there must be something more than the simple processes of thrombosis and embolism. Indeed, Virchow and his followers acknowledge that certain of the phenomena Diagram illustrating processes of thrombosis and embolism : a, clot projecting into venous trunk and increasing by aggregation ; b, clot undergoing disintegra- tion and allowing frag- ments to enter the cir- culation (embola). (Cal- lender.) 1 See Savory, in St. BartholomeAv's Hosp. Reports, vol. i. pp. 118-126. 2 According to 0. AAreber, however, as quoted by Billroth, certain forms of embola, especially flocculi of pus, may pass the pulmonary capillaries and enter the systemic circulation. Busch explains the occurrence of hepatic embola by tbe occurrence of re- trograde movements of the blood in the vena cava. 3 See AA'ilks, in Guy's Hosp. Reports, 3d s., Arol. xv. pp. 29-35. MORBID ANATOMY. 409 of pyaemia (as ordinarily seen) are not accounted for by these processes, and declare, therefore, that in many cases there is in addition a state of ichor- rhemia, due to the absorption of septic material. 3. Absorption of Septic Material___AYe are thus brought to the conclusion that the only theory Avhich is capable of accounting for all the phenomena of pyaemia, is that Avhich supposes the pyaemic condition to be induced by the absorption of septic material (usually in a liquid, but possibly sometimes in a gaseous state), which unfits the blood for the processes of healthy nutrition, induces capillary stagnation and its consequences, Ioav forms of inflammation, or serous and synovial effusions, and may, and probably does, in most cases, cause A'enous thrombosis, giving rise to the occurrence of loose and ill-formed coagula, Avhich, rapidly undergoing disintegration, cause capillary embolism, and thus produce the secondary deposits, or metastatic abscesses, which are so common in this affection. Morbid Anatomy___Under this head I shall describe very briefly the chief post-mortem appearances observed in fatal cases of pyaemia. In cases Avhich prove very rapidly fatal (the septicemic foudroyante of A'erneuil and his folloAA'ers), time is not afforded for these changes, and, under such circum- stances, the post-mortem appearances are almost negative. 'The characteristic lesions of this affection consist in local congestion, extravasation, and inflam- mation, with gangrene, and occasionally true suppuration. Small fibrinous plugs (embola) can sometimes be detected in the smaller vessels leading to the affected part, but more often the microscope reveals only a mass of granu- lar matter, lymph and blood cells, fibrils, oil globules, and debris of tissue. If true pus exist, it is the result of suppuration occurring secondarily around, and not in, the pyaemic patch. Lungs.—Pyemic patches, or, as they Avere formerly called, metastatic ab- scesses, are most often seen in the lungs, and (according to Callender) in the left, more frequently than in the right. They vary in size from that of a small pea to an inch or more in diameter. They may occupy any portion of the lung, but are most frequent at the posterior part, and are usually present in considerable numbers. They are hard and resisting to the touch, and when cut open present varying appearances, according to the stage Avhich has been reached, their color being reddish-black, brown, pale buff, or yelloAvish- gray. They are ahvays surrounded by a Avell-marked vascular zone. AVhen near the pleural surface, they often cause pleurisy, marked by the formation of hmiph, in patches, and by the effusion of turbid serum. Beside presenting these pyaemic patches, the lungs are often diffusely congested, or even in- flamed. Liver___The liver is most often affected, next to the lungs. The progress of pyaemic patches in this organ seems to be more rapid than in the pulmo- nary tissues, so that the puriform appearance is very quickly developed ; a circumstance which accounts for the fact that " metastatic abscesses," are often observed in the liver, Avhen the morbid changes in the lungs have escaped attention. Other Viscera___The Kidneys, Spleen, Heart, Brain, Bowels, Testes, Prostate, Eye, etc., may all be similarly affected, and probably in the order named, as regards frequency. Dr. BristoAve, indeed, considers that the kid- neA.s are more often affected in pyaemia than the liver. The spleen may be much enlarged, even Avhen not the seat of the characteristic pyaemic patches. The Peritoneum is not unfrequently locally inflamed, as the result of pyaemic deposits in the various abdominal viscera. Joints___The articulations are often SAVollen and inflamed, containing a 410 PYEMIA. turbid puriform fluid (sometimes, probably, true pus), the synovial structures being deeply congested, and the cartilages eroded. Bones___The bones are probably occasionally, but very rarely, the seat of secondary pyaemic changes. On the other hand, pyaemia very often origi- nates in inflammatory affections of bone, especially (as Ave shall see hereafter) in osteo-myelitis. Muscles and Areolar Tissue___Pyaemic deposits are not unfrequently met Avith among the muscular layers of the thoracic or abdominal Avails, or in the neighborhood of joints, and, according to Bristowe, occasionally in the tongue. True suppuration may occur under these circumstances, resulting in the rapid formation of abscesses of large size. External Surface___The skin presents a yellowish appearance, and is some- times absolutely jaundiced. Open wounds are found dry, the granulations having often completely disappeared, and the surface being pale and glazed, or occasionally covered with a grayish slough. Lymphatics___The lymphatics in the neighborhood of a Avound are often inflamed, and abscesses form in the adjoining lymphatic glands. It is doubt- less to the irritation of the lymphatic system, that is due the increased number of white corpuscles sometimes observed in the blood in pyaemic cases. It was this phenomenon (Avhich Virchow calls leucocytosis) Avhich first suggested to Piorry the name of Pyaemia. Bloodvessels___Phlebitis is a very frequent accompaniment of pyaemia. The veins are thickened and somewhat contracted, containing clots, Avhich are usually firm and adherent above, but softened beloAV, and disintegrated into a puriform fluid, which was formerly supposed to be actually pus. The arteries are, I believe, not affected in cases of ordinary pya'inia, except that the smallest branches may be sometimes the seat of embolism. Dr. AArilks believes that in some cases of Avhat he calls arterial pyaemia, the pathological condition is one of arterial thrombosis in situ^ rather than of embolism from softening cardiac clots. The capillaries in \rarious parts of the body are occasionally seen to be plugged by embola; but, as already indicated, this condition is, in most instances, inferred rather than demonstrated. Blood—The blood often presents no abnormal appearances, though in other cases it contains an unusually large proportion of Avhite blood corpuscles (leucocytosis). Its coagulability is usually diminished, and it is commonly found fluid or imperfectly clotted. This Avant of coagulability is one cause of the liability to capillary oozing or parenchymatous hemorrhage, Avhich is often observed in cases of pyaemia, a tendency which is probably assisted, as pointed out by Stromeyer, by the venous obstruction due to thrombosis, and Avhich is still further aided by the complication of leucocytosis, Avhen present— capillary bleeding being, as is well known, a frequent occurrence in cases of leukaemia or leucocythemia. Small organisms (bacteria) are commonly found in the blood of pyaemic patients, but have not been proved to have causal connection with the occurrence of the disease. Causes of Pyaemia—As Predisposing Causes of pyaemia may be men- tioned previous illness, visceral disease (especially of the kidneys or liver), exhaustion, loss of blood, prolonged shock, over-crowding (especially of sup- purating cases), a scorbutic condition, the puerperal state, certain diseases— such as erysipelas, hospital gangrene, carbuncle, osteomyelitis, etc___and, finally, the presence of an open wound. The Exciting Cause, according to the pathological view adopted in this chapter, is the absorption of a septic material, usually in the form of a liquid, from a Avound or ulcer, but, in some cases, from the alimentary or other mucous membrane; or, possibly, in the form of a gas, by the medium of the lungs. It is asserted by many Avriters, SYMPTOMS OF PYiEMIA. 411 that pyaemia neAer occurs except in connection with the existence of an open wround. There are, however, cases on record, in which pyaemic symptoms have not appeared until after the cicatrization of a wound, and Savory declares that pyamiia not only occurs Avithout the previous existence of any Avound, " but sometimes, so far as the most careful and complete examination can sIioav, Avithout any previous suppuration or any other local mischief what- ever."1 Dr. Savreux-Lachappelle2 has collected a number of cases of so- called idiopathic or essential pyemia, and has shoAvn that in most of these instances exposure to cold has been the apparent cause of the affection. There is, moreover, reason to believe that, in some cases, the pyamic poison is generated in the secretion Avhich lubricates mucous membranes. Hence, while in the immense majority of cases, Ave may safely assume that the mate- ries morbi of pyaemia is developed in the fluids of a wound or ulcer, we are forced to believe it possible that the septic material Avhich gives rise to the disease, may originate de novo in the system, as the result of extraneous in- fluences. With regard to the question of the contagiousness3 of pyaemia, Ave must speak Avith a certain degree of hesitation ; in the ordinary sense of the term it is certainly not contagious—not in the same sense, that is, as typhus fever or measles. Pyaemia may, undoubtedly, be inoculated by careless use of sponges, etc., or may possibly be transmitted by proximity alone ; but in either case the septic material must be generated in the fluids of the wound or ulcer of the person about to be affected, before infection can take place. Each in the rare cases in which the peculiar septic matter of pyaemia is sup- posed to have been absorbed in a gaseous form through the lungs, it is possible that the sole office of the morbid substance derived from Avithout has been to produce a change in the fluids of the part, the true pyaemic poison being there developed, and causing infection as a secondary consequence ; just as in other instances it is probable that the pyaemic poison is generated in the secretions of the alimentary or genito-urinary mucous membranes. Symptoms of Pyaemia.—The first symptom of pyaemia, at least in surgical cases, is almost always a sensation of cold, with usually a decided rigor or chill. These chills are subsequently repeated, at irregular intervals, and are commonly folloAved by profuse and exhausting diaphoresis, the hot stage Avhich is generally observed after malarial chills being, in cases of pyaemia, absent, or but slightly marked. The greatest elevation of tempera- ture coincides Avith the period of rigor, the thermometer not often going above 104°, though occasionally, if the chill be very severe, reaching 106° or 107°, or, according to Billroth, even 108°, Fahr. The irregular variations of tem- perature, which range OATer 10° or 11° Fahr., are considered by AYagstaffe of diagnostic value. During the sweating stage the temperature rapidly falls. According to Ringer and Le Gros Clark, the eleAration of temperature begins before the development of the chill, and the former author believes that the occurrence of the rigor may be predicted by thermometrical observation. The pulse rate is rarely below 90, usually ranging from 100 to 130, and (according to Bristowe) occasionally reaching 200. The respiration is usually hurried and anxious, ranging from 40 to oO in the minute, and sometimes even more. The breath is said to have a hay-like odor, though I cannot say that I have myself observed this symptom. There is commonly cough, with expectora- tion of viscid or of blood-stained sputa, and physical examination reveals the 1 St. Bartholomew's Hosp. Reports, vol. iii. p. 77. 2 See notice in Archives Ge!n. de Me"decine, October, 1869, pp. 488-491. 3 See in connection with this subject a paper by Dr. J. Burdon Sanderson, in Med.- Chir. Trans., vol. lvi. p. 345. 412 PYEMIA. signs of pulmonary congestion, with pneumonia (lobular or lobar) and pleu- risy. Pericarditis may be present, but its signs are often masked by the respiratory sounds. The countenance is flushed, the skin presents a dusky, salloAv, someAvhat jaundiced hue, and is often marked Avith sudamina, Avhich, being surrounded by a zone of congestion, have been mistaken for the spots of typhus, or of typhoid fever. At a later stage, a pustular eruption, resem- bling that of smallpox, has been observed. Petechiae, ecchymoses, and local- ized gangrene, occur in some cases. The tongue is usually furred; there is commonly complete anorexia; often nausea and vomiting; and usually diar- rhoea. The urine is frequently albuminous. The patient is often delirious, particularly at night, or may be profoundly soporose, though rousing up and answering intelligently when addressed. Intense pain often accompanies the formation of the secondary deposits or inflammations, particularly when these are superficial, as in connection with the joints. If there be an open wound, it will probably become dry and glazed, all reparative action ceasing ; occa- sionally, hoAvever, healthy granulations continue to be formed almost to the end of the case, or, on the other hand, absolute sloughing may occur. Profuse capillary hemorrhage may tend still further to Aveaken the patient. Before death the symptoms assume aprofoundly typhoid character: sordes accumu- late upon the lips and gums ; the tongue becomes dry and broAvn, and some- times cracked and bleeding; subsultus tendinum and carphologia, Avith Ioav- muttering delirium, mark the profound implication of the nervous system, and the patient may die comatose, or apparently from pure exhaustion. Diagnosis___The diagnosis of pyaemia can usually be made by carefully observing the history and the symptoms of the case. From Inflammatory Fever, from Hectic, and from Typhoid Fever, pyaemia can usually be distin- guished by its greater fluctuations of temperature and higher thermometrical range, and by its repeated rigors, occurring at irregular intervals. From inflammatory fever it further differs, in that the former affection commonly yields on the occurrence of suppuration. The irregularity of the chills, together Avith the absence, or at least the want of prominence, of the hot stage, will prove of diagnostic value as regards Intermittent and Remittent Fevers. From Rheumatism,1 and especially from Avhat is called Rheumatoid Arthritis, the diagnosis is often extremely difficult, particularly if the pyaemia assume a chronic form. Under such circumstances, the surgeon must rely chiefly upon the history of the case, the condition of the Avound (if there be one), the de- gree of prostration, and the tendency to suppuration—wliich occurs as a rule in pyaemic joint affections, and only exceptionally in those of a rheumatic character. The secondary local manifestations of pyaemia may be readily confounded Avith other diseases. Thus an idiopathic pneumonia, occurring after an amputation, might be mistaken for tbe lung complication of pyaemia, and a similar error might be made Avith regard to other organs. I Avas once asked to see a patient in Avhom marked brain symptoms, Avith general febrile disturbance, had followed traumatic erysipelas supervening upon an excision of the elbow. The case had been supposed to be one of pyaemia, but I diag- nosticated tuberculous meningitis, chiefly from observing the intense head- ache, with screaming, the absence of prostration, and the existence of the tache cerebrale, or red mark produced by lightly draAving the finger-nail over the surface of the chest or abdomen. The correctness of this opinion was subsequently demonstrated by an autopsy. 1 There is reason to believe that the affections known as Gonorrheal Rheumatism, Urethral Rheumatism, Urethral or Genital Fever, etc., are actually mild forms of pyaemia, resulting from the development of septic material in the secretion of the genito-urinary mucous membrane. PROGNOSIS AND TREATMENT. 413 Prognosis.—The prognosis of pyaemia is always unfavorable, and in an acute form the disease is almost invariably fatal. The subacute and chronic varieties, however, are less hopeless, and, in any case, the longer the patient can be kept alive, the better is the prospect of ultimate recovery. I have myself seen at least four cases of pyanuia terminate favorably—three after partial excisions of the radius or ulna, and one after partial amputation of the hand—but in none of the four did the affection assume a very acute form. The duration of the disease varies greatly in different cases. Occasionally, in Avhat the French call the foudroyante form of pyamiia, death may occur Avithin a day or tAvo of the first rigor. From four or five days to a Aveek is the usual duration of acute cases, though life may be prolonged for ten days, a fortnight, or even longer. In cases Avhich recover, the patient usually goes through a long illness, and may be left permanently crippled by secondary implication of the articulations. The occurrence of abscesses in superficial parts, Avhere they can he evacuated, is looked upon as rather a favorable omen ; and I have sometimes thought that the diarrhoea, in these cases, appeared to act as a derivative in relieving the internal viscera. Treatment—As Prophylactic Measures, all those precautions should be adopted, Avhich Avere discussed in speaking of operations in general, and of erysipelas, hospital gangrene, etc., diseases Avhich are often folloAved by pyaemia. As every patient Avith a suppurating Avound is liable to this affec- tion, the surgeon should use every effort to obtain primary union, or at least cicatrization Avithout any unnecessary delay : at the same time he must take care to secure free drainage from the Avound, lest, in his zeal for early healing, he cause purulent and other fluids to be pent up and confined, thus defeating the very object Avhich he is seeking to promote. The various predisposing causes of pyaemia should as far as possible be obviated, for we know of no way by wliich the development of the poison can be certainly prevented, nor by aa hich it can be hindered from producing its deleterious effects. The administration of various drugs has been proposed, with the idea that they Avould exercise a prophylactic influence : the perman- ganate of potassium, and more particularly the sulphites and hyposulphites (the latter agents on the recommendation of Polli, of Milan), have been somewhat extensively employed, but have not, I believe, fulfilled the expectations of those who have used them, and the same may be said of carbolic acid and the carbolates. Labat, of Bordeaux, has advised the internal exhibition of ergo- tine, Avhich he believes acts by increasing the plasticity of the blood; the evidence adduced in its favor, is, hoAvever, but negative, as is that in favor of the tincture of aconite, recommended as a prophylactic in these cases by Chassaignac. Curative Treatment___The treatment of this disease must be conducted on those principles which guide the surgeon in the management of other affec- tions of a typhoid character: there is no specific for pyemia. If the patient be at first constipated, Avith a deeply furred tongue, it may be proper to give a small dose of blue mass, folloAved by magnesia or other mild cathartic. Under such treatment the tongue will often clean off, to become, however, again furred in a short time, as the case progresses. Quinia is, I belieAe, more valuable than any other single drug, in the treatment of pyaemia : it may be given in doses of four or five grains, every three or four hours. Guerin, who has great confidence in this medicine, uses very large doses—giving as much as a drachm in tAventy-four hours. Socin, of Basle, used still larger quantities—90 to 105 grains in the tAventy-four hours—Avith success during the late Franco-Prussian war. Legouest and Bouillaud think the cinchona 414 PYEMIA. bark itself a preferable agent to quinia. Iron may be combined with the quinia in the form of the muriated tincture, or, which Braidwood prefers, the citrate of iron and quinia may be substituted. The oil of turpentine is, I think, a useful stimulant in these cases ; it may be given with muriatic acid, in an emulsion, a few drops of laudanum being added to each dose, if there be a tendency to undue purging. As diarrhoea, hoAvever, appears in some cases to be a means adopted by nature to eliminate the poison, it should not be hastily checked, unless so profuse as to be in itself a cause of exhaustion. Opium may be required to relieve pain or restlessness, and in such cases may be ghTen in any form that convenience may indicate. Carbonate of ammonia may often be employed with advantage ; if the pulmonary complications be prominent, it may be properly combined Avith syrup of senega, as a stimulat- ing expectorant. Transfusion of blood is recommended by Marcacci. In all cases the patient should be supplied with abuhdance of light but nutritious food, given in small quantities and at short intervals, and alcohol, in the form of Avine or spirit, must be likewise administered very freely ; Socin, of Basle, in connection Avith the huge doses of quinia above referred to, gave his patients three bottles of Avine per diem. In the worst case of pyaemia in which I have ever known recovery to follow, the patient got every hour, day and night, a tablespoonful of whiskey, Avith six of milk, and four of lime-water, for more than a week ; his anorexia Avas complete, with constant nausea, and retching at the very idea of food, and it was only by his taking this combination regu- larly, as medicine, that life Avas sustained. With regard to Local Measures, beyond care as to the cleanliness of Avounds, and the use of disinfectants, I do not knoAV of any plan worthy of much confidence. The application of the autual cautery in the course of the superficial veins (if these be inflamed), or to the Avound itself, has been highly recommended by several Avriters. Legouest advises that the Avound should be Avashed with the perchloride of iron. Nitric acid and various other caustic agents have been likeAvise employed, but the evidence is not very satisfactory as to any benefit derived from their use. Probably the most rational plan is to be satisfied with keeping the Avound clean and lightly dressed ; and diluted alcohol, or weak solutions of the permanganate of potassium, or of carbolic acid, are probably better applications, in these cases, than poultices or other more cumbrous forms of dressing. Free drainage from the wound should be secured by position or otherwise, and if abscesses form in accessible situa- tions, they should be opened at an early period, and their cavities afterwards frequently washed out with disinfectant fluids. Under the course of treatment above described, a certain number of the milder cases of pyaemia may be conducted to a favorable termination, and, occasionally, a patient more severely attacked, may be snatched as it were from the very jaws of death ; but there is reason to fear that the large majo- rity of pyaemic cases Avill prove fatal in spite of all our care and attention, and that this frightful affection Avill continue to deserve the name wliich has been not inaptly bestowed upon it, of the " Bane of Operative Surgery." STRUMA. 415 CHAPTER XXIII. DIATHETIC DISEASES. Struma (including Tubercle and Scrofula) ; Rickets. Beside the affections to the consideration of which this chapter is devoted, there are tAvo diseases which have claims to be regarded as of a diathetic or constitutional nature, viz., Cancer, and Hereditary Syphilis. The former Avill be described when Ave come to speak of malignant tumors, and the latter, under the head of A^enereal Diseases. Struma. The terms Struma, Scrofula, and Tubercle have been very variously applied by pathologists. Some look upon them as indentical, Avhile others use struma as a general term embracing both the others; some subdivide scrofula into two varieties, the sanguine and phlegmatic, and ignore the independent na- ture of tubercle, Avhile others recognize the tAvo forms of scrofula, and consider tubercle as a distinct affection ; some, again, recognize but one form of scro- fula (the phlegmatic), and apply the term tubercle to the sanguine variety, while still others are disposed to doubt the existence of any form of scrofula, apart from a syphilitic taint. It will thus be seen that the use of these words is necessarily attended with a good deal of confusion, and it Avould be Avell if we could dispense Avith them all, and adopt others Avhich might be univer- sally adopted as having a definite signification. Under the general term of struma, surgeons (whatever be their theoretical vieAvs) practically recognize, as justly remarked by Holmes, three classes of cases, viz., (1) those in Avhich there is evidence of the existence of tubercle, (2) those in Avhich there is no tubercle, but in which the ordinary processes of inflammation, etc., present modifications Avhich can only be accounted for on the supposition of the antecedent existence of some morbid condition or diathesis, and (3) cases which present, in reality, nothing more than the con- stitutional effects of long-continued local disease. Under the latter head come a large proportion of cases of chronic bone and joint disease, which are commonly though incorrectly called strumous. Rejecting then entirely the third class, Ave have the cases in which tubercle exists, and wliich may be properly called tuberculous, and those in which there is evidently a morbid diathesis (not tuberculous), to Avhich Ave may conveniently, if not very scien- tifically, apply the term scrofulous. Tubercle or Tuberculosis__I shall not enter into any discussion as to the nature and origin of tubercle, a question Avhich belongs more properly to the domain of general pathology than to that of practical surgery, and upon which the leading authorities of the present day are still not agreed.1 It is usually said that tubercle occurs under tAvo forms, the gray or miliary 1 See an elaborate and able review of Waldenberg's "Tuberculosis, Pulmonary Consumption, and Scrofula," by Dr. J. C. Reeve, of Dayton, Ohio, in Am. Journ. Med. Sciences, Jan. 1870, pp. 137-171. 416 DIATHETIC DISEASES. tubercle, and the yellow tubercle. The latter is probably in many instances not tubercle at all, but the result of caseous or cheesy degeneration (tyrosis) of pus, cancerous deposits, or other pathological formations ; in other cases, however, the yelloAV is the result of caseous degeneration of the miliary tubercle. Gray or miliary tubercles occur as small granular masses, about the size of millet-seeds, rather hard, semi-translucent, and presenting a glistening car- tilaginous appearance. Under the microscope, these masses sIioav a homoge- neous or slightly fibrous stroma, containing cells Avith one or more nuclei, free nuclei, granules, etc. In the so-called yellow tubercle, which usually occurs in larger masses, the cells have a Avithered appearance, and the granular matter is in larger proportion, and mixed Avith oil globules. The following scale of the frequency of tubercle, in various textures and organs, is taken from Rokitansky: lungs, intestinal canal, lymphatic glands (particularly the abdominal and bronchial), larynx, serous membranes (espe- cially the peritoneum and pleura), pia mater, brain, spleen, kidneys, liver, bones and periosteum, uterus and tubes, testicles Avith prostate and seminal \"esicles, spinal cord, and striated muscles. The favorite primary seats of tubercle, after the lungs and lymphatic glands, are the urinary and sexual organs, and the bones. Tubercles are only met with in vascular parts (hence not in cartilage), and are often deposited in the external coats (adventitia) of the smaller vessels, a circumstance which may account for their frequent ap- pearance in the choroid coat of the eye, Avhere they have been recognized during life by means of the ophthalmoscope (see AYaldenburg, and Reeve, loc. cit., p. 148). Tubercle may become indurated and calcified (obsolete), but usually tends to softening, disintegration, and liquefaction; the fact of its absorption is not established, though its possibility is admitted by both Rokitansky and A irehow. The causes, symptoms, course, and general treatment of tuberculosis are described in every Avork on the Practice of Medicine, and need not there- fore be referred to here: it maybe stated, however, that there are strong grounds for believing that, among the sources of depression which act as predisposing causes of the development of tubercle, long-continued suppura- tion1 is one which must not be ignored. Hence an additional reason in the treatment of surgical cases, for paying attention to the constitutional condition of the patient, and for preventing, if possible, deterioration of the general health. AVith regard to the question of operative interference in tuberculous cases, no general rule can be giA-en. The prognosis of an amputation or ex- cision for tuberculous disease, is undoubtedly less favorable than that of a similar operation for scrofulous or simple chronic inflammation. If there be evidence of tuberculosis of internal organs, any operation should as a rule be aAoided ; the only exceptions are—(1) Avhen it appears that the visceral dis- ease is caused by the external affection, and Avhen therefore there Avould be reason to hope that by removing the latter the progress of the former might be checked, and (2) Avhen the patient's suffering from the external disease is so great, that the operation is called for simply for the relief of pain. Scrofula or Serofulosis, as the term is here used, denotes a consti- tutional condition or diathesis, which imparts a peculiar character to the pro- cesses of inflammation and ulceration, and which is particularly marked by a tendency to cheesy degeneration in the lymphatic glands, and to a Ioav form of inflammation of the bones and joints. 1 Dr. Burdon Sanderson looks upon tuberculous deposits as closely analogous to the "metastatic abscesses" of pyaemia. SCROFULA OR SCROFULOSIS. 417 Many writers speak of a scrofulous temperament, and describe certain peculiarities of feature and complexion, as characteristic of the scrofulous diathesis. Mr. Erichsen describes two forms, the fair and the dark, and sub- divides each of these into two varieties, the fine and the coarse : Sir AATm. Jenner, on the other hand, regards the fine A'arieties (Avhich constitute Avhat is usually called the sanguine temperament) as belonging to the tuberculous diathesis, and limits the term scrofulous to the temperament commonly recog- nized as the phlegmatic. Although, hoAvever, there are doubtless many cases of tuberculosis met with among persons of a sanguine temperament, Avith delicate features, clear complexions, and highly developed nervous systems, there are perhaps almost as many among those whose temperament Avould be unhesitatingly pronounced phlegmatic, so that, as Holmes justly remarks, the exceptions to the rule are almost as numerous as its exemplifications. It is indeed questionable Avhether there be any temperament that can be positively declared to predispose to either scrofula or tubercle, or, on the other hand, any temperament in Avhich either or both of these diseases may not under favoring circumstances be deAeloped. The scrofulous diathesis may be inherited, or maybe acquired by subjection to A-arious sources of depression, such as bad or insufficient food, intemperance, bad ventilation, exposure, mental anxiety, etc. EA'en when not manifesting itself in the form of any particular malady, it is usually characterized by weakness and irritability of the digestiA'e system, by a feeble circulation, and by a state of general anaemia. Manifestations of Scrofula___The manifestations of scrofula Avhich chiefly come under the notice of the surgeon, are scrofulous inflammation and ulce- ration, affecting the skin and mucous mem- branes, scrofulous disease of the bones and Fig. 18S. joints, and cheesy degeneration of the lym- phatic glands. 1. Skin. — Various cutaneous eruptions luwe been considered as scrofulous, but upon someAvhat questionable grounds ; there can be no doubt, hoAvever, that cutaneous ulcers are modified in their appearance and course by the scrofulous diathesis, the tissues around the ulcers in these cases being greatly thick- ened and infiltrated with scrum, the granu- lations large and feeble, and the cicatrices, Avhen formed, thin, weak, and liable to re ul- cerate (Fig- 1**). 2. Mucous Membranes. — The mucous membranes, under the influence of the scro- fulous diathesis, become thickened and irri- Scrofulous ulcer of leg. (Erichsen.) table. The secretions may be thin and acrid, or sometimes mixed Avith pus. In the eyes, there may be granular conjunc- tivitis, Avith perhaps haziness or ulceration of the cornea, and in the Schnei- derian membrane, hypertrophy, giving rise to obstructed breathing and snuffling; the antrum may swell, discharging purulent mucus into the nostrils; the tonsils are not unfrequently enlarged, and the voice rendered husky, by relaxation or thickening of the laryngeal mucous membrane; diarrhoea is frequent, and cystitis, urethritis, and leucorrhea may each in turn be due to the scrofulous diathesis. 3. Bones and Joints.—The scrofulous diathesis seems to render the bones and joints peculiarly disposed to unhealthy and destructive forms of inflam- mation. Thus an accident, which occurring to a healthy person Avould be 27 418 DIATHETIC DISEASES. quite trivial, may in one of a scrofulous diathesis be productive of the most serious consequences. I have known a fall on the ice, which would ordinarily have caused a mere bruise, to give rise, in a scrofulous child, to acute osteo- myelitis of the humerus, with pyarthrosis of both elbow and shoulder, ampu- tation at the scapulo-humeral articulation being eventually required. Under the influence of scrofulosis, inflammation of bone is apt to assume the form of caries, or of caries Avith limited necrosis (caries necrotica), Avhile in the joints are found the various affections popularly called " Avhite swellings," gektini- form degeneration of the synovial membranes, ulceration of cartilages, etc. 4. Lymphatic Glands___Perhaps the most unequivocal manifestation of scrofula is the tendency Avhich it induces to cheesy degeneration (tyrosis) of the lymphatic glands. Indeed, AValdenburg, as quoted by Ree\e (loc. cit., p. 154), defines scrofula as " a constitutional anomaly in which the lymphatic glands have an abnormal tendency to disease, and possess a local disposition to undergo cheesy degeneration." Glandular enlargement, particularly in the cervical and submaxillary regions, is very frequently observed in cases of scrofulosis, and, under very slight irritation, suppuration is apt to occur in the neighboring areolar tissue, the glands themselves breaking doAvn, and mingling the caseous products of their degeneration with the surrounding pus. The abscesses thus formed are extremely indolent, not healing perma- nently until all the affected glandular structure has been removed, and cica- trizing finally with depressed and disfiguring scars. 5. Other Organs are occasionally though less frequently affected by scrofula. Among those which are most important, from a surgical point of vieAv, may be enumerated the mammary gland and the testis. Treatment of Scrofula___The treatment of scrofulosis should consist more in attention to hygienic rules than in the use of medicines. Good air, good food, habitual cleanliness, sufficiently Avarm clothing, and protection from exposure or other sources of depression, are of the highest importance. Spe- cial attention should be given to the digestive functions, and either constipa- tion or diarrhoea should be obviated, rather, hoAvever, by regulating the diet than by the use of drugs. Among medicines, certain tonics are particularly serviceable. Cod-liver oil probably deserves the first place, the most useful articles after it being iron, quinia, and the preparations of iodine. The syrup of the iodide of iron is a very good combination, particularly for administra- tion to children. These tonics should not, hoAvever, be given indiscriminately, and, as a rule, not while there is evidence of marked intestinal derangement. Alcoholic stimulants must be used with great moderation, and the lighter Avines, or malt liquors, such as lager beer, are commonly preferable to the Is stronger forms of stimulus. e By local treatment, it is doubtful Avhether much can be accomplished. A most important rule, and one which should be constantly borne in mind, is to take care lest by our treatment Ave convert this, which is essentially a chronic a affection, into one which is acute. Hence in many instances the best thing for the surgeon to do is to let the part alone, merely protecting it from exter- nal injury. In other cases more actiA'e measures may be employed, though always with care and watchfulness. Scrofulous ulcers may be dressed Avith slightly stimulating or astringent applications, and the livid, unhealthy-look- ing edges may be touched with the actual cautery, or even removed Avith the knife. Lymphatic enlargements should be protected by means of soap plas- ters, or, if very indolent, may be submitted to gentle frictions, with moderate pressure, and the use of mildly discutient lotions. Even if abscesses form, it is better, I think, to delay opening them, as long as there is the slightest chance of absorption and spontaneous disappearance. If an opening be inevi- table, it is probably better made with the knife than left to nature, as the RICKETS. 419 resulting scar Avill be still less disfiguring. Any sinuses that are left may be encouraged to heal, by stimulating injections, or by means of a seton. Re- peated tappings with the hypodermic syringe, or exploring needle, are recom- mended by LaAvson Tait and Crocq, in the treatment of suppurating glands in the neck. AArith regard to operations in scrofulous cases, no rule of universal applica- tion can be laid doAvn. I am decidedly of the opinion that, in the immense majority of instances, enlarged cervical glands should not be interfered Avith ; apart from the fact that the disease in such a case commonly extends much deeper than it appears to, these operations almost ahvays come into the cate- gory of operations of expediency, and, as such, are only exceptionally justi- fiable. AYith regard to operations for scrofulous bone and joint disease, the question is more doubtful. As a rule, it may be stated that no operation should be performed Avhile a reasonable hope remains that a cure can he effected by expected treatment; if, however, the poAvers of nature should be manifestly incompetent for the task, or if (as is often the case among patients of the poorer classes) the time Avhich Avould probably be required for a natural cure be an important consideration, operative measures may be properly resorted to, and will often be followed by the most gratifying results. Ex- cision is of course preferable to amputation, Avhen the circumstances of the case permit a choice. Rickets. Rickets or Rachitis is a constitutional disease, occurring almost ex- clusively in childhood, and characterized by a peculiar lesion of the osseous system, and by a tendency to the so-called amyloid or albuminoid degenera- tion of certain viscera, especially the spleen and liver. Causes___Rickets may possibly in some cases be inherited, but is, at least, much more frequently acquired,1 and usually results from mal-nutrition, or from other sources of constitutional depression to which children may be ex- posed. According to Heitzmann, rickets can be artificially produced by the continued administration of lactic acid. Morbid Anatomy___The most characteristic manifestation of rickets is seen in the skeleton, and affects the long bones as Avell as those of the head, chest, and pelvis. The bony changes consist essentially in increased cell- groAvth, with deficiency of earthy matter. The epiphyseal cartilages (car- tilages of conjunction) become enlarged, giving what is often called the " double-jointed" appearance observed in these cases. The periosteum is also greatly thickened, while the osseous shaft itself undergoes softening, its lacunae being much enlarged, and filled with red, pulpy granulations. Under the influence of muscular action, or other mechanical causes, the bones undergo modifications of shape, giving rise sometimes to great deformity ; if the child has begun to walk before the development of rickets, these changes will pro- bably be most marked in the lower extremities. The cranial bones are often much thickened, giving a massiAre appearance to the head; in other cases they are abnormally thin, or even perforated (craniotabes), the pericranium and dura mater seeming to be in contact; the anterior fontanelle remains open longer than in health. Circumscribed SAvellings may occur in the frontal and parietal bones, as pointed out by R. AY. Taylor, and may be mis- taken for syphilitic nodes. These SAvellings may subsequently undergo reso- 1 This subject is Avell discussed by Parry, .in an excellent paper in Amer. Journal of Med. Sciences, for April, lb72. 420 DIATHETIC DISEASES. lution, or may remain as permanent deformities. The ribs bend at their junction with the costal cartilages, alloAving the sternum to project, and causing the so-called "pigeon-breasted" deformity. In some cases the enlargement of the sternal extremities of the ribs gives the appearance of a deep gutter on either side of the breast-bone. The spine is occasionally the seat of lateral, but more often of antero-posterior curvature, the bacltAvard cur\-e being in the dorsal, and the forward in the cervical and lumbar regions. The pelvis often becomes very oblique, in consequence of the deformity of the loAver extremities, and of the "lordosis" or anterior curvature of the lum- bar spine; and serious complications may thus arise in after-life, in the pro- cess of parturition, or in operations on the pehic organs. Symptoms and Course—In the earliest stages of rickets, there are disorder of the digestive system and other evidences of mal-nutrition, but nothing that can be considered distinctive. Teething is delayed, and often accomplished with difficulty. The child sleeps badly, and is restless ; sweats profusely about the head, and constantly kicks off the bed-clothes. The mus- cular system is Aveak, and the patient, if he has already begun to Avalk, soon loses both the power and the disposition to do so. The urine is abundant, and usually loaded with phosphates. As the disease advances, a curious state of muscular hyperaesthesia is often observed, either voluntary motion or the touch of another being attended Avith acute pain, and the child, as a conse- quence, maintaining an almost fixed position, and appearing listless and indis- posed to even the slightest exertion. There is a tendency to bronchial and pulmonary inflammation, laryngismus stridulus, and cerebral irritation with convulsions. Fever is often, but by no means ahvays, present; the appetite is capricious or wanting, and the fecal evacuations (whether there be or be not diarrhoea) arc; ill-formed and offensive. The liver and spleen are often enlarged, and sometimes albuminous or amyloid, in the latter stages of the affection, while the bony deformities, Avhich ha\Te been described, frequently persist even after the entire restoration of the general health and strength. Intelligence is diminished during the existence of the disease, but the mental powers are usually completely restored with bodily convalescence. Diagnosis and Prognosis—There are no symptoms by Avhich, in its earliest stage, rickets can be distinguished from the other diathetic diseases Avhich we have considered. In any case in Avhich dentition is much delayed, or in Avhich difficulty in Avalking is observed, the surgeon may suspect rachitis, and, by careful attention to the symptoms above described, will usually be able to recognize it if present. AYhen the characteristic osseous changes have begun, the nature of the affection can scarcely be mistaken. The prognosis of rickets, if the disease be not too far advanced, is usually favorable ; as justly observed by Hillier, hoAvever, mortuary records recognize the secondary affections which complicate rickets, while the primary condition Avhich renders those complications fatal, is itself ignored. As a rule, it may be said that the earlier the disease appears, the less is the chance of recovery, Avhile even in the most favorable cases the affection may last for several years. Treatment.—The hygienic management of rickets is of the greatest importance ; if the disease occur during the first six or eight months of life, and the mother's milk be found either scanty or of bad quality, a healthy Avet-nurse should be procured, or the natural food supplemented or replaced by fresh coav's milk, diluted Avith lime-Avater (1 part to 4); dog's milk is pre- ferred by Bernard. After a time, beef-tea may be made to alternate Avith the milk, and Avine or brandy may be given, in quantities adapted to the GONORRHOEA. 421 patient's age. The child should be Avarmly clothed, and kept as much as possible in the open air, and at night in a well-ventilated apartment. Warm or cold sponging, or sea-bathing, Avill often prove of great service. If the digestive system be much disordered, a few doses of mercury Avith chalk, or some similar combination, may be given, but the remedies of greatest import- ance are tonics, especially cod-liver oil, iron, quinia, and nux-vomica. The cod-liver oil is probably the most valuable, and may be given in gradually increasing doses as the child is able to assimilate it. Some difference of opinion exists as to Avhether mechanical appliances should be used to obviate deformity in these cases. In the most acute form of rachitis, Avhen, in the vivid language of Sir AVilliam Jenner, the child "is indeed fighting the battle of life, . . . striving with all the energy it has to keep in constant action every one of its muscles of inspiration," the use of splints and bandages Avould be doubtless an unnecessary annoyance ; again, after the stage of bony con- solidation has come on, splints can be of no use, and would do harm by impeding the natural motions ; but, Avhile the bones are yet soft and yielding, a great deal may be often accomplished by the use of light apparatus, to pre- ATent if not to remedy deformity. For the lower extremities, simple wooden splints may be used, and may be made to project below the feet, so as to pre- vent the child from standing or walking; while for the spine, various forms of apparatus, such as will be described in speaking of spinal curvature, may be employed. AYhen excessive deformity of the long bones persists in after- life, it may occasionally be proper to endeavor to remedy it by cutting through the bone Avith saAv or chisel (osteotomy), or even by removing, subperiosteally, a Avedge-shaped portion. Operations of this kind have been successfully resorted to by Little, Marsh, Billroth, Guerin, Boeckel, Bradley, and other surgeons. CHAPTER XXIY. VENEREAL DISEASES. Gonorrhoea and Chancroid. The term Venereal Disease is applied to certain affections which are usually acquired in sexual intercourse. There are three separate diseases Avhich are properly described as venereal, Avhich until within a comparatively recent period were all confused together, and the distinction between two of which is even at the present time not recognized by a large number of sur- geons. These diseases are Gonorrhoea, Chancroid, and Syphilis. The first two are strictly local, Avhile the latter is a constitutional affection. The non- identity of gonorrhoea Avith the other venereal diseases, though pointed out by Balfour, B. Bell, Hernandez, and others, AAras not clearly established until the publication of Ricord's treatise, in 183atch. This change may occur in any situation, but is most often seen where mucous tissues are habitually in contact, as the inside of the lips, the tongue, the inner surfaces of the labia, the folds of the anus, or the lining surface of the prepuce. The change occurs when the repair of the chancre has been nearly completed by granulation, and consists in the formation of a Avhite membranous pellicle, which gradually spreads from the circumference of the sore to its centre. It is from inattention to this fact that a mucous patch has been in some cases supposed to be really the initial lesion of syphilis, the patient not being seen until the transformation has occurred, and the previous existence of a chancre thus escaping recognition. Mixed Chancre___It has already been stated that chancroid and syphilis may exist in the same patient. They may likeAvise be acquired at the same moment. Hence a patient, a few days after impure coitus, may present several venereal ulcers, not indurated and evidently not syphilitic— and yet in a few weeks, without further exposure, one of these may become indurated and be followed by secondary symptoms. The syphilitic has been inoculated simultaneously Avith the chancroidal poison, just as. it may be inoculated Avith the poison of coAvpox, the vaccine disease disappearing at the usual time, and syphilis folloAving after its own proper period of incuba- tion. Again, syphilis may be inoculated upon a previously existing chan- croid, a chancre being the result; or conversely, if a person Avith chancre have sexual intercourse with a Avoman affected Avith chancroid, he may acquire the latter disease, his chancre serving as a point of inoculation. The term mixed chancre is, perhaps, an unfortunate one, as seeming to imply that the venereal ulcer to which it refers is intermediate between chancre and chancroid; the fact being that it is not in any degree intermediate, but a result of the accidental coexistence of two separate diseases. Syphilitic Bubo___Induration and chronic enlargement of the neigh- boring lymphatic glands, are almost, if not absolutely, constant sequels of chancre. As in the large majority of cases the latter is situated on the geni- tal organs, it is the inguinal glands that are usually affected, constituting the ordinary syphilitic bubo; but induration will attack the facial and submaxil- lary glands, if the chancre be cephalic, and those of the elbow and axilla, if the initial lesion occupy the finger. Cases have been recorded by H. Lee, and others, in Avhich a chancre is said to have been followed by secondary symptoms, without the intercurrence of a bubo, and the possibility of such an event must therefore probably be acknowledged: such cases must, how- ever, be extremely rare, and in no instance can it be fairly claimed that this has happened, unless the patient has been continuously under the notice of a skilled observer, as syphilitic bubo is often unperceived by the patient him- self, and may, like the induration of a chancre, pass off in a comparatively short time. The development of a syphilitic bubo coincides pretty closely Avith that of induration in the chancre which precedes it; it is poly ganglionic and usually bilateral, or, in other words, involves the Avhole chain of superficial glands, and commonly invades both groins at once. The glands are hard, movable SECONDARY SYPHILIS. 443 upon each other and beneath the skin, usually painless, and about the size of almonds (amygdaloid enlargement): one is frequently larger than those which surround it, the group being fancifully designated by French Avriters as the "pleiade ganglionnaire." The syphilitic bubo has in itself no tend- ency to suppurate, and when suppuration occurs, it is due to the influence of some external irritant, to the patient's being of a scrofulous diathesis, or to the coexistence of a chancroid. In the latter case, the suppurating bubo will be chancroidal, and its pus, of course, auto-inocukble. The duration of a syphilitic bubo is variable, lasting usually longer than the induration of the chancre, and being in many cases quite distinct for six months or a year after infection. Cases have even been recorded, by Yenning and others, in Avhich the amygdaloid condition of the inguinal glands persisted tAventy years or longer; and it is believed by the above-named Avriter that the disappearance of this condition may be considered an evidence that the disease has Avorn itself out, and that the patient is susceptible of re-infection. The syphilitic bubo is often attended by induration of the lymphatics running from the chancre to the affected glands ; resolution usually occurs about the time that induration disappears from the chancre, but, occasionally, suppuration has been observed, a number of fistulous openings being formed in the course of the vessel. It is believed by some surgeons that a syphilitic bubo may occur Avithout any pre-existing chancre, and this has been spoken of as a form of the Bu- bon d'Emblee. Such cases are, however, really instances of defective obser- vation, or of voluntary deception upon the part of the patient. A superficial chancre may readily be unnoticed by a patient, or even by a surgeon, par- ticularly if situated in the urethra, or neck of the uterus, or if unaccompanied by induration: there is no sufficient evidence to throw doubt upon the truth of the axiom, that the initial lesion of syphilis is invariably a chancre. Secondary Syphilis. Between the time of appearance of a chancre, and the period at AAdiich secondary symptoms are developed, there is an interval Avhich is sometimes called the period of incubation or latency. The former term is better applied to the interval betAveen the date of contagion and that of the appearance ot the chancre, while in many cases the disease cannot properly be said to be latent, as the chancre and attendant bubo frequently continue after the appear- ance of general syphilis, the primary and secondary stages often, as already remarked', overlapping each other. The shortest period in Avhich an untreated chancre is knoAvn to have been folloAved by secondary symptoms is twenty- five days, while the average period, as shown by an analysis of nearly 500 cases, is about six weeks. Secondary syphilis rarely appears after the first three months, and almost never later than six months, unless the natural evolution of the disease has been interfered with by treatment. Secondary syphilis cannot occur without primary syphilis having preceded it f the apparent exceptions are due to the primary symptoms having escaped detec- tion, an event Avhich, as already seen, may readily occur under various cir- cumstances. Premonitory Signs__Certain premonitory symptoms usually precede the development of secondary syphilis, lasting from a feAV days to a Aveek or more, and consisting in febrile disturbance, with languor and general discom- fort, vague pains of a neuralgic character, headache, sometimes apparently i This remark does not, of course, apply to hereditary syphilis. 444 VENEREAL DISEASES. neuralgic, but sometimes due to inflammation of the pericranium,1 and (par- ticularly in women) aiuemia. AArith the exception of the pericranial head- ache, these symptoms usually disappear upon the occurrence of the eruption and other secondary symptoms. The most characteristic and usual manifes- tations of secondary syphilis, are cutaneous eruptions, sore throat, mucous patches, and general enlargement of the lymphatic glands. More rarely Ave find falling of the hair, certain affections of the eyes and ears, paralysis, and other symptoms referable to the implication of the nervous system. Cutaneous Eruptions__There is no definite syphilitic eruption. On the contrary, a large number of skin diseases may occur as manifestations of syphilis, and several of them are not unfrequently found coexisting in the same case. The limits of this work Avill not permit any extended description of the various syphilitic eruptions, or, as they are often called, Syphilo-der- mata or Syphilides, for a full account of Avhich I Avould respectfully refer the reader to any of the numerous excellent works on Arenereal which have re- cently been published, and more especially to those of Cullerier, Lancereaux, and Belhomme and Martin, in France, of H. Lee and AY. J. Coulson in Eng- land, and of Bumstead and Van Buren and Keyes in this country. Caze- nave's classification is that usually adopted, those eruptions which belong to the secondary stage of syphilis being the exanthematous (erythema and roseola), the papular (syphilitic lichen), the vesicular (herpes, eczema, syphilitic varicella, etc.), the bullous (pemphigus and superficial rupia), and the pustular (ecthyma, acne, and impetigo). Syphilitic erythema is usually the earliest of the eruptions, and is frequently so slight as to escape the atten- tion of the patient. Ecthyma is likeAvise an early manifestation of secondary syphilis, and is very often met Avith in the scalp. There are certain features wliich habitually mark all forms of syphilitic eruption, and wliich have a certain diagnostic value. There are (1) the so-called protean character of the eruption, or the appearance simultaneously, or in quick succession, of more than one variety; (2) the peculiar reddish-brown or copper-colored hue of the eruption in its declining stage; and (3) the absence of itching. Four- nier has lately pointed out a peculiarity of the skin in syphilis, wliich he con- siders quite significant. This is cutaneous anaesthesia, of which he describes three varieties, viz., anaesthesia as regards pain, or analgesia (by far the most common), anaesthesia of general sensibility, and anaesthesia as regards changes of temperature. Sore Throat___The sore throat of secondary syphilis may consist merely in erythematous efflorescence of the part, or in a superficial aphthous ulcera- tion. This may affect the fauces, tonsils, palate, cheeks, or tongue. Occa- sionally, in this stage, the tonsil may present an excavated ulcer, with sharp- cut edges and sloughy surface, which somewhat resembles a chancroid, and has been incorrectly called an amygdaline chancre. The severer forms of syphilitic sore throat, Avith the concomitant affections of the larynx and oesophagus, belong to the tertiary period of the disease. MUCOUS Patches__These, which are also called Condylomata, Moist Papules, and Mucous Tubercles, are particularly interesting as being the manifestation of secondary syphilis Avhich is chiefly concerned in the trans- mission of the disease, though it is probable that any of the moist forms of 1 According to Mauriac, periostitis, Avhether of the cranium or other parts, is much more common as an early manifestation of syphilis among the Arabs in Africa, and the inhabitants of South America, than among the residents of other countries. ENLARGEMENT OF LYMPHATIC GLANDS. 445 eruption may occasionally prove the source of contagion. Mucous patches occur on mucous membranes, or Avhere the skin is thin, and particularly Avhere tAvo surfaces are habitually in contact. They are thus chiefly seen on the vulva, or around the anus, betAveen the buttocks, on the scrotum, or on the penis; in the mouth, on the tonsils, lips, and tongue; and more rarely between the toes, on the inside of the thighs, and on other parts of the body. On the skin they appear as flat, slightly elevated papules, about half an inch in diameter, and covered with a slimy, feticT exudation. This appears as a kind of false membrane or pellicle, Avhich covers a raw surface from Avhich the cuticle has been previously removed. On the mucous membranes they are less elevated, and, in the mouth at least, the exudation takes the form of a whitish pellicle, constituting the so-called " opaline patch." Condylomata usually first appear as reddish spots, effusion taking place beneath the cuticle, Avhich drops or is rubbed off, the surface being then soon covered Avith the characteristic exudation. Occasionally a chancre is directly transformed into Fig. 192. Mucous patches. (Miller.) a mucous patch, in the manner already described. Mucous patches produce a great deal of local irritation, and give much annoyance by their offensive odor. They often become ulcerated, and are occasional confluent. At the angles of the mouth, on the tongue, and at the margin of the anus, they are apt to be fissured, in the latter situation constituting a form of what are known as rhagades. Mucous patches are very frequently met with in either sex, but probably most often in Avomen. They run a very chronic course, and are apt to recur at irregular intervals. Urethral, Vaginal, and Uterine Discharges, without the exist- ence of any recognizable ulceration, are, as pointed out by Hammond, Morgan, and H. Lee, occasionally met with as symptoms of secondary syphilis, and are probably more often the source of contagion than is commonly supposed. Enlargement of Lymphatic Glands__This is a very constant and significant manifestation of secondary syphilis. The glands most commonly 446 VENEREAL DISEASES. affected are the posterior cervical, though others are occasionally involved. The cervical engorgement is most marked AAdien a pustular eruption exists upon the scalp ; this form of glandular enlargement is very different from the glandular induration observed in the primary stage, though, like that, it usu- ally ends in resolution. The period of development of this characteristic symptom is, according to Bumstead, from six to eight Aveeks after the appear- ance of the chancre. Alopecia, or Falling of the Hair, is an early symptom of secondary syphilis. It is sometimes so slight as to be scarcely recognizable, and is most marked Avhen the scalp is the seat of an abundant eruption. Beside the hair of the head, the eyebrows may be affected, and more rarely the eyelashes and beard. This form of alopecia is amenable to treatment, and, according to Bumstead, is often absent Avhen mercury has been taken in the primary stage. There is another form met with in connection with tertiary syphilis, Avhich is usually incurable. Affections of the Eye.—Iritis is not unfrequently met with during the secondary stage of syphilis, though the Avorst form of the affection is that which occurs in the tertiary stage. The latter, according to Gascoyen, is really due to syphilitic contamination, while the variety met with during the secondary stage, and to Avhich Virchow gives the name of serous iritis or peri-iritis, results from accidental causes, beginning with congestion or inflam- mation of the conjunctiva, and involving the iris only secondarily. The vas- cular sclerotic zone around the margin of the cornea is not very well marked in this form of the disease, nor is pain a constant symptom. Xodules of lymph soon appear upon the iris, especially around the pupil, and the aqueous humor often becomes turbid; the cornea is occasionally involved. The pupil is sluggish and contracted (occasionally dilated), but there is little photo- phobia. Both eyes are often attacked, though usually not simultaneously. This form of iritis is much less intractable than the parenchymatous variety which occurs in tertiary syphilis. Retinitis and Choroiditis are occasionally met Avith in syphilis, usually as a concomitant or sequel of iritis; the symp- toms consist of mistiness of vision, micropsia, and diminution of the visual field, with a feeling of fulness in the eye, and some circumorbital pain, but without photophobia. It is sometimes possible, according to AArells, to dis- tinguish these affections from those which are not syphilitic, by their oph- thalmoscopic appearances, even if no other symptoms of syphilis are present. Syphilis is, according to Cowell, by far the most frequent cause of diffuse neuro-retinitis and exudative retinitis, Avhich are the ordinary forms of the disease. The former is quite amenable to treatment, and is fortunately much commoner than the exudative variety. Syphilitic affections of the lachrymal apparatus have been recently described by R. AV. Taylor, of NeAV York. Affections of the Ear___Acute myringitis, or inflammation of the membrana tympani, sometimes occurs in secondary syphilis, and may cause permanent deafness from inflammatory thickening of the part. Dr. F. R. Sturgis has reported tAvo cases of inflammation of the middle ear due to secondary syphilis, and syphilitic disease of the internal ear has been observed by Roosa and by Moos. Affections of the Nervous System.—Hemiplegia, Avith or with- out loss of consciousness, often preceded by persistent headache, mydriasis, and perhaps ptosis, is occasionally observed in connection Avith the secondary stage of syphilis. The explanation of these cases (in which no appreciable TERTIARY SYPHILIS. 447 lesion may be found after death) is, according to Dr. E. L. Keyes, of NeAV York, avIio has paid particular attention to the subject, that the paralysis is due to general or partial congestion of the brain, analogous to the congestions of the skin and mucous membranes, Avhich occur in secondary syphilis. Affections of Joints and Bursae__These may, according to Keyes, be affected in secondary syphilis, becoming congested and sometimes painful, though in other cases the congestion is painless and folloAved by effusion. The various manifestations of syphilis Avhich belong to the secondary stage occur Avith a certain degree of regularity (the exantliematous, for instance, usually preceding the papular eruptions), and last, Avith occasional intermis- sions, for a period varying from one to six months. They are general symp- toms, that is, are met with in various parts of the body simultaneously, and tend to a spontaneous cure, leaving, as a rule, no traces to mark their course. In mild cases of syphilis, the disease appears to Avear itself out in this stage, and tertiary symptoms are therefore by no means of invariable occurrence. Tertiary Syphilis. After the subsidence of the secondary stage of syphilis, there is usually an interval before the development of tertiary symptoms. This interval is of no definite length, being in some cases of several years' duration, and the patient meanAvhile being apparently quite Avell, Avhile in other cases the third stage begins before the second is concluded, so that they absolutely overlap each other. Tertiary syphilis may affect almost any tissue or organ of the body, and the symptoms of this stage are deAreloped with such irregularity as to ren- der it impossible to classify them chronologically. The third stage of syphilis is called the stage of deposit, as it is marked by the deposit, in various parts of the body, of new material, Avhjch may take the form of a contractile lymph, leaving depressed cicatrices, or of a soft gummy substance, constituting the so-called gummatous syphilitic tumors. We may consider successively the manifestations of tertiary syphilis, in the skin, mucous membranes, eyes, solid viscera, nervous system, areolar tissue, muscular and fibrous tissues, and bones and periosteum. Skin___The chief cutaneous manifestations of tertiary syphilis, are the tubercular and squamous eruptions, together with a destructive form of rupia. Syphilitic Tubercles, which may be either dry or ulcerated, occur most often on the face, especially about the lips and nose, where they occa- sionally produce great disfiguration. They begin as small, solid, cutaneous tumors, of a dusky-red color, and Avith a firm base, and are frequently devel- oped in connection with the hair-follicles. They are often aggregated in a circular form, and, if resolution occurs, leave depressions in the skin, Avhich, though at first copper-colored, ultimately become white and scar-like. The ulcerated syphilitic tubercle occasionally produces great ravages, and may be mistaken for lupus, rodent ulcer, or serpiginous chancroid. It heals with a characteristic Avhite and depressed cicatrix, if the ulceration have extended deeply, or with a thin and shining scar, if superficial. The squamous erup- tion assumes the form of Psoriasis, Pityriasis, or Lepra. Syphilitic psori- asis often attacks the palmar and plantar surfaces, and the eruption is in these situations very characteristic of the nature of the disease ; palmar or plantar psoriasis may be attended with cracks and fissures, Avhich cause a good deal of irritation and interfere with the functions of the part. The late form of Rupia, which occurs in connection with tertiary syphilis, differs from 448 VENEREAL DISEASES. that seen in the secondary stage, merely in the greater depth to wliich ulcer- ation extends. In this stage a severe form of Alopecia is occasionally seen, in which the hair-follicles all over the body may be destroyed, the affection being of course incurable; this variety of alopecia usually occurs in connec- Fig. 193. Syphilitic rupia. (Druitt.) tion with the tubercular eruption already described. Syphilitic Onychia, or ulceration in the matrix of the nails, Avhich become dry and distorted, and are finally throAvn off, is a concomitant of the squamous eruptions, and affects the hands more often than the feet. Mucous Membranes___The tongue is often affected in tertiary syphilis ; it may present white patches upon its surface, apparently due to lymphy deposit and opacity of the epithelium, upon the detachment of Avhich a smooth and slightly depressed spot remains—or there may be a tubercular condition of the tongue, analogous to that described as affecting the skin, which may end in ulceration, or may assume the form of a deep-seated lymphy deposit, causing stiffness, contraction, and distortion of the organ. The ulcerated form of lingual syphilis may cause great destruction of the part, and has been mistaken for epithelioma: the latter affection attacks particu- larly the side of the tongue, is solitary, and involves the submaxillary gan- glia ; while the lingual syphilitic tubercle is commonly multiple, occupies the dorsum and base of the tongue, and is not attended by enlargement of the lymphatic glands. The tonsils, fauces, and palate suffer in tertiary syphilis from ulceration. Avhich may be circumscribed or phagedaenic. The latter variety usually re- sults from the ulceration of syphilitic tubercle, and may produce very Avide destruction of parts, involving the soft palate and uvula, pillars of the fauces, and orifices of the Eustachian tubes, and causing difficulty of SAvallowing, Avith perhaps regurgitation through the nostrils, deafness, and difficulty of articula- tion. The, discharge is very offensive, and the ulceration may extend to the nose, larynx, or oesophagus, or may even involve the cervical vertebrae. The larynx and trachea may be affected with a deposit of syphilitic tubercle, Avhich may undergo ulceration, causing dyspnoea, often of a paroxysmal cha- racter, and perhaps requiring tracheotomy for its relief. Contraction of the windpipe may occur, constituting tracheal stricture, or the voice may be per- manently impaired by alterations of the vocal cords. The pharynx and oesophagus may be the seat of syphilitic ulceration, and oesophageal stricture may result after cicatrization. The colon may be, accord- ing to Paget, affected in tertiary syphilis Avith a form of ulceration analogous to the ulcerated tubercle of the skin. Cullerier has described a syphilitic enteritis, which he considers analogous to the erythema of the skin, and as therefore belonging to the secondary period; his vieAVS upon this point, hoAV- ever, are not generally accepted. The rectum may become ulcerated in tertiary syphilis, giving rise to a troublesome form of stricture in that part. The urethra may be involved in tertiary syphilis, and H. Lee believes that many cases of stricture are of syphilitic origin. SYPHILIS OF THE NERVOUS SYSTEM. 449 Eye.—The worst form of syphilitic iritis is that which occurs during the tertiary stage. In this Aariety of the disease the iris is primarily attacked, but in an insidious and almost painless manner, becoming the seat of a deposit of yellow tubercles, which are shown by the microscope to be identical in structure Avith the gummatous tumors found in other parts of the body. The deeper-seated structures are occasionally involved, permanent disorganization being then apt to occur, though Dr. Rankin, of Ncav York, has reported a remarkable case of syphilitic atrophy of both optic nerves, cured by large doses of mercury, strychnia, and iodide of potassium. R. AAr. Taylor reports cases of tertiary, as well as of secondary, syphilitic disease of the lachrymal apparatus, while C. S. Bull has observed optic neuritis and paralysis of the ocular muscles as a result of syphilis. Solid Viscera__Visceral syphilis has, until recently, not attracted as much attention as it deserves. Among the organs (apart from those of the nervous system) in Avhich syphilitic lesions have been observed, may be par- ticularly mentioned the testis, liver, spleen, kidneys, mesenteric glands, lungs, and heart. The limits of this work Avill not permit a description of the changes produced by syphilis in any of these viscera, except the testis; and, indeed, syphilis of the internal organs is habitually treated by the physician, rather than by the surgeon. For a full account of these affections I Avould refer the reader to the work of Lancereaux, which has been translated for the New Sydenham Society, and which gives a very complete account of visceral syphilis. Syphilitic Sarcocele, or Syphilitic Orchitis, appears under two forms, the interstitial, and the circumscribed or gummy. Interstitial Orchitis occurs in the early part of the tertiary stage, and is attended Avith the formation of a contractile lymph, which occupies the trabecular of the testis, rendering the organ hard and dense, and sometimes eventually leading to its atrophy. One testis only is usually affected, becoming someAvhat enlarged, but painless, and giving annoyance only by its weight. Hydrocele often accompanies this form of the disease, which is very chronic, and rarely followed by suppuration. The Circumscribed or Gummy Orchitis Avas first described by Hamilton, of Dublin, as Tubercular Syphilitic Sarcocele. In this variety, numerous masses of a yellowish-gray color are deposited in various parts of the testes, both of which are usually affected. These masses, at first firm, undergo softening, Avith fatty or cretaceous degeneration, and not unfrequently lead to suppuration, with the formation of fistulous openings, and occasionally a fun- gous protrusion of the testicle itself. Under the microscope, these yelloAvish masses are found to differ from ordinary lymph, in containing a large amount of cells and fat globules, with crystals of margarine. The ovary is occasion- ally affected in tertiary syphilis, in a similar manner to the testicle. Nervous System___The brain and spinal cord suffer in tertiary syphilis, deposits of a lymphy or gummy nature taking place in the substance of those orirans, or in their membranes, and giving rise to various nervous disturbances, such as Epilepsy, Paralysis (which may be local or general), Chorea (a rare manifestation of syphilis of which Dr. R. H. Alison has col- lected four cases), Mental Perturbation, or, as pointed out by M. H. Henry, absolute Dementia. Diabetes is said to have resulted from syphilitic disease of the base of the brain. The credit of first distinctly recognizing the exist- ence of syphilitic lesions of the central nervous system, is due, I believe, to Reade, of Belfast, Ireland, Avhose first paper Avas Avritten in 1817, though not published till some years subsequently. The subject has since then recei\red a good deal of attention, and elaborate memoirs have been written on syphi- 29 450 VENEREAL DISEASES. litic affections of the nervous system by several authors, especially by Lag- neau, the younger, and Zambaco, to whose Avorks the reader is respectfully referred. A feAV cases are on record, in which syphilitic deposits have been found in the nerves, as Avell as in the nerve-centres. Arteries___The occurrence of arterial degeneration as a result of syphilis has long been recognized, but the change has been supposed to be identical Avith atheroma. According to Heubner and Evvald, however, it differs from that condition in affecting exclusively the smaller arteries, and in having no tendency to gelatinoid or cartikginoid change, or to fatty or calcareous de- generation. The syphilitic change, according to these authors, consists in the formation of a new groAvth of the connectiAre-tissue type, occupying the inner coat of the vessel, and formed by nuclear proliferation of the cells of the epithelial lining. If so large as to occlude the artery, thrombosis occurs and is followed by atrophy of the vessel. Areolar Tissue___The subcutaneous and submucous areolar tissues are the favorite seats of the so-called gummy or gummatous deposits of tertiary syphilis. These usually occur as hard, round, indolent, subcutaneous nodules, which gradually undergo softening and become adherent to the skin ; ulcera- tion finally takes place, and, after the extrusion of a slough, the part heals, leaving a depressed scar, Avhich is at first purple, but subsequently becomes white. AVhen cut open, these nodules or gummatous tumors present a toler- ably firm cystic investment, containing a semi-solid, gelatinous or gummy substance, whence their name. Their size varies from a half inch, to two or more inches in diameter, and they are usually solitary, occurring at successive intervals, though occasionally multiple. They are chiefly seen upon the ex- tremities and upper part of the trunk. Under the microscope, they are found to consist principally of fibres, granules, and nucleated cells, with a few elastic fibres, free nuclei, and capillary bloodvessels. AVhen situated in the sub- mucous tissue, gummata give rise to troublesome ulcerations, and cause some of the most intractable forms of syphilitic sore throat. They are also met Avith in the submucous tissue of the genito-urinary organs, in both sexes. Muscular and Fibrous Tissues; Bursae__Gummatous Tumors occur in the voluntary muscles, tendons, and fasciae, interfering Avith the Fig. 194. Syphilitic panaris. (From a patient at the Children's Hospital.) functions of the parts, and sometimes causing deep and painful ulcers. They may also, according to Keyes, affect the bursae, either primarily or by exten- sion from other tissues. In the fingers and toes, in wliich situations they may HEREDITARY SYPHILIS. 451 involve either the superficial tissues, or the periosteum and bone (when dis- organization of the joints may follow), they give rise to the troublesome con- dition knoAvn as Syj>hititic Panaris or Whitlow, or Syphilitic Dactylitis, the latter name being preferred by Taylor, of Ncav York, who has given an excellent account of the affection. (See Fig. 191.) Ricord and others state that syphilis may cause rigid muscular contraction (as of the biceps), Avithout organic change. The so-called congenital tumor of the sterno-mastoid muscle appears in some cases to be a syphilitic lesion. Bones and Periosteum—Periostitis is of frequent occurrence in ter- tiary syphilis, and the periosteum of those bones which are subcutaneous is most often affected, a* of the tibia, cranial bones, clavicle, sternum, radius, and ulna. Osteocopic (literally, bone-tiring) pain is often observed long before any other symptom, and, in a large majority of cases, has the pecu- liarity of being aggravated by the warmth of bed. Syphilitic periostitis is usually circumscribed, and gives rise to the formation of oblong swellings, called njul.es, which are commonly hard and indolent, being due to lymphy deposit in and beneath the periosteum, but which in other cases are fluctuating and tender, and apparently due to the deposit of gummatous material. They may often be dispersed by treatment, but occasionally persist, becoming con- verted into exostoses. Suppuration rarely occurs, unless the bone itself be involved. Syphilis affects the bones by producing chronic osteitis, leading to hypertrophy and induration, or to caries and necrosis. These may affect any bones, but are most frequent in the jaAvs and skull—either the vault or base, but, according to H. Allen, rarely both together—and sometimes lead to destruction of the hard palate, falling in of the nose, or grave cerebral disturbance. Syphilitic necrosis may, according to A irchow, be recognized by observing that the sequestrum has a perforated and worm-eaten appear- ance, Avhich he attributes to the previous existence of gummy matter in the part. A peculiar form of dry caries is described by the same writer, as due to the pressure of a gummy tumor, leading to inflammatory atrophy without suppuration. Two such cases are referred to by Erichsen, both occurring in the head of the tibia. Hereditary Syphilis. The natural history of this form of syphilis differs from that of the acquired variety, chiefly in having no primary stage. A foetus may be infected in several AA-avs: (1) the mother may be the subject of secondary or tertiary syphilis, the father being healthy; (2) both parents may be syphilitic, when the disease Avill probably be inherited in a worse form than if one alone be affected; (3) the mother may be healthy at the time of conception, but may acquire syphilis during pregnancy, and transmit it to her ofspring; and (4) the father may transmit the disease to the fietus, Avithout directly infect- ing the mother, who, however, may in turn be infected by the embryo. The latter mode of transmission is denied by many authors, and is certainly of rarer occurrence than the others. The syphilitic embryo very often dies before the full term of intra-uterine life is accomplished, and abortion then folloAvs. Occasionally, though rarely, a child presents mucous patches and other unmistakable evidences of syphilis at the moment of birth, and the disease is then properly called congenital. More often, hoAvever, the child is apparently healthy Avhen born, or, if cachectic, presents no definite morbid lesions. Hereditary syphilis is usually developed from a fortnight to two months after birth, but may appear at any time within the first year. It is very doubtful Avhether the first manifestation of hereditary syphilis ever occurs 452 VENEREAL DISEASES. at a later period, the apparent exceptions which have been reported, being probably cases of acquired syphilis, or, if of the hereditary form of the disease, cases in Avhich the early symptoms have been overlooked. The early manifestations of hereditary syphilis belong to the secondary period of the disease, those Avhich are most characteristic being mucous patches, syphilitic pemphigus, and coryza—the snuffles of the popular voca- bulary. Laryngitis may also occur in this stage, Avith inflammation of the buccal mucous membrane, or syphilitic stomatitis. If the latter exist, the temporary teeth are apt to be ill-formed and carious, and often drop before the usual time. The child becomes salloAv and Avithered, and seems prematurely old. If death do not occur from malnutrition, during this stage of the dis- ease, there is usually a lull in the symptoms, the later manifestations (Avhich belong to the tertiary period) not being developed until after the fifth year, and usually about the age of puberty. The most characteristic signs of hereditary syphilis, in this stage, are inter- Fig. 195. stitial keratitis and a peculiar notched con- dition of the permanent teeth (Fig. 19o), particularly of the upper central incisors, a condition the significance of which Avas first pointed out by J. Hutchinson. Inter- Syphilitic permanent teeth. "(Hut- stitkd keratitis usually affects both eyes, chinson.) and is attended with a formation of lymph betAveen the lamina* of the corneae, which often remain permanently opaque in spots. Iritis is much rarer in the heredi- tary, than in the acquired, form of the disease. Inflammation of the choroid^ and optic nerve, and deafness, are also sometimes observed as a result of here- ditary syphilis. The viscera affected in these cases are chiefly the liver and lungs, the brain and thymus gland being more rarely involved. The bones may be affected in hereditary syphilis, the lesions particularly deserving at- tention being the syphilitic panaris or dactylitis (p. 4.Y1), and a peculiar inflammatory condition of the epiphyseal extremities of the bones, sometimes attended with suppuration and caries, and, from the loss of function Avhich attends the disease, called by Parrot the pseudo-paralysis of inherited syphilis. A person avIio is the subject of hereditary syphilis, is in a great degree, if not altogether, protected from syphilitic contagion in after-life, this being another proof of the essentially constitutional nature of the disease. Acquired infantile syphilis does not present any marked difference from the same dis- ease as observed in the adult. Diagnosis of Syphilis. I have dwelt at length upon the natural history and morbid anatomy of syphilis, because it is only by means of a thorough comprehension of these, that the surgeon is able to recognize and attach due significance to the various symptoms of the affection—these symptoms being often developed Avith ap- parent irregularity, and being constantly modified by previous treatment, or by various extraneous circumstances. In the diagnosis of most diseases, great assistance can often be obtained from the patient, avIio, if ordinarily intelli- gent, can usually give a more or less complete history of bis OAvn case; but in syphilis, very little reliance can be placed upon the statements of the patient. Apart from wilful deception, or concealment, to which there is of course 1 Dr. C. S. Bull has seen syphilitic iritis and irido-choroiditis within a few hours of birth, the affection then being properly called congenital. DIAGNOSIS OF STPHILIS. 453 unusual temptation in many cases of syphilis, there is another difficulty, which is that, the symptoms being spread over a term of years, and often in themselves trivial, the patient either does not notice them, or subsequently forgets their existence, and thus, Avith every intention of honesty, is constantly apt to mislead the surgeon by giving erroneous answers to such questions as are propounded. The most important point for consideration Avith refer- ence to the diagnosis of primary syphilis, is the mode of distinguishing the chancre from the chancroid. It is by no means ahvays easy, or even pos- sible, to make this diagnosis, without careful and repeated observation : the surgeon must in fact rely more upon the natural history of the disease, than upon the symptoms presented at any one period. The diagnostic marks betAveen chancre and chancroid may be conveniently presented in parallel columns:— Chancroid. No period of incubation ; the sore is fully developed from four to six days after exposure. Usually multiple, if not at first, becoming so subsequently by auto-inocu- lation. An excavated ulcer, with sharply-cut, punched out edges, a gray sloughy surface, and furnishing a copious auto-inoculable pus. Not adherent to subjacent tissue. No induration unless from extraneous causes, and then merely temporary in- flammatory engorgement. Little or no tendency to heal ; often spreads, and liable to become phagedaenic. Bubo not visual, and when present, com- monly mono-lateral, and mono-ganglionic; apt to suppurate, and, if it do so, the re- sulting ulcer usually chancroidal. A strictly local disease, never producing systemic infection, and one attack afford- ing no protection against subsequent con- tagion. Chancre. A distinct period of incubation ; sore appears from one to seven (usually three) weeks after exposure. Usually solitary, and when multiple, is so from the first; very rarely, if ever, by auto-inoculation. A superficial erosion, or an ulcer with hard, elevated sloping edges, scooped out surface, and furnishing a scanty, serous, usually non-purulent secretion. If an ulcer, adherent to subjacent tissue. Peculiar, persistent, non-inflammatory induration, often parchment-like in cha- racter. Tends to heal spontaneously, and rarely becomes phagedaenic. Bubo almost inva- riable, bilateral, polyganglionic, indurat- ed, and indolent; rarely suppurates, and does not furnish auto-inoculable pus. A strictly constitutional disease, sys- temic infection being present from the first, and manifesting itself by definite symptoms, usually from six weeks to three months after the appearance of the chan- cre. One attack usually protects from subsequent contagion. Beside the information derived from observation of the patient, valuable aid in forming a diagnosis may be sometimes derived from confrontation and inoculation. Confrontation consists in examining the person from Avhom the disease has been contracted, and its value depends upon the fact that chan- croid can only produce chancroid, while syphilis can only be imparted by a syphilitic lesion. It is in many cases, from obvious reasons, impossible to make use of confrontation, but, when available, it is a diagnostic means of great value. Inoculation of either chancroid or chancre, should never be practised ex- cept upon the patient's own person ; if the suspicious sore be a chancroid, inoculation will produce another chancroid, while if it be a chancre, the result will almost invariably be negative—unless the original sore have been first irritated by treatment, when inoculation may indeed produce an ulcer, though not, probably, one of a chancrous nature (see p. 111). Microscopic examination has been employed by Biesiadecki as a means of distinguishing chancroid from chancre. Sections of a chancroid present ap- pearances identical with those of simple ulceration, while in chancre the 454 VENEREAL DISEASES. interior of the bloodvessels and lymphatics is packed with Avhite cells, thus accounting in some degree for the characteristic induration. It is often possible to declare a sore to be a chancroid, when yet it would not be safe to assert positively that symptoms of syphilis "will not folloAV, for (1) the patient may have acquired both diseases simultaneously—in which case he may have what is called a mixed chancre, or may have a genuine chancroid on the genital organs, and a chancre (derived perhaps from a secondary lesion) elseAvhere, as, for instance, in the mouth; or (2) he may have acquired syphilis in some previous exposure—the disease remaining latent until excited to activity by the fresh irritation produced by the chan- croid, which, in such a case, Avould naturally appear to the patient to be the actual cause of syphilitic infection. Chancre may occasionally have to be diagnosticated from cancer, epithe- lioma, or similar affections. This is particularly the case Avhen chancre occurs in unusual situations, as on the fingers, lips, or tongue. The syphilitic nature of the disease may usually be recognized by observing the early impli- cation of the neighboring lymphatic glands, and the effect of anti-syphilitic treatment, which should always be tried before resorting to operative measures in any doubtful case. Syphilitic Bubo is not likely to be mistaken for any affection except chronic scrofulous adenitis. If there be no concomitant signs by which the nature of the case may be reArealed, the surgeon should avoid giving mercury until the de\Telopment of secondary symptoms. Diagnosis of Secondary and Tertiary Syphilis__Here the surgeon must rely not upon any one or Iavo symptoms, but upon the coexist- ence of a number, and especially upon their course and order of development; in other words, he must rely upon careful clinical observation, and his general knowledge of the natural history of the disease. A surgeon meeting with a case of iritis, or of cutaneous eruption, or of periosteal rheumatism, in a person of notoriously lax morality, should not at once jump to the conclusion that the disease is probably syphilitic ; for to do so would be as unphilosophical as it might be unjust. If, on the other hand, a patient should suffer from fre- quent attacks of recurrent iritis, copper-colored eruptions of various forms, post-cervical engorgement, alopecia, and occasional development of mucous patches ; or from osteocopic pains, indolent nodes, and gummatous tumors of the areolar tissue—even though such a patient should appear as virtuous as Joseph, or as wise as Peneloj e—the surgeon might reasonably conclude that he had to deal Avith a case of syphilis, and should direct his remedies accordingly. The diagnosis may often be assisted by observing the traces of past manifestations of the disease, such as induration of the genital organs, or of the inguinal glands, or the depressed white cicatrices of syphilitic ulcer- ation. The seat of ulceration is often in itself significant. Leg ulcers Avhich are not syphilitic, are almost ahvays found below the middle of the calf, and any ulcer of obscure origin, situated at a higher point, may accordingly be looked upon with suspicion. Finally, the diagnosis of syphilitic affections of the viscera, or nervous system, in the absence of external manifestations, can often be merely con- jectural. Light may, however, often be thrown upon such cases, by noting the effect of anti-syphilitic treatment. TREATMENT OF SYPHILIS. 455 Prognosis. Syphilis, as seen at the present day, is certainly a milder affection than formerly. This is apparently due chiefly to the tendency which it shares Avith other diseases,1 to become less virulent by frequent transmission. A considerable number of persons—more than is commonly supposed—are, besides, at least partially protected by inheritance. Moreover, as surgeons more generally understand the natural history of the affection, their treatment has become more judicious; and the reckless use, or abuse, of mercury, which was formerly so common in cases of syphilis, and which undoubtedly exer- cised an untoward influence on the course of the disease, has now given way to a more moderate and philosophical employment of this poAverful remedy. In any individual case, the prognosis Avill depend upon several circum- stances. Infection from a deep (Hunterian), or from a phagedaenic chancre, will probably give rise to a worse form of the disease than Avould be acquired from contact Avith secondary lesions. A deep chancre usually indicates a graver infection than a superficial erosion. If a patient be of a strumous constitution, or broken doAvn by previous illness, or of dissipated habits, the prognosis will, other things being equal, be less favorable than in the case of one avIio is robust, and Avho will probably take due care of his health during the course of treatment. Secondary symptoms will almost invariably occur, in every case of syphilis, but in a mild case Avill probably declare themselves at a later period, will be less intense, and will be more evanescent, than in one which is severe. Again, the form of the first eruption is of prognostic value, an erythema, or roseola, indicating a milder form of syphilis than one of the other varieties. AVhen the tertiary stage has once appeared, the chances of complete recovery become very doubtful; though the disease, however, can rarely under these circumstances be entirely eradicated, its manifestations may, in most instances, be, by judicious treatment, held more or less in check, and life prolonged with considerable comfort to the patient. Death from acquired syphilis is rare. The prognosis of hereditary syphilis, if properly treated, is usually favora- ble as regards life, unless the disease be manifested at the time of, or A'ery soon after, birth, when a fatal result may be feared. Treatment of Syphilis. Treatment in Primary Stage—As syphilis is a constitutional dis- ease, it is to be met principally by constitutional treatment. The most valu- able anti-syphilitic remedy is unquestionably mercury, the next in value being probably the iodide of potassium.2 It is believed by most authorities that not only do the primary manifestations of syphilis disappear more quickly when mercury is given, than Avhen it is Avithheld, but that the development or evolution of secondary symptoms is, if not prevented, at least retarded and favorably modified by the administration of the remedy during the pri- mary stage. Prof. Bumstead and others believe, however, that, upon the whole, those cases do better in which mercury is withheld until the onset of 1 A familiar example is the ATaccine disease, which is more violent when produced by matter fresh from the cow, than when transmitted from arm to arm in the ordi- nary way. 2 The modus operandi of these drugs is still a matter of dispute ; perhaps we may come nearest the truth in saying that they probably act by promoting elimination and absorption—elimination of the syphilitic virus, Avhatever that may be, and ab- sorption of the lymphy and gummy deposits which characterize the later manifesta- tions of the disease. 456 VENEREAL DISEASES. the secondary stage, and hence only use this drug for primary syphilis, in exceptional cases. My own opinion is that, Avhile there can be no doubt that a chancre will heal under local applications alone, yet that, if the nature of the sore be well marked, and particularly if it be accompanied by the charac- teristic syphilitic bubo, it is, on the whole, safer to give mercury, taking care, of course, to guard against salivation, and discontinuing the remedy if it appear to irritate the patient's system. If, however, there be the slightest doubt as to the nature of the sore, or if the general condition of the patient be such as to contra-indicate the use of mercury, it is much better to rely upon local measures, giving only tonics, or such other medicinal agents as may be required by the particular exigencies of the case. For primary syphilis, mercury is, perhaps, best given by the mouth, and the preparation Avhich I prefer is the protiodide (hydrargyri iodidum viride of the U. S. Pharmacopoeia), which may be conveniently combined with opium, as in the following formula. R. Hydrarg. iodid. virid. gr. iij-iv ; Ext. opii gr. ij ; Confect. opii 3j. M. Div. in pilul. No. xij. Sig. One three times a day. This combination may often be used for many weeks, or even a longer time, without salivating, purging, or producing any other disagreeable effect. It should be discontinued as soon as any tenderness of the gums is perceived. AVith regard to the Local Treatment of chancre, all that can be done is to keep the part clean and free from sources of irritation, hastening cicatrization, when healing has begun, by occasional light touches Avith nitrate of silver. There is no advantage to be gained by attempting to destroy the indurated base of the sore by cauterization, for there is every reason to believe that sys- temic infection has taken place at or before the first appearance of the chancre. Excision is recommended by some authors, and may be resorted to under exceptional circumstances: thus if, in a case of phimosis, a chancre Avere situated at the extremity of the prepuce, circumcision would be justifiable, though it could hardly be expected to exercise any curative influence over the course of the disease. If a chancre be attacked with phagedena, advan- tage may be derived from the use of opium, and of the potassio-tartrate of iron, both locally and generally, Avith free stimulation, if the condition of the patient require it. Mercury may be given cautiously, and, as it Avere, tenta- tively, being discontinued if the phagedaenic action continue to spread under its employment. Cauterization -with nitric acid, Avhich, it will be remembered, is the great remedy for phagedaenic chancroid, is rarely needed in the treat- ment of phagedaenic chancre. If the surgeon suspect the existence of a mixed chancre, he should treat the case as one of simple chancroid, until the syphilitic nature of the affection becomes evident. Cauterization Avith nitric acid will, in such a case, be required under any circumstances, and little or no harm will result from delaying the use of mercury until the diagnosis has been rendered positive. But little can be done for the treatment of Syphilitic Bubo : attempts may be made to promote resolution by pressure, or by the employment of discu- tient applications, though the latter should be used with great caution, lest they induce suppuration. Pressure may be conveniently applied by means of a compressed sponge and spica bandage, or by means of a suitable truss. If the patient remain in bed, a weight, or bag of shot, may be simply laid upon the groin. Inunction with mercurial or iodine ointment, combined with the ointment of hyoscyamus, or of stramonium, may sometimes be advan- tageously employed ; or the part may be simply covered Avith mercurial plaster, or even with the ordinary soap plaster. I have sometimes observed benefit from the application of tincture of iodine, around, but not over, the enlarged glands, in the way recommended by F. Jordan. An Austrian surgeon, Dr. JakuboAvitz, recommends injections with a hypodermic syringe of a solution TREATMENT OF SECONDARY SYPHILIS. 457 of iodide of potassium (R. Potass, iodid. gr. xv, Tine, iodin. gtt. v, Aquae f,5J. M.). If suppuration occur, troublesome sinuses will probably be hit, Avhich must be treated on the general principles laid doAvn at page 385; Avhile if, as is often the case, the patient give evidence of struma, mercury must be abandoned, and iodine and cod-liver oil substituted. Secondary Stage.—By the course of treatment above described, it is possible, though not probable, that the development of secondary symptoms may be prevented. In Secondary Syphilis, the use of mercury is generally acknowledged to be proper, though, even here, its employment will occasion- ally be forbidden by the constitutional condition of the patient, or by inju- rious consequences having resulted from its incautious or too prolonged administration, during the primary stage of the disease. An important rule to be remembered in the use of mercury, in all stages of syphilis, is that the drug should be very gradually introduced into the system, and that salivation should be carefully avoided.1 In the secondary stage, mercurial inunction is, I think, preferable to the internal administration of the remedy ; half a drachm of mercurial ointment, or, which Berkeley Hill prefers, an ointment containing tAventy per cent, of the oleate of mercury, may be sloAvly rubbed into the inner part of the thighs, once a day (the hand being covered with a soft leather glove, soaked in fat to prevent absorption, if the treatment be carried out by an attendant), or into the soles of the feet, as recommended by Coulson, in Avhich case woollen socks should be constantly worn. In in- fantile cases, a feAV grains of the ointment may be smeared upon a strip of flannel, Avhich is then applied as a belly-band. In many cases, the use of inunction is objected to by the patient, and, under such circumstances, various preparations of mercury may be given by the mouth, the best probably being the corroshe chloride, in doses of from one-sixteenth to one-eighth of a grain, three times a day, after meals. It is best given in solution, much diluted, and may be conveniently combined Avith the bitter tonics, Avith the muriated tincture of iron, or (dissolved in ether) Avith cod-liver oil. The following formulae, the second and third of Avhich are imitated from Bumstead, Avill usually prove satisfactory :— R. Hydrarg. chlorid. corrosiv. gr. j; Tinct. gentian, comp. f.^ij; Syr. zingiberis f Jj; Aquse f§v. M. Sig. Tablespoonful three times a day. R. Hydrarg. chlorid. corrosiv. gr. vj—viij; Tinct. ferri chlorid. fJ j. M. Sig. Ten drops for a dose, in water. R. Hydrarg. chlorid. corrosiv. gr. i-ij; Etheris f 5j; 01. morrhuae f^viij. M. Sig. Tablespoonful for a dose, in the froth of porter. The red iodide of mercury is also a good preparation, in cases of secondary syphilis, and may be given in combination with the iodide of potassium, in doses of one-sixteenth of a grain of the former to eight or ten grains of the latter remedy. Mercurial fumigation may be employed in obstinate cases of cutaneous syphilis, and is the method preferred by Langston Parker and H. Lee. The patient being inclosed in a suitable framework, covered with oil-cloth, steam is introduced, together Avith the fumes derived from the slow volatilization of a drachm or two of calomel, or of the red oxide of mercury, by means of a tin plate heated with a spirit-lamp, or, which is perhaps better, by means of the ingenious apparatus devised by Dr. Maury, of this city (Fig. 196). The use of mercury by hypodermic injection has been of late successfully 1 Dr. Keyes, of New York, has shown by actual counting, that small doses of mer- cury absolutely increase the number of red corpuscles both in healthy persons and in the subjects of syphilis. 458 VENEREAL DISEASES. resorted to, in cases of syphilis, by Lewin, of Berlin, R. AA\ Taylor, of Ncav York, and others, and this mode of exhibiting the drug may be employed when other methods are for any reason contra-indicated. From one-twelfth to three-eighths of a grain of the corrosive chloride, dissolved in 15 minims Fig. 196. Maury's fnmigating apparatus. of Avater, or, Avhich Staub prefers, in a chlor-albuminous solution, made Avith muriate of ammonium, common salt, and Avhite of egg,1 may be injected once or twice daily, or, Avhich is preferred by Ragazzoni, half a grain of the biniodide, dissolved with a little iodide of potassium in half a fluidrachm of distilled water. Either of these methods I should consider upon the whole better than the injection of calomel, suspended in a mucilage of acacia, as recommended by the Italian surgeons Pirochi and Porlezza. Should Salivation occur during the administration of mercury, the remedy must be stopped, and astringent and detergent mouth-washes freely employed. The treatment may be subsequently cautiously resumed, or the iodide of potassium may be used instead. The occurrence of Mercurial Eczema, which, however, is rarely produced by the doses of mercury employed at the present day, Avould, also, of course, require the discontinuance of the remedy. The Local Treatment of secondary syphilis is sufficiently simple.^ The irritation produced by Mucous Patches, may be relieved by the application of nitrate of silver, or, which I prefer, the solution of nitrate of mercury, ' Staub's solution may be made according to the following formula:— |£ Hydrarg. chlorid. corrosiv., Ammonii muriat., aa gj; Sodii chlorid. £j; Aq. dest. i'fiv. Misce et cola, deinde adde Ovi alb. no. j, Aq. dest. q. s. pro f 3iv. Of this solution 15 minims, containing about r'j grain of tbe sublimate, may be injected tAvice daily. TREATMENT OF TERTIARY SYPHILIS. 459 Avith bkck-Ayash as jin after-dressing. Conradi and Charon recommend the use of nitrate of silver, followed instantly by the application of metallic zinc. Syphilitic Sore Throat may be treated with chlorate of potassium gargles, or Avith caustic applications, if there be any phagedaenic tendency. The use of dilute muriatic acid, by means of the atomizer, may occasionally be advan- tageously resorted to. Iritis demands the unsparing instillation of atropia. The great risk is from occlusion of the pupil, and, in this affection, the local is even more im- portant than the general treatment. AVith regard to the use of mercury for syphilitic iritis, I do not, in ordinary cases, recommend it, unless it be required for other syphilitic manifestations. The plan of treatment which I prefer is that recommended by Carmichael, which consists in the administration of drachm doses of the oil of turpentine, in addition to which may be given (in the iritis of the tertiary stage) the iodide of potassium. The following form- ula will be found satisfactory, in most cases :— R. 01. terebinth, f^jss ; Tinct. opii f £ss; Acaciae, Sacch. Ufa., aa gij; 01. gaul- theriae gtt. iv; Aquae f§iv.. M. Sig. Tablespoonful three times a day. If, hoAvever, a very rapid effect be needed, or if the patient cannot take the turpentine, it may be necessary to resort to mercury. Alopecia is sometimes the source of a good deal of annoyance, and may be treated with washes containing the tincture of cantharides. The course of treatment briefly sketched in the preceding paragraphs, is that adapted to a case of secondary syphilis occurring in a healthy person. If the patient be debilitated, tonics, and especially iron and quinia, should be given at the same time as mercury, if it be deemed safe to give the latter drug at all. The diet should be plain but abundant, and a moderate amount of alco- holic stimulus should be given, if the patient is used to its employment. The clothing should be sufficiently Avarm, and preferably of wool, and great care should be taken to avoid all exposure to wet or cold. The mercurial course should, as a rule, not be begun until the disappearance of the premonitory signs, but should then be continued regularly, and with as few intermissions as possible, until all secondary symptoms have passed by. By careful. and judicious treatment, and by strict attention to hygienic rules, there is reason to hope that the disease, if of ordinary mildness, will exhaust its virulence in this stage, and that the patient may thus escape the tertiary manifestations of syphilis, which are at the same time the most distressing and the most hopeless. To remove the pigmentary stains left by syphilitic eruptions, Lan- glebert applies small blisters kept open for a few days, so as to substitute white for copper-colored cicatrices. Tertiary Stage___In tertiary syphilis, mercury may be employed (pre- ferably by inunction) for the dry tubercular and squamous eruptions, and for the interstitial form of syphilitic orchitis; but for the other manifestations of the tertiary stage, the iodide of potassium is usually a better remedy. It may be given in doses of from five to fifteen grains, three times a day, either alone, or in combination with the bitter tonics, mineral acids, or cod-liver oil. As a Local Application to syphilitic ulcers, black-wash, or iodoform, either in poAvder or in solution with glycerin and alcohol, may be commonly em- ployed, or, if the ulceration be Avidely diffused, as in bad cases of rupia, calomel fumigation may be substituted. For the tertiary affections of the throat, chlorinated gargles, with caustic applications, or atomization of dilute muriatic acid, may be suitably resorted to. The use of iodide of potassium must often be persisted in, more or less continuously, for many years, and it is therefore a good plan to ascertain by l 460 TUMORS. experiment, the minimum dose which will keep the symptoms in check, and let that be constantly employed. The same hygienic rules should be observed in the tertiary as in the secondary stage of the disease. Hereditary Syphilis, in its early manifestations, is best treated by mercurial inunction, in the Avay already described. In the later stages, iodide of potassium, with tonics, and especially iron and quinia, will be found of service. The saccharated iodide of iron is particularly recommended by Monti. A syphilitic infant need not be weaned, if its mother be able to nurse it. It should not, however, be put to the breast of a healthy woman, lest the latter should be infected by contact with secondary lesions in the child's mouth. If a pregnant woman be syphilitic, she should take mercury, in order, if possible to prevent abortion, and to save her offspring from inheriting her disease. Syphilization___Syphilization, or inoculation with the pus obtained by artificial irritation of a chancre, or Avith that form a chancroid, was first recom- mended by Auzias de Turenne, of Paris, both as a prophylactic and as a remedy for syphilis, and has been extensively used in the treatment of the dis- ease by Prof. Boeck, of Christiania. This mode of treatment has been tho- roughly tested by a number of surgeons in different parts of the world, and the opinion of the profession is almost unanimously opposed to its employ- ment. Its use as a means of prophylaxis, is clearly unjustifiable, for there is no evidence that the artificially inoculated disease is more tractable than that which is acquired in the ordinary way; and as to the curative effect of syphilization, the testimony of most unprejudiced observers tends to shoAV that (1) it is very doubtful Avhether it exercises any beneficial influence, and that (2) if it do any good, it is probably merely as a means of producing a depurativre effect, just as has been done by vaccination, or by the use of blisters. Inoculation with chancroidal pus (Avhich is sometimes practised under the impression that the chancroid is a syphilitic lesion), is quite unjustifiable, as merely adding another disease to that from which the patient is already suf- fering. I do not recommend a resort to syphilization under any circumstances, and have mentioned it simply as a matter of historical interest. CHAPTEK XXVI. TUMORS. The word tumor, in its etymological sense, signifies a swelling. In the writings of surgeons and pathologists, however, it is used with a more re- stricted meaning, and may be defined as a circumscribed enlargement of a part, due to the presence of a morbid growth. Tumors occur in both sexes, and at every age, and may be occasionally found in almost every region of the body. Though originating in, and deriving their nourishment from, the tissues in which they occur, they have, in a certain sense, an independent organic life, groAving or withering without regard to the state of nutrition of the rest of the body. They may be more or less strictly limited by an in- CLASSIFICATION OF TUMORS. 461 vesting membrane, or may be widely diffused, or infiltrated, among the sur- rounding tissues. Their anatomical elements may be the same as those of the tissue in Avhich they groAv (homologous, homomorphous), as in the case of a fatty tumor growing amid fat, or may be quite different (heterologous, heteromorphous), ahvays, however, preserving a certain analogy to normal tissue elements, from which, though in character they may deviate, they never entirely depart. Tumors maybe either solitary or multiple; if the latter, they may be of the same or of different kinds. AVhen tAvo or more tumors of the same nature coexist, they may have been developed simulta- neously, or consecutively; and in the latter case it is occasionally, though (except in the case of cancer) rarely, possible to trace a direct anatomical connection, through the vascular system (as in the process of embolism1), or otherwise, between the first, which is then called primary, and the secondary tumors, or those Avhich are subsequently formed. The origin of secondary cancerous tumors is, in the large majority of cases, traceable to absorption from the primary tumor, through the medium of the lymphatic system. Causes—The causes of the development of tumors, are sometimes suffi- ciently obvious ; as Avhere a cystic tumor results from obstruction of an excre- tory duct, or where the occurrence of a fatty tumor, or of an adventitious bursa, is directly traceable to the effect of pressure. In most instances, however, no direct cause of the occurrence of a tumor can be detected, Avhile the indirect or predisposing causes are usually matters of conjecture, rather than of demonstration. Inheritance is sometimes a cause of the development of tumors, especially of the cancerous variety. Age, and the degree of func- tional activity of any particular organ, sometimes exercise a causative influ- ence upon the development of tumors : thus morbid growths are more frequent in adults than in children, and occur more often in an organ the functional activity of which is decreasing, than in one Avhich is undergoing development, or in one which, though completed, is still active. Sex exerts a certain causative influence, Avomen being, upon the whole, more liable to tumors than men. Finally, as direct irritation has been seen to give rise to a tumor, it is occasionally possible to trace the origin of a morbid growth to indirect irritation, transmitted through the nervous system ; mammary tumors thus sometimes appear to be caused by uterine disturbance. Classification of Tumors.—It is a matter of common observation that certain tumors occasion inconvenience merely by their bulk or position, and by their interference with the functions of adjacent parts, having no ten- dency in themselves to cause death ; Avhile other tumors inevitably prove fatal if left to themselves, and have an almost invariable tendency to recur in the same or another part if removed : hence the ordinary division of tumors into those which are benign, innocent, or non-malignant, and those which are malignant. Certain tumors, again, are fatal if neglected, but if removed are not certain, though apt to recur: these have been looked upon as occupying an intermediate position, aud have been called semi-mat'ignant. This general division, founded upon the clinical characters of morbid growths, has many advantages, but is obviously not as accurate or scientific, as would be a classi- fication of tumors founded strictly upon their anatomical peculiarities. Such a classification has been proposed by Virchow and other authors, and Avould 1 A remarkable case has, however, been recorded by Hayem and Graux, in which a fibro-plastic tumor of the ligamentum patellae was followed by a similar growth in the lung, directly traceable to embolism. Other examples of transference of non- cancerous tumors have been recorded by Virchow, Moore, Bryant, and Heitzmann, of New York. 462 TUMORS. doubtless have been generally adopted by surgical Avriters as Avell as by patho- logists, but for the fact that a knoAvledge of the microscopical characters of a tumor does not ahvays give definite information as to its clinical history, Avhich is of course (from the surgeon's point of view) the most important matter for consideration. The classification adopted in the following pages, aims to combine, in a manner conAenient to the student, a reference to both the clinical histories and the anatomical peculiarities of the A'arious morbid growths. CLASSIFICATION OF TUMORS. Nox-Maligxaxt Tumors. 1. Cystic Tumors; Cysts. A. Simple, or Barren (1.) Serous; hygromata (2.) Synovial. (3.) Mucous. (4.) Sanguineous. (5.) Oily. (6.) Colloid. (7.) Seminal. 2. Solid Tumors and Outgrowths. (1.) Fatty or adipose. (2.) Fibro-cellular or connective-tissue. (3.) Mucous or myxomatous. (4.) Fibrous, fibro-muscular, fibro-cystic, etc. (5.) Cartilaginous, fibro-cartilaginous, and mixed. (6.) Osseous. (11.) Neuralgic. (7.) Glandular. (12.) Pulsating. (8.) Lymphoid. (13.) Floating. (9.) Vascular. (14.) Phantom. (10.) Papillary. Skmi-Malignant or Recurrent Tumors. (1.) Recurrent fibroid. (2.) Myeloid. (3.) Sarcomata. Malignant Tuaiors. 1. Carcinoma. (Cancer.) (1.) Scirrhous or hard cancer (Scirrhus). (2.) Medullary or soft cancer (Encephaloid) (a) Melanoid. (6) Hsematoid. (c) Osteoid. 2. Epithelioma. (Epithelial or skin-cancer.) Non-Malignant Tumors, as a rule, displace, without involving, surround- ing tissues ; they possess considerable vitality, and hence may persist for a long period without undergoing either ulceration or interstitial degeneration; they are homogeneous, or at least do not commonly exhibit, in the same mass, any great diversity of structural elements; and if removed, they do not usually recur. Malignant Tumors, on the other hand, are commonly infiltrated among the surrounding tissues, Avhich they gradually replace or appropriate to them- selves ; they possess comparatively little vitality, and hence tend to ulceration and destructive degeneration ; they exhibit, in the same mass, a considerable number of diverse structural elements ; and though removed with the greatest care, almost invariably recur. B. Compound, or Proliferous. (8.) Complex. (9.) With intra-cystic growths. (10.) Cutaneous. (11.) Dentigerous. {d) Villous. (e) Colloid. (/) Fibrous. SIMPLE OR BARREN CYSTS. 463 The Semi -Malignant or Recurrent Tumors occupy an intermediate posi- tion ; they often groAv rapidly and cause ulceration of the over-lying integu- ment ; they frequently contain, in the same tumor, a great variety of structural elements ; and, though they do not commonly spread to distant organs, they mostly have a strong tendency to recur after even apparently complete removal. These remarks, though generally, are not universally, applicable. It occa- sionally happens that a tumor, Avhich is undoubtedly cancerous, does not recur after removal, Avhile, on the other hand, a growth Avhich, structurally, is such as Avould be placed among the non-malignant tumors, may recur indefinitely, and eventually cause death. The special characters and appropriate treatment of each variety of tumor which comes under the observation of the surgeon, Avill now be briefly described. Cystic Tumors, or Cysts. Cysts may originate in several Avays. The most common is from the dis- tension and enlargement of ducts, or sacs, as is usually the case Avith the mucous and ordinary cutaneous cysts (Retention cysts). Another mode of origin is from the enlargement and coalition of the natural interspaces of the areolar and other tissues ; these interspaces being distended Avith fluid, the surrounding structures undergo condensation, until a cyst Avail is formed. It is in this Avay that adventitious bursa? are formed, as Avell as cystic develop- ments in solid tumors. A third mode of origin is from the direct growth of neAvly-fonned elementary structures, cells, or nuclei—the cysts thus formed being sometimes called primary or autogenous, as distinguished from the other, or secondary, cysts. Finally, a cyst may be formed by the protrusion and subsequent separation of a portion of a serous membrane, as happens in some cases of so-called " false spina bifida." A. Simple or Barren Cysts. Serous Cysts, or Hygromata, may occur in any part of the body, but are most usual in or near glandular structures. These cysts contain a liquid of variable consistency, and of a yellowish, reddish-broAvn, or olive hue ; this liquid sometimes contains crystals of cholestearine, and in other cases is fibrinous and coagulates when removed. The cyst Avails are of con- necthe tissue, adherent to surrounding structures, not very vascular, and lined Avith a tessellated epithelium. These cysts may be single or multiple, and, in the latter case, may intercommunicate, or may be merely aggregated. When found in external parts, they may commonly be diagnosticated by ob- serving that they have a smooth and rounded outline, are movable with, though adherent to, the neighboring healthy structures, are painless, covered Avith normal skin, and sometimes translucent,1 and fluctuate, or, if A'ery tense, are at least found to be elastic and resilient on pressure. The treatment may consist in puncture (which may also be used as an exploratory measure), the application of tincture of iodine, the injection of the same substance after tapping, the use of a seton, incision Avith or Avithout cauterization, or partial or complete excision. Iodine injections or the seton, are particularly adapted for cysts found in the cervical region, and incision, with cauterization or simply stuffing the cavitAr with lint, for those met Avith in the gums or hones. Partial excision is usually sufficient if the cyst be solitary, any portion that is left subsequently granulating and undergoing cicatrization. For multiple 1 AA'hen occurring in the neck, they constitute the so-called hydroceles of that part. 464 TUMORS. cysts, however, total excision may be required, and, if seated in the mam- mary gland, it may be necessary to remove the Avhole breast, in order to pre- vent any portion of the diseased structure from remaining. Serous cysts are occasionally connected Avith Aascukr nasvi, in Avhich case the operation for removal may be attended Avith profuse bleeding. In the breast, it sometimes happens that a serous cyst coexists with a cancer. Synovial Cysts may consist simply in enlargement and distension of the normal synovial bursae ; or may be adventitiously developed in abnormal situations, as the result of pressure ; or may occur in the sheaths of tendons, constituting ganglia. The fluid of these cysts varies in consistency from that of serum to that of honey, and they not unfrequently contain small bodies, about the size and shape of melon-seeds, Avhich may be loose, or attached to the cyst Avails, and which are composed of a dense connective-tissue substance. The treatment of synovial cysts consists in the use of external irritation, in tapping, folloAved by stimulating injections, in the formation of a seton, in subcutaneous division and scarification, or, finally, in excision. MUCOUS Cysts are chiefly seen in mucous membranes and in connection with the mucous glands, where they result from distension of obstructed ducts or follicles. They are met Avith in connection with CoAvper's or Duverney's glands, in the antrum, and beneath the tongue, Avhere they constitute a form of ranula. Their general characters are those of the serous cysts, from which they differ chiefly in the nature of their contained fluid (Avhich resembles mucus), and in their locality. The treatment consists in free incision, or in cutting away a portion of the cyst Avail, the cavity being allowed to heal by granulation. Sanguineous Cysts, or Haematomata, may result from accidental hemorrhage into the cavity of a serous cyst (just as hematocele from hem- orrhage into the sac of a hydrocele), from transformation of a vascular nsevus, from occlusion and dilatation of a portion of a vein, or from effusion of blood Avhich subsequently becomes encysted by the condensation of the surrounding areolar tissue. They are chiefly met Avith in the cervical and parotid regions (in the former locality constituting hamiatocele of the neck), though they also occur in other parts of the body. These cysts contain blood, which may be clotted and partially decolorized, or Avhich may be liquid. In the latter case it may have been fluid from the first, and will then coagulate Avhen evacuated, or may have been clotted at first and subsequently re-liquefied. The Avails of these cysts may be simply membranous, or may be deeply ribbed, and the cyst Avails may, in some instances, present the characters of a sarcoma or re- current fibroid tumor. These cysts occasionally resemble, in their outward appearance, encephaloid tumors, with which indeed they may coexist. The treatment ordinarily to be recommended for sanguinous cysts, is excision, with precaution against hemorrhage, if the cyst be connected Avith a mevus or bloodvessel; or, if the tumor be very large, it may be reduced in size by repeated tappings, and then laid open, as has been successfully done by Erichsen. Amputation may occasionally be required, as in a remarkable case reported by Moore, in Avhich the cyst was developed in the course of the popliteal nerve, and in Avhich loss of blood during an attempt at excision ne- cessitated the removal of a limb. Oily Cysts___Cysts containing oil or fatty matter alone, are very rare, though fatty substances not unfrequently occur in cysts, as the result of de- generation of other materials, or as a curdy residue from milk. Oily cysts COMPOUND OR PROLIFEROUS CYSTS. 465 do, however, occasionally occur in the orbital and superciliary regions, and in the breast. The treatment should consist of excision. Colloid Cysts occur in the kidney and thyroid gland, in the latter situa- tion constituting a variety of goitre. Their contents vary in consistency from that of serum to that of firm jelly, being clear or turbid, and of very variable color. The treatment of cystic goitre consists in tapping and the injection of iodine, or the formation of a seton. Seminal Cysts.—This is the name used by Paget for most examples of the affections usually known as Encysted Hydrocele, Hydrocele of the Cord, and Spermatocele. Seminal cysts possibly arise in some cases from dilatation and subsequent isolation of a portion of a seminal tubule, but usually originate in the so-called " non-peduncukted hydatids" Avhich are remnants of the AArolffian body of foetal life. They may be single or multi- ple, and may occur in any part of the spermatic cord, though usually just above the epididymis. Their walls are of areolar tissue, sometimes lined with tessellated epithelium, and they contain a milky fluid, in Avhich sperma- tozoa are commonly found. The treatment consists in the injection of iodine, or in the use of a seton ; or, if these fail, in free incision of the sac, which is then alloAved to heal by granulation. B. Compound or Proliferous Cysts. These are such as have the power of producing vascular or other organized structures, which may be inclosed within the original cyst wall, or may pro- ject from its surface. It is sometimes very difficult to distinguish a true pro- liferous cyst from a mass of simple cysts closely aggregated together, the latter indeed constituting a considerable proportion of Avhat are knoAvn as multilocular cysts. Complex Cystigerous Cysts are chiefly met with in the ovary, and in the chorion, in the disease of that membrane knoAvn as the hydatid mole, in Avhich the cysts are probably merely secondary formations (see p. 471). Complex ovarian cysts present a parent cyst Avith numerous secondary cysts variously arranged, Avhich project into its cavity (endogenous), or from its surface (exogenous groAvths). Dr. AVilson Fox has carefully investigated the mode of origin of these tumors, and believes that the parent cyst origi- nates, like the simple ovarian cyst, in the Graafian vesicle. Into the interior of the parent cyst, tubular gland structures, or villous or papillary groAvths (which Dr. Fox looks upon as everted follicles), project, and it is by the dila- tation and constriction of these tubules, or by the adherence of these papil- lary growths, that the secondary cysts are formed. The treatment of these ovarian cysts will be considered Avhen Ave come to speak of ovariotomy. Cystigerous cysts occurring in other parts of the body, could hardly be dis- tinguished from multiple simple cysts aggregated together, and Avould require the same treatment, viz., total excision. Proliferous Cysts -with Vascular Intra-cystic Growths occur in connection with various glands, especially the mammary and thyroid, though they are also seen in the prostate, in the lip, and in other parts of the body. This class of cysts embraces many of the tumors described by Brodie and others as sero-cystic sarcomata. These cysts may be single or multiple, their Avails being formed of thin areolar tissue, and closely adherent to sur- rounding structures. Their contents at first are fluid, but subsequently a 30 466 TUMORS. vascular groAvth, apparently of glandular structure, Avhich may be Avell formed, rudimentary, or degenerate, springs from some point of the interior, and, in- creasing more rapidly than the cyst, gradually encroaches on its cavity, which it afterAvards entirely fills, sometimes at last perforating the cyst Avail, and protruding as a fungous mass. The form of these growths varies in different cases ; sometimes they appear as layers of coarse granulations, sometimes as nodulated caulifloAver-like masses, sometimes as clusters of delicate leaf-like processes, and again as masses of closely-packed lobules. Their color, con- sistency, and degree of vascularity, are equally various. The course of these tumors is very chronic. The diagnosis from cancer may be made by observ- ing the slow progress of the sero-cystic sarcoma, its occurrence at an earlier age (usually from thirty to forty, though it may occur at a much later period), the healthy character of the skin over the tumor, the feeling of fluctuation, if the cyst still contain fluid, and the freedom from disease of the neighbor- ing lymphatic glands. Even when ulceration takes place, and the intra-cystic growth protrudes as a fungous mass, the surrounding integument has not the infiltrated appearance which it has in cases of cancer. Before the skin gives Avay, it may present a bluish-black color over the most prominent part of the cyst, an appearance which is of itself quite characteristic. The treatment consists in total excision, which will usually be followed by a permanent cure, though, if any portion of the growth be alloAved to remain, the tumor Avill be apt to recur; it may even do so after repeated removal, and when every care has been taken in the operation. ATirchow records a case in which the tumor traversed the chest Avail and involved the lung, and in which metastatic growths existed in the lungs, mediastina, liver, ribs, vertebra?, pelvic bones, dura mater, and sphenoid bone. These tumors have therefore, occasionally, a clinically malignant character, but, as pointed out by Paget, the recurrent are essentially like the primary groAvths, and never become truly cancerous. Proliferous cysts may coexist with cancer, as in the ovary and testicle. Cutaneous Proliferous Cysts__These are defined by Paget as " cysts within wliich, in the typical examples, a tissue groAvs, having more or less the structures and the productive properties of the skin." In the majority of cases, no true cutaneous lining can be recognized, but the cysts are found to contain epidermal scales, sebaceous matter, fat granules, cholestearine, and rudimentary hairs. These cysts are chiefly met with in the ovaries and sub- cutaneous tissue, but have also been seen in the testicle, lung, kidney, bladder, brain, and tongue. Among those in the subcutaneous tissues, such as are congenital approach most nearly to the typical character. These occur usually in the orbital region, close to the external angular process of the frontal bone : they have a round or oval contour, and consist of a thin cyst Avail, of a more or less cutaneous structure, pretty tightly filled Avith oily or sebaceous matter, Avith or Avithout hair. These cysts are sometimes deeply seated, and may adhere to the periosteum, or even erode, or possibly perforate, the subjacent bone. The treatment consists in total excision, which, in the orbital region, requires careful 'dissection. The common non-congenital cuta- neous cysts may occur in any region of the body, but are most frequent in the scalp. ( In this situation they are ATery loosely attached, so that they may commonly be readily removed by transfixing and laying open the tumor, and, after evacuating the contents, pulling out the cyst Avail with forceps.) In other parts of the body they may require more careful dissection. These sebaceous tumors, as they are ordinarily called, sometimes appear to have very thick Avails, owing to the accumulation of epithelial debris in their interior. In some cases a dark spot is observed on the surface of the tumor, which marks an orifice through which a probe can be introduced, and through which the NON-MALIGNANT SOLID TUMORS AND OUTGROWTHS. 467 contents of the cyst may perhaps be evacuated. In these cases, it is probable that the cyst has originated from obstruction of a sebaceous duct, though in other instances these growths appear to be autogenous formations. Seba- ceous tumors may become inflamed, when the cyst, if small, may be loosened and throAvn off by suppuration : in other cases, ulceration takes place, and the contents of the cyst protrude, becoming dry by exposure, and constituting Fig. 197. Sebaceous tumors and horn. (Bryant.) some of the so-called "horns" of the face or other parts. Occasionally the protruded contents of a cutaneous cyst become vascular, and present the appearance of a fungous, bleeding mass, Avhich may be mistaken for cancer. The treatment, as already observed, consists in total excision, but this should not, as a rule, be done unless the patient be in good general health at the time, as the operation, though in itself a trifling one, has not unfrequently been followed by fatal erysipelas. Sebaceous cysts in the auditory canal, or in the orbital region, may occa- sionally prove fatal by perforating the skull, and inducing meningeal and cerebral inflammation. Hence, early excision is particularly imperative in these cases. TJentigerous Cysts, or cysts containing teeth, occur in the ovaries and testes, but are chiefly interesting to surgeons Avhen met Avith in the upper or loAver jaAV. These cysts appear to be tooth capsules, from which the teeth, though Avell formed, have not been extruded, and which become enlarged by the accumulation of fluid. The treatment consists in making a free opening into the cyst, taking away a portion of its Avail, and, after extracting the misplaced tooth, stuffing the cavity Avith lint. NON-MALIGNANT SOLID TlMORS AND OUTGROAVTHS. The term Outgrowth is here used in the sense in Avhich it is employed by Paget, to denote the " Continuous Hypertrophies" Avhich are occasionally met Avith, in Avhich the limiting and imresting capsule of a Tumor or "Dis- continuous Hypertrophy" is absent. These outgrowths differ from the infil- trations of malignant diseases, in that in the former, the neAv material is 468 TUMORS. homologous Avith that Avhich surrounds it, while in the latter, it is quite dif- ferent, causing indeed degeneration and wasting of the normal tissue in which it is placed. Fatty Tumors and Outgrowths__These are the most common of all the non-malignant tumors, and have been described by surgical writers under Ararious names, such as Lipoma, Steatoma, etc. The Fatty Outgrowth consists of an accumulation of fat in the subcutaneous tissue of some part of the body, and may be either single or multiple. It is usually annoying only, on account of the deformity produced, but is occasionally painful. A favorite seat of the fatty outgrowth is the neck, where it gives the appearance knoAvn as a double chin. It also occurs in the abdominal Avails, and may be met with in other situations. Brodie succeeded in procuring the absorption and disappearance of a groAvth of this kind by the internal use of liquor potassae, but usually excision would be the only means likely to effect a cure, and this could rarely be advisable, for the resulting scar would probably be as dis- figuring as the disease itself. The Fatty or Adipose Tumor, or Lipoma Circumscriptum of systematic writers, is a much more common affection. It usually occurs in the trunk, especially the upper part, or in the proximal portions of the limbs, though it may be met Avith in any region of the body, as beneath the tongue, in the sole of the foot, or in the scrotum. A peculiarity of the fatty tumor is its proneness to shift its position, in obedience to the law of gravity; thus a lipoma has been known to pass from the groin to the perineum, or from the abdominal Avail to the thigh. The usual seat of a fatty tumor is in the sub- cutaneous tissue, though cases are on record in which these growths have been found in the intermuscular planes, in contact with bones or joints, in the Fig. 198. Fig. 199. Structure of a fatty tumor ; a, isolated cells Fatty tumor ; the lobated appearance well showing crystalline nucleus of margaric acid. shown. (Miller.) (Bennett.) nerves, and in the fat around internal organs. Fatty tumors are always in- vested by capsules, fibro-cellular in structure, and of varying density ; from the capsule, septa pass inwards, dividing the tumor into lobes of various size. The capsule is dry, and supplied with bloodvessels, and separates the tumor from the surrounding structures. Its layers have less cohesion among them- selves than adhesion either to the tumor or to the neighboring tissues. The skin adheres to the capsule more closely at the points at Avhich the septa pass off than at other parts, thus giving a dimpled appearance to the mass when FIBRO-CELLULAR TUMORS AND OUTGROWTHS. 469 it is lifted away from the subjacent structures. The fat of an adipose tumor does not differ materially from the ordinary normal fat by which the mass is surrounded, though, according to Butlin, the individual cells of the tumor are much larger than those of adipose tissue in general. The development of fat in a tumor is like that of natural fat, the gradual formation of fat cells from connective tissue corpuscles being, according to AVeber, as quoted by Paget, traceable in these tumors. Fatty tumors derive their vascular supply chiefly from arteries that ramify in the capsule, though, in addition, a large vessel frequently passes directly into the mass. Fatty tumors are usually single, but may coexist in large numbers, fifty- eight having been observed in one case by R. P. Harris, of this city. They are most common in early adult and in middle life, and, as a rule, grow very sloAvly. They occasionally attain a very large size, one being referred to by Gross, Avhich weighed not less than seventy pounds. Fatty tumors are usually, though not ahvays, painless. They occasionally inflame and ulcerate (par- ticularly such as are pendulous), and may contain oily cysts, or bony or cal- careous nodules. The diagnosis can commonly be made by observing the smooth, indolent, lobated character of the SAvelling, the sensation of elasticity or semi-fluctuation communicated to the touch, and the peculiar dimpling, corresponding Avith the position of the interlobar septa, Avhen the skin is rendered tense by com- pressing and lifting the mass. Another point, insisted on by Labbe, is that by thus manipulating the skin the general surface becomes red, Avhile the positions of the interlobar septa are marked by Avhite lines. The surgeon may also avail himself of the knoAvledge that all fatty matters become hardened by the application of cold, and thus aid the diagnosis by directing a spray of ether upon the surface of the tumor. The treatment consists in excision, Avhich may be practised in any case in which an operation of any kind Avould be admissible. A single incision may be made, corresponding as much as possible Avith the long axis of the tumor and the natural curves of the part, and, the capsule being then split Avith the knife, the Avhole mass may be often enucleated, by traction aided by the handle of the instrument. Occasionally, however, prolongations of the tumor may extend into deeper parts, and require more careful dissection. The cure is usually permanent, though, if any portion of the tumor be left, reproduction may possibly occur. In the case of pendulous growths, and particularly if ulceration have occurred, it may be proper to remove an elliptical portion of skin Avith the tumor. Should excision be in any case contra-indicated, attempts may be made to disperse the tumor by injections of alcohol or ether, Avhich are said to have proved successful in cases recorded by Hasse, of Xordhausen, and Schwalbe, of AVeinheim. Fibro-cellular Tumors and Outgrowths are such as in their anatomical characters resemble the ordinary areolar or connective tissue. The Outgrowths are more common than the tumors, and constitute most of the softer and more succulent kinds of Polypi, as well as the Cutaneous Out- growths, or Wens, which are so frequently met with in the generative organs, and other parts of the body. In the polypi, the fibro-cellular is commonly associated Avith gland structure, while in the cutaneous outgrowths, the skin itself appears to be hypertrophied. Closely connected with these fibro-cellular outgrowths, are the cases of Elephantiasis Arabum, Scleroderma, etc., which are chiefly observed in the scrotum and lower extremities, and Avhich are occa- sionally accompanied with a dilated state of the lymphatics, Avith or without lymphorrhoea, and more rarely with a nasvoid condition of the skin and sub- 470 TUMORS. jacent tissues. If these wens are of moderate size, they may be readily removed, but if very large, the operation, though justifiable, becomes a rather formidable proceeding. AYhen met Avith in the form of " Barbadoes leg," attempts may be made to reduce the SAvelling by the continued use of firm compression, and, as advised by Olavide, of Madrid, the internal and external use of iodine, and if these fail, it may be occasionally proper to resort to liga- Fig. 200. Fibro-cellular tumor of labium. (Holmes.) tion of the main artery of the limb—an operation Avhich has been performed under these circumstances with good results by Carnochan, of New York, and numerous other surgeons, but which is, according to Fayrer, usually pro- ducti\-e of only temporary benefit. The statistics of this mode of treatment haAre been particularly studied by Casati, AATernher, Fischer, and Leisrink, the latter of Avhom has collected about 30 cases from an examination of which he concludes that though the operation frequently fails, yet it is often pro- ductive of benefit, and occasionally effects a complete cure. Casati has analyzed 21 cases as follows:— Ligation of Cases. Recovered. Relieved. Disease returned; no benefit. Died. Iliac artery..... Femoral artery .... Popliteal artery . . Spermatic artery . . . Axillary artery .... Brachial artery .... 5 12 1 2 1 3 *5 1 2 *2 '4 i 2 1 3 2 1 Total . . . 24 10 5 3 6 FIBROUS TUMORS AND OUTGROWTHS. 471 Fibro-cellular Tumors are comparatively rare affections. They are chieflyv met with in the deep intermuscular planes of the limbs, the scrotum, labium, J and vaginal Avail, but are occasionally seen in the subcutaneous tissue, or in/ other parts, as the testicle, tongue, or orbit. These tumors occur as firm, round, or oval masses, tense, somewhat elastic, and invested with a thin cap- sule of areolar tissue. In this respect they markedly differ from the cutaneous outgroivths met Avith in the same regions, for these are continuous Avith the surrounding structures. On laying open a fibro-cellular tumor, it is found to consist of opaque white, intersecting bands of contractile tissue, the inter- spaces being filled Avith a more or less viscid serous fluid, of a yelloAvish-green or yelloAV hue. This fluid flows or may be squeezed out, the fikmento*us structure then contracting, and assuming a firmer and denser appearance. The tumor in fact closely resembles a mass of oedematous areolar tissue. Under the microscope, the elements of ordinary connective tissue are seen— undulating filaments, with nuclei (rendered more distinct by acetic acid), and elongated cells of various forms. YelloAV elastic tissue is very rarely found, but cartilaginous or bony nodules are occasionally observed. These tumors are met Avith in late adult life, and increase in size rather rapidly, more, hoAvever, by serous distension than by absolute groAvth. They are usually painless, giving trouble only by their position and Aveight, Avhich sometimes exceeds forty pounds. AAlien very large and dependent, Fig. 201. they may cause ulceration or sloughing of the surrounding skin. The treatment consists in excision, the groAvth being enucleated as a fatty tumor from its capsule. The operation usually results in a per- manent cure. Myxoma, or Mucous Tu- mor, is a name given by Vir- chow to a rudimentary form of fibro-cellular tumor, Avhich on sec- tion has a quivering, jelly-like appearance, the contained yellow fluid readily floAving aAvay, and the microscopic appearances of the tumor presenting oval, elongated, or branched corpuscles, Avith in- distinct fibrilke, and imperfectly formed filaments. The structure of the tumor resembles, in fact, embryonic connective tissue, or the so-called mucous tissue of the umbilical cord. Myxomata occur in the connective tissue of the brain, eye, nasal sep turn, breast, nerves, neck, or extremities, and in suitable cases maybe exci with a prospect of permanent relief. AVhen met Avith in the eye, they require extirpation of the globe. The disease of the chorion knoAvn as the hydatid mole, is believed by Arirchow to be an example of myxoma, consisting in hypertrophy of the proper tissue of the villi of the membrane in question. The cysts Avhich are met Avith in this disease are, according to Paget, pro- bably not essential, but merely secondary formations (see page -Kio.) Structure of myxoma. (Holmes.) iep-\ sed J Fibrous Tumors and Outgrowths (including Fibro-muscular, Fibro-cystic, and Fibro-calcareous Tumors)___Fibrous or fibroid tumors and 472 TUMORS. outgrowths (also called desmoid, chondroid, and tendinous), are such as ana- tomically resemble the ordinary fibrous or ligamentous tissue. Under the head of fibrous outgrowths, may be included most of the firmer polypi met with in the uterus, nose, pharynx, etc. Fibrous tumors have naturally a round or oval shape, and are smooth, or but slightly lobed on the surface. Under the influence, however, of gravity or pressure, they deviate from the normal form, becoming pyriform when pendulous, and when confined in a cavity, becoming gradually moulded to its shape. Fibrous tumors are usually surrounded with a capsule of connective tissue, and Avhen cut into present a basis-substance, commonly of a yelloAvish or bluish-gray color, intersected with very numerous opaque Avhite bands. These white fibres are variously arranged, sometimes in concentric circles, sometimes in undulating bundles which interlace with each other, and some- times again matted closely together, so as to appear to the naked eye as a nearly uniform, white, glistening, mass. The tumors are more or less lobed, and divided by septa of areolar tissue, the vascularity of the growth being 202. Fig. 203. Structure of fibrous tumor. (Erichsen.) Structure of fibro-muscular tumor of the uterus. (Bennett.) greatest in those tumors AArhich are most loosely arranged. Beside the char- acteristic fibres seen in sections of these tumors, there are commonly fusiform cells and nuclei perceptible ; and elastic fibres, plates or spiculae of bone, and cartilage, may occasionally be found mingled with the fibrous tissue. In the uterus, and occasionally in other situations, the fibrous tissue may be so mixed with non-striated muscular fibre as to entitle the tumor to be called Fibro- muscular; if the muscular fibre be in excess, the tumor becomes a Myoma (A lrchow), the Muscular Tumor of A'ogel. The Fibro-cystic and Fibro- calcareous varieties are the result of secondary degeneration, and may occur in either the ordinary fibrous, or in the fibro-muscular tumor. In the fibro- cystic tumor the cyst may be single, but more frequently there are a number of cysts, variously scattered through the mass ; this is Avell seen in the disease of the testicle to Avhich Cooper gave the name of " hydatid testis." The occurrence of calcareous degeneration in fibrous tumors, is chiefly seen in those met with in the uterus, and indicates a cessation of growth in the mor- bid mass. Fatty degeneration occasionally, though rarely, occurs in fibrous tumors. The favorite seats of fibrous tumors are the uterus, the nerves (where they CARTILAGINOUS TUMORS. 473 constitute the disease called neuroma),1 the bones and periosteum (especially \1 about the jaAvs), the subcutaneous areolar tissue, that in the neighborhood of joints, the tendinous sheaths, the testes, and the lobules of the ear, Avhen pierced in order to wear ear-rings; they are also met with, though more/, rarely, in the breast, prostate, submucous and subperitoneal areolar tissues, J and possibly in other localities. Fibrous tumors are usually solitary, except in the uterus and nerves, where they are commonly multiple, and may exist in large numbers. They are of sIoav groAvth, are indolent, and attain sometimes a very large size—Aveighing perhaps over seventy pounds ; they may persist for thirty years, or even longer. Sometimes they become oedematous, and soften internally, the outer part giving Avay or sloughing, and the disintegrated interior being discharged; an irregular cavity is left, from which fungous and bleeding granulations may protrude, giving the part a decidedly cancerous appearance. The diagnosis of fibrous tumors may usually be made by observing their smooth and regular outline (unless distorted by compression), their uniform firmness, their mobility (Avhen in the subcutaneous tissue), their sIoav groAvth and painlessness, and the healthy character of the surrounding tissues. AYhen groAving in, or connected with, bones, the diagnosis from other forms of tumor is often very difficult, and sometimes almost impossible, until after removal of the growth. The treatment consists in excision, in situations admitting of this operation, the tumor being enucleated from its capsule, if this can be done, and if not, removed by careful dissection. AVhen the tumor springs from bone, as in cases of epulis, it is necessary to remove, Avith the groAvth, the osseous sur- face to Avhich it is attached. Recurrence is rare, except in the case of the Fig. 204. Fig. 205. CartilaginOUS TumOrS, Or Enchon- Large enchondroma of scapula. dromata (including Fibro-cartilaginous and Mixed Tumors).'1—The anatomical and chemical characters of these groAvths are essentially those of foetal cartilage. Enchondromata are commonly lobu- 1 Or the false neuroma. (See Chap. XXVIII.) 2 The "loose cartilages" met Avith in joints, present certain analogies to enchon- dromata, but will be more conveniently considered in another part of the volume. 474 TUMORS. lated, and (in parts unconnected with bone) invested Avith a dense connective tissue capsule, from which proceed septa which divide the lobules from each other. On section, these tumors present a glistening, bluish, or pinkish- Avhite appearance, and differ from other non-malignant groAvths, in that they show, under the microscope, a considerable diversity of structure, in speci- mens derived from the same tumor. The intercellular substance has a more or less fibrous appearance, and is often so markedly fibrous as to render the name Fibro-rartilaginous appropriate. The cells vary greatly in number, size, shape, and mode of arrangement, and are sometimes so fused with the basis-substance that the nuclei alone are perceptible. The nuclei themselves vary in different specimens, occasionally seeming shrivelled, or containing oil globules, or having a granular appearance. Cartilaginous tumors are commonly hard and resisting, though sometimes soft and compressible ; they are always elastic. They interfere but little with surrounding structures, Avhich remain healthy, though displaced by the groAv- ing mass ; if the part be exposed to friction, a bursa sometimes forms over the prominent part of the tumor. Enchondromata usually occur at an early period of life. These tumors are most frequently seen in connection with bones (Avhen they may grow beneath the periosteum, or in the medullary cavity), but also occur in or near the parotid gland, in the testis or mamma, and occasionally in other localities. Their" rate of increase, and the size to Avhich they may attain, are both extremely variable ; Paget mentions a cartilaginous tumor which, after four years, Avas but half an inch long; and another Avhich, in three months, occupied nearly the whole length of the thigh, and Avas as large round as a man's chest. The principal changes which occur in enchondromata, are ossification and degenerative liquefaction. Ossification may take place in the older portion of a tumor, while the rest is still growing, or may occur in the form of de- tached bony nodules scattered through the mass. As a result of degeneration, or possibly of arrested development, a honey-like or jelly-like fluid is often found in one or more parts of an enchondroma, giving a soft and fluctuating character to the tumor. As the result of inflammation and ulceration, an enchondroma may protrude and slough, leaving a large suppurating and offen- sive cavitv, and death may occur from exhaustion under these circumstances. A large proportion of the so-called Mixed Tumors contain cartilage as one element of their structure. Thus, nodules of cartilage may occur in fibro- cellular tumors, and, on the other hand, enchondromata may contain cysts, glandular tissue, or myeloid structure—and may even be apparently mingled Avith encephaloid, in the same general mass. Cartilaginous tumors are usually solitary, except Avhen occurring in the bones of the hands, where they are commonly multiple. The bones most frequently affected, after those of the hand, are the femur and tibia, and, next to these, the humerus, ribs, pelvis, and last phalanx of the great toe—though enchondromata have been occasionally seen in almost every bone of the body. AArhen groAving near the articular extremity of a long bone, a car- tilaginous tumor is usually seated betAveen the periosteum and bone, gradually eroding the Avail of the latter, and involving it in its own mass. The articular extremity itself Multiple enchondromata of hand. is probably never involved. Enchondro- (Druitt.) mata in the middle of the shaft of a long Fig. 206. OSSEOUS TUMORS AND OUTGROWTHS. 475 bone are rare, and, Avhen met Avith, commonly groAV both externally and in- ternally, the bone Avail finally yielding, and the tumors coalescing. In the hand, enchondromata arise within the bone, the walls of Avhich they gradually expand ; but in the rare cases of single enchondromata in this situation, the tumors are subperiosteal, as in the long bones. The diagnosis may usually be made by observing the various characters Avhich have been described as belonging to the enchondroma, especially its hardness combined with elasticity; but Avhen occurring in certain situations, as Avithin the jaAv, the diagnosis from other innocent tumors may be impossible until after excision. The treatment of cartilaginous tumors consists in removal of the growth by enucleation, dissection, excision, or amputation, according to the locality and other circumstances of each particular case. Enchondromata rarely recur after removal, though they may do so when of a soft and rudimentary struc- ture : when mixed with cancer, the latter affection runs its course indepen- dently. A case has been recorded by Moore, in which a pure enchondroma gave rise to secondary deposits in the lungs by a process analogous to embolism. Osseous Tumors and Outgrowths; Exostoses___Osseous Tumors are very rare except in connection Avith bone, and may be defined, Fi-. 207. Ivory like exostoses of the skull. (Miller.) in the words of Paget, as exostoses or bony outgrowths, '• whose base of attachment to the original bone is defined, and groAVS, if at all, at a less rate than its outstanding mass." Osseous tumors consist solely of pure bone ; they may arise from the ossification of cartilage, or may be deATeloped, as normal bone, from the periosteum or other fibrous tissue. They are usually solitary, and when mul- tiple are often symmetrical and hereditary. Tavo varieties of bony tumor may be recognized, the cancellous (con- sisting of a thin layer of compact substance, Avith cancel- lated structure and marrow internally), and the compact, hard, or ivory-like, bony tumors, which consist, as their name implies, of hard and solid bone. The cancellous tumors usually constitute the ultimate stage of the cartilaginous tumors already described ; they are indolent, and AVhen thoroughly ossified rarely groAv ; thev are situated outside of the bones with which they are connected, and in suitable cases may be treated by excision. A favorite locality of this form of bony tumor is 'the last phalanx of the great toe, Avhere it groAVS from the inner margin of the bone, lifting up the nail and causing troublesome ulcera- Cancellous exostosis, growing from the low- er part of the femur. Druitt.) 476 TUMORS. tion of the skin : it is very seldom that any but the great toe is affected. The treatment consists in excision, taking care to remove, Avith the groAvth, the bony surface from which it springs. Birkett has recorded a remarkable case of cancellous exostosis of the frontal bone. The ivory-like bony tumors are rare, except in connection with the cranial bones (Fig. 208), where they may be small, superficial, and perhaps pedun- culated, or may originate in the diploe or frontal sinus,1 etc., Avhere they may groAv both inwardly and outwardly, in the form of large nodulated masses, involving the orbit, causing protrusion of the eyes and great deformity, and perhaps inducing fatal compression of the brain. For the superficial variety, excision may occasionally be attempted, though the operation is sometimes rendered impossible by the hardness of the tumor. For the deep orbital groAvths, attempts at excision are not to be recommended, but as a cure has sometimes followed necrosis and spontaneous separation of the mass, it may be proper to expose the most prominent part of the tumor, and apply nitric acid or caustic potassa, as recommended by Stanley, in hope of inducing exfoliation. Those exostoses which are not pedunculated, and which, therefore, are pro- perly called Outgrowths (Osteomata), in contradistinction to osseous tumors, do not, as a rule, admit of removal. A favorite seat of these growths is in the superior maxillary bones, whence they may spread to other bones of the face, causing great deformity, or even death, by interference with the brain. If limited to the jaw, and to one side, excision of the bone might be properly tried; but if bilateral, or involving neighboring parts, no operation should be attempted, except, perhaps, the application of caustics, as in the frontal and orbital growths already referred to. Glandular Tumors—These, which are also called Adenomata, or Adenoid Tumors, are such as in their structure resemble the normal glands, Avhether the secreting, lymphatic, or ductless glands. The principal localities of ade- noid tumors, are in or near the mammary, the prostate, the thyroid, the labjal, and the lymphatic glands, though they also occur in the parotid, sebaceous, and sudoriferous glands. Glandular structure, moreover, forms an important part of the submucous fibro- cellular tumors which consti- tute mucous polypi, as Avell as Adenoma of the Mamma. X 300. (Rindfleisch.) of the Complex Ovarian cysts. The mammary and probably some other glandular tumors, originate as proliferous cysts, wliich become solid by the extension of intra-cystic growths. Glandular tumors have usually a regularly curved outline, are somewhat lobated, and may be flattened by pressure. They have commonly a distinct 1 According to Dolbeau and others, many of these ivory-like tumors originate in the mucous membrane of the nasal fossae and other cavities of the face ; their attach- ments to surrounding parts are then very slight, and their enucleation compara- tively easy. (Sec a Critical Review by Rendu, in the Archives Ginlrales de Medecine for August, 1870.) Colignon reports a case in wliich such a growth was successfully removed by Demarquay from the maxillary sinus. (Gaz. Med. de Paris, Fev. 21, 1874.) ERECTILE AND PAPILLARY TUMORS. 477 investing capsule of connective tissue, and are but slightly vascular. On section, they appear of a gray or yelloAvish-Avhite hue, of variable density and elasticity, and are frequently intermingled Avith cysts. The labial and parotid adenomata may also contain nodules of cartilage or bone. Their groAvth is extremely variable, and, though usually indolent, glandular tumors, especially of the breast, are occasionally the seat of great pain. They occa- sionally disappear by absorption : thus a mammary adenoma may be entirely removed without operation, upon the restoration of the suspended functions of the mammary gland itself, or of the uterus. The treatment consists in the use of pressure, with the application of sorbe- facients, and, when these fail, in excision, which can usually be readily effected by enucleation. The interstitial injection of alcohol is recommended by ScliAvalbe, of AA'einheim. Lymphoid Tumors—This name is used by Prof. Turner as equiva- lent to the Lymphoma of Virchow, " to express those neAV formations Avhich, Lymphoma.—a, a thin section of a lymphomatous tumor of the mediastinum, b, a similar section, from which most of the cells have been removed by pencilling, so as to show the reticulated network, and the nuclei in its angles. This network is much more marked than that often met with. X 200. (Green.) in their essential structure, are composed of corpuscles like the round, pale corpuscles that form the characteristic cell-elements of the lymphatic glands." In many eases these lymphoid tumors occur in parts where lymphatic glands are known to exist, but in other instances they have been met Avith as entirely independent formations. They are frequently multiple. They have been observed by A7irchoAv in the liver and kidney, by Church in the mesentery and extra-peritoneal tissue, and by Murchison in all these organs, as well as in the intestine and heart. The treatment recommended by Billroth is the use of arsenic both internally and by parenchymatous injection ; excision is seldom justifiable. Vascular or Erectile Tumors (Angeiomata) are of most fre- quent occurrence in the skin and • subcutaneous tissue, though they may also be found in any structure which is itself vascular. They are subdivided, according to their structure, into the capillary, arterial, and venous vascular tumors. The arterial variety constitutes the disease knoAvn as Aneurism by Anastomosis, Avhile the capillary and venous vascular tumors are what are commonly designated as Nevi. The diagnosis and treatment of these affec- tions will be considered in the chapter on diseases of the Vascular System. Lymphatic Vascular Tumors, erectile, and usually congenital, have been occasionally described. They closely resemble some of the venous vascular tumors, but contain a fluid resembling lymph, instead of blood. Papillary Tumors (Papillomata) resemble in structure the ordi- nary papillae of the cutaneous and mucous tissues. They occur in the skin, Fig. 210. 478 TUMORS. where they form the common cutaneous Avarts, and some of the so-called horns met with, chiefly about the face and head ; and in the mucous mem- branes, Avhere the papillary structures may occur in connection Avith fibro- cellular groAvths, in the form of mucous polypi, may be scattered over a con- siderable extent of surface, giving the part a villous appearance, or may be aggregated into distinct tumors : the mucous membranes chiefly affected are those of the larynx, colon, rectum, bladder, and urethra. I have seen a Avell- marked papilloma of the tongue in a boy, the affection being attributed to the patient's habit of smoking stumps of segars which he picked up in the street. According to R. AV. Taylor, the warty form of lingual ichthyosis is a true papilloma. Finally, papillary groAvths may occur in serous tissues, particu- larly the arachnoid ; the Pacchionian bodies are, according to A"on Luschka, merely enlargements of the villi normally existing in this part. The papil- lary tumors, above referred to, are of a non-malignant character, and must not be confounded Avith Villous Cancer (see p. 491). The treatment of papil- lomata consists in excision, ligation, or the application of caustics, according to the size and situation of the growth. Neuralgic Tumors__This is a group embracing such tumors as are, Avithout any perceptible reason, the seat of intense neuralgic pain. They are usually fibrous or fibro-cellular in structure, though adipose, fibro-cartilagin- ous, or even glandular tumors may occasionally be similarly affected. The Painful Subcutaneous Tumor or Tubercle, which is the most common of the neuralgic tumors, is usually seen on the limbs, particularly the loAver, but occasionally on the face or trunk. It is rarely more than half an inch in Fig. 211. Painful subcutaneous tubercle on the forearm. (Smith.) diameter, has a round shape, and is firm, tense, and elastic. It is usually single, and is much more common in Avomen than in men—in both respects differing from the ordinary neuroma, which is frequently multiple, and is oftenest seen in the male sex. The painful subcutaneous tubercle is an affec- tion of adult life. In many instances, the most careful dissection has failed to show any con- nection betAveen these tumors and nerve fibres, though it is believed by many 'writers that the painful subcutaneous tubercle is really a " true neuroma" (see Chap. XXVllL), containing an excessive formation of nervous elements.1 1 See Labbe and Legros, in Journal de VAnatomie de la Physiologie, etc., t. vii. (1870), p. 171. SEMI-MALIGNANT OR RECURRENT TUMORS. 479 The so-called " irritable tumor of the breast" is properly termed a neural- gic tumor, being, indeed, otten really a painful subcutaneous tubercle, though occasionally a simple adenoma. The pain in all of these cases is of a paroxysmal character, and is often compared to an electric shock. During the paroxysm, the tumor itself com- monly becomes sensitive and SAVollen. The treatment consists in excision, which operation may be expected to afford permanent relief. As a palliative measure, circumferential pressure, Avith a ring placed around the tumor, may be occasionally resorted to with advantage. Pulsating Tumors—These are such as have a pulsation, due to the state of the bloodvessels in the tumor itself, independently of its proximity to a large vessel. The pulsating tumors are the arterial vascular (aneurism by anastomosis), the myeloid, and the encephaloid—the tAvo latter pulsating only when the tumors are partially surrounded by bone. The chief interest per- taining to pulsating tumors, is the liability of mistaking them for aneurisms, an error Avhich has occasionally been committed by the most distinguished surgeons. Floating Tumors are tumors felt in the abdomen, wliich change their place and float aAvay, as it Avere, under the surgeon's manipulations. They consist in some cases of movable kidneys, but are probably sometimes loosely- attached ovarian cysts, portions of thickened omentum, etc., or even fecal accumulations. Phantom Tumor is the name given to an apparent tumor which vanishes spontaneously, and which usually consists of a partially and spas- modically contracted muscle. In other cases, an accumulation of gas, or a thickerfed or fatty omentum, has been known to simulate an OA-arian tumor, and laparotomy has actually been performed under these circumstances. The usual seat of phantom tumors is in the abdomen, though they are occasionally seen in other localities. Seaii-Malignaxt or Recurrent Tumors. Recurrent Fibroid Tumors—It has been remarked, in describing almost each form of non-malignant tumor, that under certain circumstances it may recur after removal, and occa- sionally Avith such persistence as to Fig. 212. Virchow Calls the "SpinMe-celled Sar- Recurrent fibroid tumor, or spindle-celled COma. sarcoma. (Green.) 480 TUMORS. These recurrent tumors differ in general character from the non-recurrent groAvths of the same varieties, in being softer and more friable, rather more juicy, and someAvhat more glistening on section. Under the microscope, they exhibit a larger proportion of cells, and fewer formed fibres, with large, and often free, nuclei and nucleoli. Under the name of Fibro-nucleated Tumor, is described by Bennett, a group of recurrent tumors very analogous to the recurrent fibroid of Paget, and which under the microscope exhibits filaments, Avith elongated, oval, nucleokted nuclei. The treatment of recurrent tumors consists in excision, which may be repeated as often as the tumor reappears. A permanent cure is occasionally obtained after repeated removals, though more often the patient ultimately dies from exhaustion caused by the ulceration of the tumor, Avhich commonly returns with a shorter interval after each operation. Esmarch is said to have prevented the redevelopment of recurrent tumors by the administration of large dose.s of iodide of potassium. Myeloid Tumors are such as in their microscopic characters resemble foetal marrow. The characteristic myeloid cells are round, or irregularly oval, clear, or slightly granular, from ^qq to ^i^ of an inch in diameter, and containing from two to ten, or even more, nucleokted nuclei. Beside these, there may be free nuclei, and lance-shaped, caudate, or spindle-shaped Fig. 213. " Giant-celled sarcoma," or myeloid tumor, a points to a part where cysts were being formed by the softening of the tissue of the tumor ; 6, to a focus of ossification. (Billroth.) (fibro-plastic) cells, whence the name sometimes used of Fibro-plastic Tumor, though this is more appropriate to the Recurrent fibroid variety. These tumors are rarely found except in the bones, where they usually occur as internal growths. AVhen not so situated, they have commonly a firm, fleshy feel, but are occasionally soft and easily broken. On section, they have a yellow or gray, glistening appearance, marked with spots of red- ness, which do not seem to depend upon their vascularity. They not unfre- quently contain cysts, and are often partially ossified. Myeloid tumors commonly originate in early adult life, aad are usually single, of slow groAvth, SARCOMA. 481 and indolent: the surrounding structures are, as a rule, healthy, though per- haps greatly distended and displaced. The diagnosis from purely non-malignant tumors of hone is rarely possible before operation ; when seated on the surface of a jaw (almost the only locality in which it occurs externally), a myeloid may perhaps be distin- guished from a fibrous tumor, by its greater softness and elasticity. The treatment consists in excision (with the surface of bone from which it grows), or, in the long bones, in amputation at a higher point ;* as a rule, recurrence is not as much to be feared as with the other tumors of this class, provided that early extirpation has been resorted to. Secondary myeloid tumors have, however, occasionally been met Avith in the lymphatic glands, and in the lungs. Sarcoma—This term is used by A irolioAv and other German pathologists, to designate a group of tumors Avhicli possess an analogy " not only Avith granulations, but also with true flesh of recent formation, or in process of development." (AlrchoAv, Path, des Tumeurs, trad, par Aronssohn, t. ii., p. 183.) Connective tissue tumors "become, under certain circumstances, richer in cells, and enlarge, Avhilst their interstitial connective tissue becomes more succulent, nay, in many cases disappears so completely, that at last scarcely Fig. 214. orifu-M mucous Intercellular Large Hound-Cell or Zympko Sarcmia Mjjx.o Sarcoma J Several varieties of sarcoma. (Bryant.) anything but cellular elements remain. This is the kind of tumor Avhich . . . . ought to be designated by the old name of sarcoma." (A lrehow, Cellular Pathology, Chance's edit., p. 48G.) The following are VircliOAv's subdivisions of sarcomata, according to their cellular structure:— (a) Reticulo-cellular Sarcoma; like the typical connective tissue (fibro- cellukr) tumor, but Avith a larger proportion of cells. (b) Spindle-celled Sarcoma ; containing fusiform or fibro-plastic cells ; cor- 1 Successful cases of excision of the lower ends of the ulna and radius for myeloid tumors of those parts have been reported by Lucas and Morris. 31 482 TUMORS. responds Avith fibro-plastic, recurrent fibroid, and fibro-nucleated tumors. Cells often arranged in lamelk, bundles, or trabecular (lamellar, fasciculate, and trabecular sarcomata). (c) Globo-cellular or Round-celled Sarcoma ; often mistaken for medul- lary cancer, but can be distinguished by observing that the cells of the sarcoma are in constant relation Avith the intercellular substance, Avhereas the cancer cells are intimately connected Avith other cells alone. Glioma is a variety of round-celled sarcoma, originating in the neuroglia or delicate connective tissue of the brain, auditory nerve, or retina. Under the microscope, the tumor is found to consist of round or oval, and some- times caudate or stellate, corpuscles, Avith a greater or less amount of a faintly fibrilkted stroma. These tumors occur in the outer layers of the retina, in Aery young children, and, as they groAV, cause increased intra-ocular tension. They may prove fatal by extending backwards Avithin the cranium. Complete and early extirpation of the eyeball, is the only treatment to be recommended, though evTen this will not always pro\Te successful. (d) Colossal or Gigantic-celled Sarcoma ; contains A'ery large cells, with numerous nucleokted nuclei; corresponds with the myeloid or myeloplaxic tumor. Billroth also describes an alveolar sarcoma, in which the cells are grouped in alveoli, the microscopic appearances of the growth thus closely resembling Fig. 215. Alveolar sarcoma. (Billroth.) those of carcinoma; and a, pigmentary or melanotic sarcoma, in which the cells contain pigment matter. If in portions of a sarcoma the process of cell-development is so rapidly carried on that no intercellular substance is formed, those portions become cancerous, and a mixed variety of tumor results, which might properly be called Carcinomatous Sarcoma. The intercellular substance in sarcomata, usually contains albumen, casein, or mucin (whence another subdivision might be made into albuminous, case- ous, and mucous sarcomata), and, under the microscope, appears homogeneous, granular, or fibrillar. Finally, sarcomata are distinguished by the vascularity upon Avhich depends their characteristic succulence. They are often the seat of parenchymatous extravasations, these " hemorrhagic infarctus" sometimes giving rise to neAV MALIGNANT TUMORS. 483 productions of pigment matter. For further information upon the subject of sarcomata, the reader is referred to the nineteenth lecture of A irehow's work on Tumors, from which this account has been principally taken. Malignant Tumors. The division of tumors into malignant and non-malignant, is, as has been already observed, not perfectly satisfactory; for some of those Avhich, from their structure, Ave should class as benignant growths, are in their clinical cha- racters almost, if not quite, as malignant as some of those to Avhich we apply the latter name. A Recurrent Fibroid may, for instance, run a more malig- nant course than an Epithelioma. The term Malignant Tumor is used by Paget, Moore, Pemberton, and other writers, as synonymous Avith Cancer, and Epithelioma is by them considered to be merely a variety of cancerous disease. It is, however, upon the whole, better, I think, to separate epithe- lioma from cancer or carcinoma (from Avhich, indeed, it differs in a good many points), though its clinical characters are such as to make it convenient to retain it among malignant tumors. Cancer or Carcinoma__There are two principal forms of cancer, the hard or schirrous, and the soft or medullary—the terms melanoid, hematoid, etc., being applicable to varieties of these, rather than to distinct and inde- pendent forms of cancer. Hard and soft cancer may coexist in the same patient, and even in the same tumor; but they are not interchangeable—that is to say, a mass of scirrhous tissue never becomes medullary, nor vice versa. 1. Scirrhus, or Scirrhous Cancer, is the most common form of can- cer, and is more frequently seen in the female breast than in any other locality, though it also occurs in lymphatic glands, skin, muscle, and bone ; in the tongue, tonsils, intestinal canal, lungs, liver, eye, testis, ovary, uterus, etc. Scirrhus is more frequent in Avomen than in men, and occurs more often in persons betAveen forty-five and fifty years of age, than at any other period of life ; it is rarely if ever seen in childhood. It is usually supposed that the development of scirrhous cancer is in some Avay connected Avith the cessation of the menstrual Aoav, but statistics do not support such a vieAv. Scirrhus is sometimes predisposed to by inheritance, and its development is sometimes directly traceable to the reception of an injury, or other local cause. It appears to be proportionally more common among married than among single women. Scirrhus usually occurs in persons Avho are otherwise healthy, and is at first unattended Avith much pain ; so that it may frequently exist for some time before its presence is discovered. Course___Scirrhus originates as a small nodule, and groAvs Avith very varia- ble rapidity.in different patients, or even at different times in the same patient. Scirrhus is infiltrated} among the tissues in which it occurs, and increases in size by gradually involving the surrounding structures. Even Avhen to the naked eye, and to the touch, the parts around a scirrhous tumor appear quite healthy, the microscope may reveal the presence of cancer elements, so that scirrhus is said to be often surrounded with a halo of cancerous matter. In its first stage, a scirrhous tumor is, as has been said, very small; indeed, it sometimes renders the part in Avhich it occurs smaller than normal, by inducing contraction of the neighboring tissue. Even in its earliest stage, 1 CullingAvorth has, hoAvever, reported a remarkable case of mammary scirrhus which was completely surrounded by a distinct fibrous capsule. 484 TUMORS. hoAvever, scirrhus has usually its characteristic hardness, a peculiarity which is so marked as to have given the disease its name. As a scirrhous tumor groAvs, it becomes painful, the pain commonly being of a lancinating, "electric" character. Though the groAvth is in itself not sensitive to the touch, the pain in the tumor is aggravated by handling. As the scirrhous mass in its growth approaches the skin, the latter becomes adherent, the shortening of various subcutaneous fibres giving a dimpled or pitted, some- Fig. 216. Fig. 217. mmmm Section of scirrhous breast, showing retraction of the nipple. (Liston.) ¥ "% Scirrhus of breast, in stage of ulceration. (From a patient at Episcopal Hospital.) Avhat brawny or lardaceous, appearance to the part, and, in the case of the breast, in- ducing retraction of the nip- ple. After a time, ulceration occurs, either (1) superficially, when the adherent skin, hav- ing become infiltrated and congested, becomes excoriated or cracked, a small, superficial, indolent ulcer resulting; or (2) as the result of disintegration of the cancerous tissue at a deeper point, when a yelloAvish-gray mass, consisting of cancerous debris with ill-formed pus, works its way, abscess-like, to the surface, and is evacuated, leaving an excavated ulcer, which constantly enlarges as the cancer itself groAvs, and continues to discharge an ichorous and offensive fluid, which often excoriates the neighboring parts. The latter form of ulceration has certain features, such as elevated, knobbed, and everted edges, a hard and nodular base, cancerous walls, and a peculiarly offensive discharge, which, Avhen combined, serve to characterize the so-called Cancerous Ulcer. The ulceration of a scirrhous tumor may persist for a long time, and even cicatrization may occa- sionally occur, the cicatrix being thin, red or livid, with an irregular surface, and much disposed to reulcerate. More commonly the ulcer, as has been said, constantly enlarges, though not so rapidly as the cancer itself; consider- able portions of the tumor may become, from time to time, inflamed, and slough, and hemorrhage may occur from the fungous granulations, or from the ulceration invading neighboring \-essels, until finally the patient dies ex- hausted by the profuse and fetid discharge, pain, and loss of blood. Scirrhus (which is at first usually solitary) not only grows in the locality in which it first occurs, but becomes diffused, by multiplication, in other parts SCIRRHUS, OR SCIRRHOUS CANCER. 485 Fig. 218. of the body.1 The most frequent seat of secondary deposits, is unquestionably the h'niphatic vessels and glands in the neighborhood of the original tumor;. next, in the tissues around, but not immediately connected Avith, the point of original disease; and lastly, in distant organs, especially the liver, lungs, and bones. It is occasionally possible to trace the occurrence of secondary cancerous deposits to a process analogous to embolism, but more often the effect only is seen, Avithout the mode of its production being recognizable. According to Cohnheim and Maas, embolic transference of fragments of malignant and other tumors is constantly going on in patients thus affected, but the embola do not persist and form neAV groAvths except in particular states of the con- stitution ; the disease thus remaining a local affection until some deterioration of the patient's health permits the development of secondary groAvths. Colomiatti believes that cancer some- times spreads along the nerves of a part before the lymphatics become affected. When any of the important internal viscera are affected by secondary cancerous deposits, a marked state of constitutional depression is often produced, which has received the name of Cancerous Cachexia; the older writers, in- deed, looked upon this cachexia as a condition peculiar to cancer, and described it as occur- ring in almost every case of the disease. Sir Charles Bell's vivid picture, is that usually referred to, and the continued emaciation, leaden hue of countenance, pinched features, and livid lips and nostrils, of Avhich he speaks, are undoubtedly seen in cases of scirrhus, but probably not more often than in other exhausting and painful diseases; in fact, Avhile cases of external cancer often run on to a fatal termination Avithout the development of any cachexia Avhatever, the cachectic state Avhich accompanies internal cancer is not, in itself, distinguishable from that seen in cases of visceral disease of a non-cancerous nature. To complete the natural history of scirrhus, its duration must be briefly referred to : a feAV cases last ten or twelve years, or even longer, and, the tumor ceasing to groAv, and perhaps cicatrizing if ulcerated, the patient may at last die trom some other cause. I have myself operated upon persons in Avhom the disease had lasted six and eight years. The large majority, Iioav- eA-er (about three-fourths), of patients Avith scirrhous tumors, die within four years from the time when the groAvth is first discovered, and the expectation of life, as far as figures bear upon the subject, may be said to be about Iavo years and a half—as many dying before as after that period. The earlier the age at wliich scirrhus appears, the more rapid, usually, is its course. Morbid Anatomy___AVhen a scirrhous tumor, in its early stage, is cut into, it is found very hard and resisting, and the groAvth creaks, as it is said, under the knife. AVhen laid open, both the cut surfaces are usually found to be concave, a very significant feature, and one Avhich, Avhen present, is eminently characteristic of scirrhus. The section is smooth and somewhat glistening, bleeds rather freely at first, is of a pale grayish-white hue, some- *>™&tljl, ftl ill Secondary (Miller.) growths of scirrhus. 1 It is often said that tbe secondary growths in cases of scirrhus are of an encephafoid nature, and such is occasionally tbe fact; in most instances, however, the secondary tumors are, as stated in the text, of the same character as the primary growths. 486 TUMORS. times with a slight purple tint, and is often marked with Avhite or yelloAV lines and spots. The tumor appears evenly tough and resisting in all directions, and has no distinct margin, being evidently infiltrated into the normal struc- tures of the part. By scraping or pressing the tumor, a grayish-Avhite, gruel- like fluid can usually be obtained, which is diffusible in Avater, and contains cancerous matter, mingled Avith the softened tissue of the part, and with the exuded contents of the neighboring Aessels ; this constitutes the so-called cancer-juice, the denser structure Avhicli remains being called the stroma. Under the microscope, the cancer elements may often be seen to be clearly infiltrated among the interstices of the normal tissues of the part. The can- cer-elements themselves consist of tAvo parts, viz., a pellucid, dimly granular, or fibrillar basis-substance, and someAvhat cloudy cells, of variable size— usually round or oval, but sometimes angular, caudate, fusiform, lanceolate, etc___commonly containing one, but often tAvo, large nuclei, and occasionally Fig. 219. Fig. 220. Cells from a scirrhus of the mamma. Microscopic appearance of scirrhus. X 250. (Green.) (Green.) still more—and frequently mingled Avith a certain number of free nuclei. The nuclei themselves contain one, tAvo, or even more nucleoli, wliich are large, bright, and Avell defined. The size of the scirrhus cell varies from Tjott to yig of an inch in diameter, the most usual size being about T5^ or y^1^ of an inch ; the average length of the nucleus is about ^g1^^ of an inch. It is thus seen that there is no distinctive cancer cell; the nature of the groAvth is to he recognized by the great multiplicity of forms seen in the same specimen, and by the fact that the cells are closely packed together in groups, Avithout the intervention of any recognizable intercellular substance. Beside these, which may be regarded as the normal elements of scirrhous cancer, cells are often seen Avhich are Avithered, or in various stages of degen- eration ; the cells may be shrivelled, containing oil globules and granular matter, or may be completely disintegrated, the nuclei being set free, and ap- pearing to be mingled Avith granular matter and molecular debris. In addition to the cancerous elements themselves, a scirrhous tumor sIioavs, under the microscope, various structures, glandular, muscular, fibrous, areolar, etc., which belong to the tissues in Avhich the cancer happens to be groAving, and Avhich are present in varying quantities, being least apparent Avhen the cancer- structure itself is most abundant. The anatomical characters of scirrhus, Avhen occurring as a secondary de- posit, as, for instance, in the lymphatic glands, do not differ in any essential respect from those above described. The surface, hoAvever, does not com- monly become concave on section, nor are the Avhite fibrous lines so well marked as in the primary tumor. Scirrhus, in some cases, appears as a spreading, comparatively superficial affection, rather than as a tumor : it is thus met Avith on the surface of the thorax, sometimes originating in the skin itself, at other times in the mam- mary gland, or as tubercles in the deeper plains of tissue, but ahvays at last involving both superficial and deep structures, and surrounding the chest Avith MEDULLARY OR SOFT CANCER. 487 a mass of cancer, appropriately called, by the French, cancer "en cuirasse." The course of this form of scirrhus is often extremely chronic, patients living in this condition for over twenty years, in spite of the pain and occasional hemorrhages Avhich attend the disease when ulceration is present; partial cica- trization even sometimes occurs, giving the part someAvhat the appearance of a serpiginous chancroid. Under the name of Acute Scirrhus, many Avriters describe a form of the disease in which the tumor is less hard and more elastic than in ordinary scirrhus, does not appear concave on section, is more succulent, has usually smaller cells, grows more rapidly, and altogether runs, as the name implies, a quicker course than the average. Acute scirrhus occurs at a comparatively early age, and forms to a certain extent a connecting link with medullary cancer. Fig. 221. 2. Medullary or Soft Cancer (Encephaloid) is so called from its often presenting a brain-like appearance Avhen laid open. It occurs in the uterus and other internal organs, in the testis, eye, bones, intermuscular spaces, mammary gland, lymphatics, etc. It is rather more frequent in women than in men (though less markedly so than is the case Avith scirrhus), and may occur at any age, more than one-fourth of the whole number of cases of external medullary cancer being met Avith in persons under twenty, and nearly tAvo-thirds in those under forty. The influence of inheritance is about as Avell marked in medullary as in scir- rhous cancer, Avhile the proportion of cases in Avhich previous injury is sup- posed to act as an exciting cause, is nearly tAvice as great. The victims of encephaloid are less often in robust health, before the appearance of the disease, than are those affected with scirrhus. Course___Medullary cancer appears as a solitary growth, except in the subcu- taneous tissue, where it is often multiple. I had under my charge in the Avards of the Episcopal Hospital, some years since, a man fifty-one years old, who, beside a large encephaloid tumor of the left shoul- der, had smaller masses of the same kind upon the neck, chest, abdomen, back, arms, and thighs. The growth of me- dullary cancer is commonly very rapid, sometimes, according to Paget, exceed- ing a pound per month. On the other hand, cases are occasionally met with in which the growth of medullary cancer is spontaneously arrested, the tumor remaining Avithout change for a number of years. Medullary cancer may occur, like scirrhus, as an ill-defined infiltration, or as a distinct tumor invested by a tolerably complete capsule. It has no tendency to draw in adjacent parts, as scirrhus does, but distends and displaces them. The skin over a medullary cancer becomes thin and tense, and finally gives way, just as it Avould in the case of any other rapidly-growing tumor, so that the ulceration over a mass of encephaloid presents none of the peculiar charac- ters Avhich have been described as belonging to the "cancerous ulcer." AATien ulceration has occurred, however, the cancer, being freed from the restraining Medullary cancer in stage of ulceration tumor protruding. (Druitt.) 488 TUMORS. pressure of the skin, appears to groAv Avith increased rapidity, and soon pro- trudes through the opening—the exuberant mass usually becoming inflamed, sloughing, and bleeding, and constituting the bleeding fungus, or Fungus Hematodes, of the older Avriters. Medullary cancer occurring in bone, is sometimes attended Avith a distinct pulsation (see p. 479). The course of medullary cancer is commonly toAvards an early death, but occasionally—even after ulceration-^large masses of encephaloid matter may slough away, cicatrization following, and thus leading to at least a temporary recovery. Medullary cancers sometimes wither, becoming shrivelled and concentrated, and finally temporarily disappearing; in other cases they undergo fatty degeneration, ceasing to grow, and becoming " obsolete." Usually, hoAvever, Avhile this change occurs in one tumor, others continue to increase. Calcareous degeneration is a rare occurrence, and, when seen, is usually combined with the fatty change above referred to. The occurrence of hemorrhage and of sloughing in medullary cancer, has been already men- tioned. More rarely, inflammation of such a groAvth ends in suppuration. and in this Avay, too, temporary disappearance of the tumor may be effected. Medullary, like scirrhous cancer, tends to multiplication in various parts of the body, and there is reason to believe that, in many cases, fragments of the primary growth are detached, and carried by the general circulation to remote organs, where they lodge and groAv as independent centres of disease. The pain of medullary cancer is usually much less than that of scirrhus ; indeed, when pain is observed, it appears to be referable to the organ affected, rather than to the diseased mass itself. The general health fails in many cases of medullary cancer, more rapidly than can be accounted for by the amount of disease. The cachexia thus caused does not appear, hoAvever, to be of any specific constitutional nature, for it often rapidly disappears Avhen the morbid growth is remo\*ed, the patient quickly regaining flesh and strength. The a\erage duration of medullary cancer is decidedly less than that of scirrhus, more than three-fourths of those affected dying within three years, and the expectation of life being, in general terms, not more than a year and a half. Morbid Anatomy___Medullary, or soft cancer is, as its name implies, com- monly a soft, compressible tumor, giving a deceptive feeling of fluctuation, though it is sometimes comparatively firm and elastic, approximating in character to the acute variety of scirrhus. The tumor has a rounded or oval outline, but is often markedly lobated, the lobes extending through muscular, fibrous, or bony interspaces, to a considerable distance from the position of the principal mass. These outlying projections are apt to acquire deep attach- ments, or may surround and inclose important structures, such as the carotid artery, jugular vein, or phrenic nerve. The superficial veins, over a soft cancer, are usually enlarged and tortuous. AVhen a medullary cancer is surrounded Avith a capsule, the latter, which is of thin connective tissue, often sends in septa, Avhich may separate the lobes of the tumor, or, if it be not lobated, merely traverse its substance. The capsule is vascular, tense, and may or may not be adherent to surrounding structures. A\rhen cut into, the contained tumor protrudes, or, if very soft, oozes out like a thick fluid. AVhen laid open, a medullary cancer has com- monly a lobated appearance, the various lobes, with their investing septa, being often distorted by mutual compression, and having the appearance of a mass of cysts filled with intra-cystic growths. The substance of a medullary cancer varies in color, being usually grayish-white, but sometimes tinted Avith yelloAV, pink, or violet. In the softer tumors, it has but little con- sistency, being friable or pulpy, like softened brain-matter, or grumous and shreddy; wliile in the firmer varieties, it is compact and resisting, is some- what glistening on section, and occasionally presents a fibrous appearance. MELANOTIC CANCER. 489 By pressing or scraping a medullary cancer, a considerable quantity of a turbid, creamy "cancer-juice" is obtained, which is readily diffusible in water—the " stroma " which remains being in comparatively small amount, and ap- Fig. 222. are among the chief variations observed in the corpuscular structure of medullary cancers : (1) there may be free nuclei, with few or no cells, scattered through a nebulous or granular basis- substance: the nuclei are usually oval, og1^ to 20W °f an iuch long, bright, Avell defined, and containing large and often double nucleoli; (2) large elon- gated or caudate nuclei, containing granular matter, or one or more large nucleoli; (3) large round or oval nuclei, resembling lymph corpuscles, and containing numerous shining granules, but no distinct nucleoli; (4) Aery numerous elongated and caudated cancer cells, resembling the cells of the recurrent fibroid tumor, and giving the mass a fibrous appearance on section; (5) large round cells, containing granules, and either no perceptible nucleus, or one Avhich is smaller and more granular than that of the ordinary cancer cell; and (6) multi-nucleated cells, or parent cells containing numerous smaller cells. These various forms of cancer corpuscle may simply float in a turbid liquid, which is sometimes called "cancer-serum;" in other cases, this liquid is itself diffused through the interspaces of a spongy basis-sub- stance, Avhich may be homogeneous, may present imbedded nuclei, or may have a fibrilkted appearance ; while in other cases, again, there may be a distinct frameAvork, or skeleton, of delicate filamentous, fibro-cellular, fibrous, or eATen osseous structure. Still further variations in appearance are caused by the occurrence of fatty degeneration, giving rise to yelloAV, scrofulous-looking masses, or by the inter- mingling of cartilaginous, cystic, or other morbid growths. 3. Other Varieties of Cancer__Of the other forms of cancer men- tioned in the classification on page 462, I shall say but little, as they are comparatively rare, and are indeed probably but modifications of those already described. Melanoid or Melanotic Cancer is medullary cancer, with the super-addition of black pigment in the elemental structure of the groAvth ; it bears the same relation to ordinary encephaloid that the pigment or melanotic sarcoma does to the other varieties of that group of tumors (p. 4, 400). Elephantiasis Ara- bum, or Arabian Elephanti- asis, may be described as a hypertrophy of the skin and subcutaneous areolar tissue. In its structure it corresponds Avith the fibro-cellular out- growths described in Chapter XXAI. It is chiefly seen in the scrotum, and in the loAver extremity, where it constitutes the affection knoAvn as Barba- does leg. Its appearances are Avell shoAvn in the annexed cut (Fig. 20G), from a paper by Dr. Isaac Smith, Jr., of Fall RiA'er, Mass. This form of elephantiasis is closely ana- logous to the affections knOAVn Elephantiasis Arabum in the lower extremity ; Barbadoes by modern pathologists as leg. (Smith.) Sclerema or Scleroderma, as well as to that described by Mott and Stokes as Pachydermatocele, the Eiloides of AVarren, the Dermatolysis of Wilson, and the Molluscum, fibrosum of Pollock and Ford. The treatment consists in the use of pressure, ligation of the main artery of the part, excision, or amputation, according to the cir- cumstances of the particular case (see page 470). Diseases of the Lymphatic System. Angeioleucitis or Lymphangeitis (Inflammation of the Lymphatic Vessels, or Absorbents) may occur as an idiopathic affection, as a complication of erysipelas, or as the result of the irritation produced by a wound, ulcer, or local inflammation, as in cases of gonorrhoea. Its occurrence is usually pre- ceded or accompanied by marked constitutional disturbance, rigors, and febrile reaction. If the inflamed lymphatics be superficial, their course will be marked by a number of fine lines, which soon coalesce into a band about an inch wide, of a vivid red color, running from the point at which the disease 506 DISEASES OF MUSCLES AND TENDONS. originates, to or beyond the nearest lymphatic glands, Avhich are ahvavs themselves inflamed. The line of the absorbents is someAvhat dougliy, and not very tender, and the limb is usually SAVollen and often erythematous. If the inflammation affect only the deep lymphatics, the affection of the glands may alone be perceptible. Resolution usually occurs in the course of a Aveek or ten days, though suppuration often takes place in the glands, and some- times in the lymphatics themselves; the prognosis is favorable, though death » may occur from the supervention of erysipelas, pyaemia, or diffuse cellulitis. The only disease Avith Avhich angeioleucitis is likely to be confounded is phlebitis, from Avhich it may be distinguished by observing that the red line in the latter affection has a dusky hue, and gives a peculiar cord-like and knotty sensation to the touch. The local treatment consists in the application of nitrate of sihrer along the line of inflamed lymphatics, so as to blacken Avithout blistering the skin ; the limb may then be Avrapped in carded cotton. Should suppuration threaten, poultices may be employed, and pus evacuated by early incisions. The constitutional treatment consists in the use of saline diaphoretics and anodynes, Avith or Avithout stimulants, according to the general condition of the patient. If erysipelas occur, the tinct. ferri chloridi may be given in combination Avith the liq. ammonii acetatis. Adenitis, or Inflammation of the Lymphatic Glands, ahvays accompanies angeioleucitis, but may also occur independently, as the result of transmitted irritation (as in sympathetic bubo), or of the absorption of morbid matter (as after poisoned Avounds, or in chancroidal bubo), or as the result of direct violence, or of over-exertion in Avalking or otherwise. The so-called bubon d'emblee is, as already mentioned (p. 437), an instance of this form of adenitis. The symptoms of adenitis are those of circumscribed, deep-seated inflamma- tion in general, terminating sometimes in resolution, but more often in sup- puration, or in chronic induration and hypertrophy. The treatment consists in the use of blisters, nitrate of silver, or tincture of iodine, applied around but not over the inflamed gland, Avith poultices and early incisions if suppura- tion ensue, together Avith the administration of anodyne diaphoretics during the acute stage, and tonics, such as cod-liver oil and iron, especially in the form of the iodide, when the affection assumes a chronic form. The lymphatic glands are affected in Tuberculosis, in Scrofula, and in Syphilis, and are frequently the seat of various morbid growths, particularly the adenoid, and those of a malignant nature. The treatment appropriate to these various conditions has already been described in the chapters on the several affections referred to. Varicose Lymphatics__A dilated or varicose condition of the lym- phatic \ressels has been occasionally met with, and may form a troublesome complication in cases of Arabian Elephantiasis. By spotaneous rupture, or accidental Avound, a fistulous opening may be formed, through Avhich the lym- phatic fluid escapes, constituting the disease knoAvn as Lymphorrhcea. The treatment consists in the application of caustic, and in the use of pressure. Diseases of Muscles axd Texdons. Myositis, or Inflammation of the muscular tissue, may occur as a pri- mary affection, as the result of injury, etc., or may be secondary, depending upon various lesions of other structures, especially of the bones and joints. Its symptoms and treatment have already been sufficiently considered in the chapters on Inflammation in general. TENOSYNOVITIS. 507 Patty Degeneration of muscle, is a not infrequent sequence of inflam- mation of the muscular tissue, conjoined Avith long disuse, and may probably in some cases he dependent on the latter cause alone. In some cases, to which the name of interstitial fatty degeneration has been given, the striated character of the muscular fibre is still preserved, the connecting tissue alone being replaced by oily matter ; in other cases the change is more complete, the Avhole muscle being converted into a fatty and granular mass (necrobiotic or intrinsic fatty degeneration). The latter condition appears to depend upon more complete disuse of the muscle than the interstitial form, and is probably incurable. The treatment of the milder cases consists in endeavoring to restore, or at least maintain, the nutrition of the part, by passive exercise, frictions, etc. Rigid Contraction of Muscles__Another consequence of muscular inflammation, especially in persons of a gouty or rheumatic tendency, is rigid contraction of the affected muscle, giving rise to deformity, and often attended Avith much pain. This is most often seen in the sterno-cleido-mastoid and splenius muscles, the rigid contraction of which causes the affection known as stiff or wry-neck. The pelvic muscles also often become contracted as a consequence of hip disease. Rigid muscular contraction may likeAvise result from mere disuse, from long-continued spasm, and from paralysis of opposing muscles. Examples of the two latter conditions are seen in cases of club- foot. AThen rigid contraction persists for a long time, it is accompanied by atrophy and usually by fatty degeneration of the muscular tissue. The treatment of the inflammatory form of the affection consists in the use of stimulating embrocations, and the administration of anodynes, colchicum, iodide of potassium, etc. ; Avhile the more permanent cases require the use of elastic extension, or division of the contracted muscle or its tendon. (See Orthopedic Surgery.) Ricord and others have described a peculiar form of muscular contraction which is dependent upon syphilis ; it is chiefly seen in the biceps, and yields readily to the administration of iodide of potassium. Ossification of Muscle is a rare affection, of Avhich cases haAe been recorded by Abernethy and Hawkins, and which apparently depends on the coincidence of muscular inflammation Avith a tendency to excessive bony deposit. The treatment consists in the repeated application of blisters, with the internal use of colchicum, iodide of potassium, etc. Tumors in Muscle__Akrious forms of tumor occur in muscular tissue, the most important being of the cancerous, fibrous, cystic, and vascular varie- ties. Cartilaginous and osseous tumors are also met Avith, but are compara- thely rare. Hydatids are occasionally found in muscle. The treatment of these various affections is to be conducted on ordinary surgical principles. Excision usually presents no particular difficulties, and, except in the cases of malignant tumor, may be expected to effect a permanent cure. For the can- cerous tumors, unle.-s the case be seen at a very early period, amputation (if the tumor be suitably situated) offers a better chance than excision, and should in most instances be preferred. If, hoAvever, the case be seen at a very early stage, an attempt should be made to preserve the limb, by extirpating the tumor with a Avide margin of healthy tissue. If practicable, the plan sug- gested by Teevan might be adopted, of dissecting out the entire muscle in which the malignant groAvth was seated. Tenosynovitis, or Inflammation of Tendons and their Sheaths or Tltece (Thecitis), not unfrequently occurs as the result of injury, as Avell as 508 DISEASES OF MUSCLES AND TENDONS. in cases of gout or rheumatism. The disease is characterized by the appear- ance of a tender, puffy swelling in the course of the affected tendon, together with a peculiar sensation of fine crackling or dry crepitation, which is best marked when the disease has become chronic. The treatment consists in rest, with the use of stimulating embrocations or blisters. Paronychia or Whitlow (Panaris) consists in inflammation of the flexor tendons and sheaths of the fingers. In the mildest form of the disease, the theca is but slightly, if at all, involved, the inflammation being chiefly confined to the dense subcutaneous tissue of the pulp of the finger, being in fact a mere digital abscess. In the true paronychia, or tendinous whitlow,^ the theca is princTpally affected, suppuration often extending in the course of the tendon beneath the palmar fascia (giv- 237. ing rise to palmar abscess), or even to the forearm, involving, perhaps, the remaining fingers, and causing exten- sive destruction of parts by sloughing. In the Avorst form of the disease, or felon, the phalangeal periosteum is in- volved, often leading to necrosis and exfoliation of considerable portions of bone, Avith destruction of neighboring articulations. The disease commonly originates from some slight puncture Felon. (Liston.) or other injury to the extremity of the finger, and is usually, though not in- variably, confined to the palmar surface. ° Paronychia occasionally occurs as an epidemic, without being traceable to any traumatic cause, and is believed by Erichsen to be uniformly of an erysipelatous nature. The symptoms are those of deep-seated inflammation, with intense throbbing pain and tender- ness, much aggravated by the depending position, and with considerable con- stitutional disturbance. Though suppuration may occur pretty early in the disease, fluctuation is not very apparent, on account of the density of the in- tervening tissues. Gangrene is occasionally, but rarely, met Avith. The treatment consists in the application of leeches, followed by poultices, or by soaking the hand in water as hot as can be borne, together with the internal administration of laxatives and anodyne diaphoretics. If relief do not follow in the course of twenty-four hours, a deep incision should be made on one or both sides of the affected phalanx, so as to relieve tension and evac- uate any pus that may be present. The incision should net be made in the centre of the finger, lest the sheath be opened, when the tendon would almost certainly slough; nor too far towards the side, lest the digital artery be wounded. The incision should be made from above downwards, so that, if the patient withdraw his hand suddenly, he may rather assist than hinder the completion of the operation. If suppuration extend along the sheath of the tendon towards the palm, the surgeon must follow it up with free incisions, re- peated as often as necessary. The strength of the patient must be, at the same time, sustained by the administration of tonics, concentrated food, and stim- ulus. If necrosis occur, the sequestra must be extracted as soon as they are loosened—partial or complete amputation of a finger being occasionally re- quired, though excision of the phalangeal articulations may sometimes be advantageously substituted. By unremitting care and attention on the part of the surgeon, a hand may often be preserved which will prove quite useful, though somewhat stiff and deformed ; but occasionally the destructive process continues in spite of treatment, involving the wrist, and eventually requiring GANGLION. 509 removal of the limb. During the whole after-treatment of a AvhitloAv, the hand should be supported on a broad splint, to keep the parts at rest and pre- vent contraction of the fingers. Some surgeons endeavor to abort AvhitloAv by the application of blisters, tincture of iodine, spirit of camphor, or nitrate of silver; the plan may occa- sionally succeed, but, if it fail, cannot but aggravate the affection. Ganglion___A ganglion is a synovial cyst, developed in connection Avith the sheath of a tendon. Erichsen distinguishes two \arieties, the simple ganglion, Avhich is found on the tendinous sheath, and the com- pound ganglion, which consists of a dilatation of the sheath itself, and Avhich often involves several adjacent tendons. Gan- glia vary in size from a third of an inch to tAvo or more inches in diameter, that of the sim- ple ganglion rarely exceeding three-fourths of an inch. Their shape is round or oval, and they contain a clear fluid, Aarying in consistence from that of se- rum to that of honey, mingled sometimes Avith irregularly- shaped melon-seed-like bodies; these are formed of a compact connecthe substance, and ap- pear to have become separated from the lining Avail of the sheath, Avhich is itself often fringed and A'ascular. Ganglia occur chiefly in connection with the extensor tendons on the back of the hand or wrist, or on the dorsum of the foot, though they are also seen in the palm, extending beneath the annular ligament, or on the side or sole of the foot. They occasion, in some cases, a good deal of pain by pressing on adjacent nerves, and sometimes in- terfere considerably with the motion of the tendons on which they are seated. The presence of the melon-seed-like bodies may be recognized by the occur- rence of a peculiar grating or creaking sound on manipulation. The treatment of the smaller ganglia may consist in rupture by forcible compression Avith the thumbs ; or by a sudden blow, as Avith a book ; or in puncture, and subse- quent compression. If these means fail, the interior of the cyst may be scari- fied, after puncture, Avith the point of a knife; or iodine may be injected ; or a seton established. Excision is attended Avith a good deal of risk—diffuse inflammation sometimes ensuing-^-and should therefore be employed Avith hesitation. For the larger ganglia, and especially those beneath the annular ligament of the wrist, repeated blisters may be employed, in hope of inducing consolidation ; or recourse may be had to iodine injection, or to the seton. If suppuration occur, the cyst must be opened, the melon-seed-like bodies evacuated, if there be any present, and the wound allowed to heal by granu- lation. Excision may be required if the ganglion be of large size and with semi-solid contents. ^ Fig. 238. Compound ganglion. 510 DISEASES OF BURSAS. Diseases of Bursae. Synovial bursre exist normally in certain situations, and may be adventi- tiously developed by continued friction or pressure in other localities. The most important bursa1, in a surgical point of vieAv, are that between the hyoid bone and thyroid cartilage, and those over the acromion, the condyles of the hnmerus, the olecranon, the styloid processes of the radius and ulna, the tuber ischii, the trochanter major, the anterior superior spinous process of the ilium, the patella, the femoral condyles, the tuberosity of the tibia, the malleoli, the heel, and the heads of the first and last metatarsal bones. Bursa' are also met Avith beneath the deltoid and gluteus maximus, between the point of the scapula and the edge of the latissimus dorsi, and in the popliteal space. Bursitis, or Acute Inflammation of a Synovial Bursa, is most frequently seen in the bursa patelle, constituting a variety of the disease ordinarily knoAvn as " Housemaid's Knee," from the fact that women who constantly kneel in scrubbing are peculiarly exposed to the affection. Similarly the enlargement of the bursa over the olecranon is known as "Miner's Elbow." Acute inflammation of a bursa is attended with much pain and considerable constitutional disturbance. The SAvelling is superficial, and in the case of the bursa patellar above the bone—a diagnostic point of some importance, as in inflammation of the joint the patella is floated up by the articular effusion. The treatment consists in the enforcement of rest, with the application of a suitable splint, a few leeches perhaps, evaporating lotions—or poultices and warm fomentations, if more agreeable to the patient—together Avith the ad- ministration of anodyne and sedative diaphoretics. If suppuration occur, a free and early opening must be made, and the case treated as one of abscess. If the incision be delayed, the pus may diffuse itself somewhat widely around the part, necessitating numerous counter-openings. Caries of the patella is an occasional sequence of housemaid's knee, re- quiring the use of the gouge to remove the diseased bone. Sloughing of the bursa may likewise some- times occur, leaving a large ulcer which sloAvly heals by granulation. Simple Enlargement or Dropsy of a Bursa (Hygroma) may result from subacute inflammation, or simply from long-continued pres- sure. This condition in the bursa patelke consti- tutes the true housemaid's knee, and sometimes causes considerable inconvenience by the bulk of the SAvelling. The fluid in these enlarged bursas may be of the ordinary synovial character, or may be of a darker hue, containing cholesterine and disintegrated blood, Avhen it is not unfrequently mixed with numerous rice-like or melon-seed- shaped bodies such as have been described as oc- curring in compound ganglia, and which appear to consist of imperfectly developed connective tissue, formed originally upon the lining Avail of the bursa, and subsequently separated by the friction and constant motion to which the part is subjected. ATirchow and others have observed intra-bursal bands, attached by both ends to the Avail of the tumor. The treatment consists in the application of dis- Enlarged bursa over the pa- tella, the result of pressure; housemaid's knee. (Liston.) BUNION. 511 cutients, such as iodine or blisters ; or in tapping, followed by the injection of iodine ; or by the establishment of a seton—the thread being passed through Fig. 240. Formation of seton with trocar and canula. (Erichsen.) the canula as in Fig. 240. If the bursa contains the rice-like bodies above referred to, they must be evacuated through a tolerably free incision, Avhen the seton may be passed as before. Solid Enlargement of a Bursa is caused by the gradual deposit of organized lymph in the interior of the sac, previously filled with fluid, until the whole or nearly the whole of the cavity is obliterated. A bursa, when cut open under these circumstances, presents a laminated appearance, such as is seen in a partially consolidated aneurism. In some cases, according to Erichsen, the tumor is solid from the first, fibroid matter being primarily de- posited in the bursa. The treatment consists in the use of sorbefacient reme- dies, or, if these fail, in excision—taking care not to injure any neighboring articulation, and, in the case of the bursa patellae, not to open the deep fascia which is attached to that bone, lest the structures of the ham should become involved in suppuration. Annandale has recorded a remarkable case of bony tnmor occupying the situation of the bursa patellae. Bunion___The term bunion is applied to an enlarged bursa occurring in any part of the foot, the most usual seat of the affection being at the side of, or beloAV, the metatarsal joint of the great toe. Bunions appear to be caused by distortion of the foot from Avearing narrow-soled and high-heeled shoes, by which the weight of the body is throAvn forwards, Avhile the toes are crowded together. The distortion consists in the great toe being thrust outAvards, by Avhich means its metatarsal joint becomes prominent—a large corn usually forming over the projection, and either the normal bursa of the part, or one adventitiously developed, becoming enlarged and painful. The bunion is liable to repeated attacks of inflammation, and suppuration may occur, leading perhaps to the formation of a fistulous ulcer, accompanied by a carious condi- tion of the bone and disorganization of the joint, constituting a form of the " perforating ulcer of the foot" of French Avriters. (See p. 503.) The treat- ment consists in the use of poultices or fomentations, followed by the applica- tion of nitrate of silver, to subdue inflammation, together with means adapted to restore the toe to its proper place. This may be best accomplished by the use of Bigg's apparatus (the action of which may be seen from Fig. 211) ; or, in more severe cases, by dividing subcutaneously the external lateral liga- ment of the metatarso-phakngeal joint, or the tendons of the adductor or flexor brevis pollicis. In mild cases, it may be sufficient to protect the part by the application of two or three thicknesses of soap plaster, cut into a horse- shoe form, as recommended by Brodie, and by the adaptation of a loose and well-fitting shoe. If the bunion contains fluid, and is uninflamed, attempts 512 SURGICAL DISEASES OF THE NERVOUS SYSTEM. Fig. 241. Apparatus for the treatment of bunion. to promote absorption may be made by applying an ointment of the red iodide of mercury (gr. x-^j), Avhich is highly recommended by T. Smith. If this fail, subcutaneous puncture and discission of the sac, followed by the external use of iodine, may be tried, and is, according to Gross, as satisfactory as, Avhile it is certainly a safer method than, excision or in- cision Avith cauterization. If suppuration occur, the bunion must be opened, and treated as an abscess. If caries and articular disorganization follow, amputa- tion through the metatarsal bone may be required, and will, I think, in this position, usually be prefer- able to excision either of the joint or of the head of the metatarsal bone—though the former operation has been performed with good results by Kramer, Pancoast, and others, and the latter by several sur- geons, including Hueter, Hamilton, Gay, of Buffalo, and A. Rose, avIio recommend the operation even in cases of simple contraction Avithout caries (hallux valgus). CHAPTEK XXVIII. SURGICAL DISEASES OF THE NERVOUS SYSTEM. The affections of the nervous system which specially demand attention from the surgeon, are Neuritis, Neuroma, Neuralgia, and Tetanus. Neuritis. Neuritis, or inflammation of a nerve, may occur as a consequence of rheu- matism, etc., from exposure to cold, or from Avounds or other injuries. The chief symptoms are pain, extending dowmvards in the course of distribution of the nerve and aggravated by pressure, Avith general febrile disturbance. The line of the nerve is sometimes reddened and swollen, and there may be spasmodic jerking of the muscles of the part, with various reflex phonomena manifested in other portions of the body. The pathological appearances are SAvelling and increased vascularity of the neurilemma, Avith softening of the mucous structure itself. The treatment, in the acute stage, consists in the use of local depletion, with the application of ice or of anodyne and emollient fomen- tations, as most agreeable to the patient, together with laxatives and diapho- retics, if there be much fever. The affected part should be kept in a state of absolute rest, and hypodermic injections of morphia, Avith or Avithout atropia, may be employed if the pain is very intense. Colchicum may be used in cases of rheumatic origin, and iodide of potassium, quinia, etc., with counter- irritation, in those of a subacute or chronic character. Neuroma. Neuromata are tumors developed on or between the fasciculi of a nerve. They are usually fibrous tumors, though a few appear to belong to the fibro NEURALGIA. 513 Section of a neuroma; three nervous trunks terminating in it. The fibrous ar- rangement shown, as observed by the naked eye. (Smith.) cellular variety, a few also containing cysts. Billroth, and other modern patho- logists, divide neuromata into the true and false, the latter being the fibrous or fibro-cellular groAvths commonly found in connection with the nerves, wliile the for- mer, or true neuromata, are " composed entirely of nerve filaments, especially of those with double contours ; they appear to come only on nerves, and are very rare." Billroth is disposed to regard the " amya- line neuromata" of A'irchow as really false neuromata, or, in other Avords, as fibrous tumors. Neuromata are almost exclusively con- fined to the nerves of the cerebro-spinal system,1 are most common in the male sex, and grow slowly, sometimes attaining a Aery large size ; they are commonly mul- tiple, not less than 1200 sometimes coexisting, according to R. VZ. Smith, in the same patient. A neuroma is movable transversely, but not longitudinally on the nerve upon which it is developed. Neuromata may arise spontaneously, or as the result of injury ; they may occur in the continuity of a nerve, or at its cut extremity, as is seen in stumps after amputation (see page 106.) They are often but not always painful, the pain being usually of a paroxysmal character, and sometimes excited only by pressure. In idiopathic neuroma, the pain is referred almost exclusively to the peripheral distribution of the nerve, but in traumatic cases, is frequently felt in other parts, as a reflex phenomenon. AVhen present in very large numbers, neuromata are, fortu- nately, usually painless. The painful subcutaneous tubercle is believed by many Avriters to be a " true neuroma" (see page 478). It is advised by Brown-Sequard, that, in examining a neuroma, the nerve should be firmly compressed above the tumor, so as to diminish the pain caused by the neces- sary manipulations. The treatment consists in extirpation of the tumor, wliich should, if possible, be dissected from the nerve Avithout dividing the latter; if this cannot be done, Notta's plan might be followed, and the cut ends of the nerve approximated by means of a suture (see page 20(5). For the treatment of neuromata in stumps, see page 106. In cases of multiple neuromata, operative interference can seldom be justifiable, but under such circumstances a trial may be given to electro-puncture, or the hypodermic use of morphia may be resorted to as a palliative measure. Prof. Kosinsky, a Gorman surgeon, and Drs. Duhring and Maury, of this city, have, however, reported remarkable cases of multiple painful neuromata of the skin, in Avhich temporary relief Avas afforded by excision of the nerves of the affected parts. Neuralgia. Neuralgia is an affection of the nervous system, characterized by intense pain of a paroxysmal form, usually referred to the course of particular nerves. Any discussion as to the nature and pathology of neuralgia in general, would be out of place in a Avork such as this, and I shall therefore consider merely those forms of the disease Avhich come particularly under the notice of the 1 The "plexiform neuroma," however (a name given by Verneuil), has been found in the solar plexus. 33 514 SURGICAL DISEASES OF THE NERVOUS SYSTEM. surgeon. Neuralgia occurs usually in persons avIio are debilitated, and ia predisposed to by various depressing causes, such as exposure to miasmatic influence, etc. It frequently coexists with hysteria, and not seldom Avith anaemia. It may be excited by some source of local irritation, as a decayed tooth, piece of necrosed bone, or exostosis, or may be a reflex phenomenon from irritation of another part, as in the toothache of pregnancy. The pain of neuralgia may follow accurately the course and distribution of a nerve, or may be felt over a considerable extent of surface, or in particular organs, such as the breasts, testes, or articulations—as in the cases of so-called " hys- terical knee-joint." The pain may begin suddenly, or may come on grad- ually, and is, in different cases, of every Aariety of character and intensity; it is ahvays paroxysmal, and often absolutely intermittent, and is uniformly aggravated by the supervention of any additional source of depression. There are almost always tender spots (points douloureux) in the course of the affected nerve, particularly where it penetrates a fascia, or emerges from a bony canal, and very constantly there is tenderness over the spinous pro- cesses of those vertebrae which correspond to the part of the spinal cord whence the nerve originates. Another peculiarity of neuralgic pain is that it is almost ahvays unilateral. Neuralgia is sometimes accompanied with spasm of the muscles supplied by the affected nerve ; in other cases the sur- face becomes red, hot, and even slightly swollen, and there is often an in- creased secretion from neighboring glands, as the salivary or lachrymal. Though any part of the body may be affected by neuralgia, its most frequent seats are the branches of the fifth pair of cerebral nerves, and the great sciatic ; in the former situation it constitutes the disease known as " tic dou- loureux." The diagnosis is usually sufficiently easy: from inflammatory pain, neu- ralgia may be distinguished by its paroxysmal character, by the absence of fever, by the superficial nature of the pain (often accompanied with marked cutaneous hyperaesthesia), and by its being relieA'ed rather than aggravated by pressure; if, hoivever, as sometimes happens, neuralgia coexist with deep-seated inflammation, it may be extremely difficult to decide how much of the pain felt is to be attributed to one, and how much to the other affec- tion. In cases of neuralgia affecting the joints, the diagnosis may be assisted by remembering that organic disease cannot long exist in an articulation Avithout causing deformity or other physical alteration. The prognosis of neuralgia, as regards life, is usually favorable : the disease, however, is often very intractable, and may cause so much suffering as to render existence almost insupportable. The treatment must be both general and local. As the disease is almost always accompanied by debility, tonics are usually required : having first cleared out the bowels by means of a cathartic, the surgeon may begin at once the use of quinia, in doses of four grains, three or four times a day ; this drug, though particularly serviceable in cases of malarial origin, is adapted to all cases of neuralgia in which the paroxysmal clement is marked. Ar- senic is another remedy of great value, and may be given in the form of arsenious acid, or of Fowler's solution. Iron is particularly adapted to anaemic cases, and valerianate of zinc and assafoetida, to those which are com- plicated with hysteria. Advantage may often be derived from sea-bathing, or from the systematic employment of electricity, the cold douche, etc. In cases in which there is nocturnal exacerbation, the iodide of potassium is found a valuable remedy. The local treatment consists in the application of sedatives or counter-irritants, and, in certain cases, in excision of a portion of the affected nerve. Chloroform and aconite liniments, and the Aeratria ointment, are among the most useful applications, but the hypodermic injec- NEURALGIA. 515 tion of morphia is unquestionably the most powerful means we possess for controlling neuralgic pain: from eight to fifteen minims of Magendie's solu- tion may be used at a time, the injection being repeated in the course of three or four hours if the pain is not relieA^ed. Advantage may be sometimes derived from the simultaneous administration, by the hypodermic method, of morphia and atropia. A quarter of a grain of the former with a thirtieth of a grain of the latter may be used, great care being exercised lest a poisonous effect be induced. Chloroform, carbolic acid, and nitrate of silver have also been employed hypodermically Avith advantage in some cases. Excision of a Portion of the Affected Nerve has been not unfrequently practised in cases of neuralgia affecting branches of the fifth pair, and occa- sionally Avith the happiest results. In many cases, hoAvever, the relief has proved but temporary, the pain recurring after an interval of a few Aveeks or months, in the same or another branch. The Infra-orbital and Mental'Nerves may be reached by simply cutting doAvn at their points of exit from the infra- orbital or mental foramina, the nerves being then isolated and a portion excised. The Inferior Dental Nerve may be reached by raising a semilunar flap from over the ramus of the lower jaAv, and exposing the dental canal by means of a trephine; the nerve is then picked up with a blunt hook or di- rector, and a portion of it excised. Prof. Gross has, by repeated applications of the trephine, succeeded in exposing and removing the Avhole extent of the nerve, from its entrance into the inferior dental canal to its exit at the chin— the portions of nerve thus exsected varying in length, in different cases, from two and a half to three inches, and the operation having been apparently fol- loAved by the best results. Paravicini, Mosetig-Moorhof, Michel, and Ter- rillon, recommend an intra-buccal section of the nerve, Avhich, however, appears to me more difficult and less satisfactory than the ordinary mode of procedure. The buccal branch of the inferior maxillary nerve has been divided from without by Michel, Letievant, and Valette, and from within by Nekton and Panas. The Superior Maxillary Nerve may be reached, close to the foramen rotundum, by means of a Y-shaped or simple curved incision, both Avails of the antrum being cut away with the trephine, and the lower Avail of the infra-orbital canal Avith cutting-pliers and chisels. The nerve being separated from the other tissues in the spheno-maxillary fossa, and traced beyond the Ganglion of Meckel, is divided from below upAvards with blunt-pointed, curved scissors. This bold and severe operation, Avhich Avas introduced by Carnochan, of NeAv York, has been at least temporarily suc- cessful in several instances ; but that the relief is not permanent, would appear from the researches of Conner, of Cincinnati, avIio has collected thir- teen cases, in seven of which the pain is known to have recurred, Avhile in only two of the remainder Avas the subsequent history of the patient traced for more than a year. Neurotomy of the median, musculo-spiral, and other nerves of the ex- tremities, has been practised by A'arious surgeons, including Sapolini, Brinton, Morton, Hodge, and myself, with at least temporary benefit. If the neuralgia arise from peripheral irritation, so that the affected portion of the nerve can be removed, an operation such as those Avhich have been described, may probably suffice for a cure ; if, hoAvever, the disease be of cen- tral origin, it is obvious that no operation can be of permanent benefit. AArhen neurotomy is in any case resorted to, at least two inches of the affected nerve should, if possible, be removed, and care should be taken that the upper section is made through healthy structure ; to prevent reunion, Dr. Mitchell approves Malgaigne's suggestion, that the distal end of the cut nerve should be doubled upon itself. It is almost needless to say that if the neu- ralgia appear to depend upon the irritation caused by a decayed tooth, or by 516 SURGICAL DISEASES OF THE NERVOUS SYSTEM. a spicula of necrosed bone, the effect of removing this should be tried before proceeding to any graver operation. Prof. Gross has described a form of neuralgia depending upon a morbid condition of the alveolus, and curable by removing that part with cutting-forceps, and Drs. T. G. Morton and E. Mason have cured neuralgia of the metatarso-phalangeal joints by excision of the articulation. The operation of stretching nerves for neuralgia of traumatic origin has already been referred to at page 206. Ligation of the common carotid artery, in cases of facial neuralgia, is advised by AVeinlecher and Patruban. Tetanus. Tetanus is a disease of the nervous system, characterized by persistent tonic contraction of some or all of the voluntary muscles. In the large ma- jority of cases tetanus results from a wound, or is traumatic, though it is also met Avith (especially in Avarm climates) as an idiopathic affection. Tetanus occurs in both sexes and at all ages ; excluding, however, cases of Puerperal Tetanus, and of Tetanus Nascentium (which according to Parrot has much closer analogies with uraemic ecclampsia1 than with true tetanus), it is by far most common in males in early adult life, though, probably, not dispropor- tionately so, in view of the peculiar liability of these to be exposed to trau- matic lesions. It occasionally occurs as an epidemic, and appears to be predisposed to by hot weather and by sudden changes of temperature. It is more frequent in the negro than in the white. Traumatic tetanus is the form of the disease Avhich particularly demands the surgeon's attention. It may follow upon a mere contusion, such as the stroke of a Avhip, but is chiefly seen after punctured or lacerated wounds, or after burns and scalds ; the extent of the wound appears to have no causative influence, the slightest being as often followed by tetanus as the most extensh'e injuries. It may occur after any surgical operation, without regard to its severity. Tetanus is more frequently met with in military than in civil practice, the proportion of cases in {he Peninsular war having been 1 of tetanus to 200 wounded, in the Crimean Avar 1 to 500, in the Schleswig-Holstein campaign 1 to 350, and in our late war 1 to 212.2 Exposure of the wounded to severe cold, and more particu- larly a sudden change from heat to cold, has been found a prolific source of tetanus in military surgery. The disease is apt to occur in those who are depressed or debilitated; it thus seems occasionally to follow in the Avake of secondary hemorrhage. Varieties___Several varieties of tetanus ha\~e been distinguished, accord- ing to the group of muscles affected: thus, Trismus, or Lock-jaw, refers to the clenching of the teeth, from tonic spasm of the muscles of mastication ; Opisthotonos, to spasm of the muscles of the back, the patient with arched body resting merely on head and heels; Emprosthotonos (very rare), to a similar arching of the body in a forward direction ; and riglit or left Pleuros- thotonos, to a similar bending to one or the other side. Tetanus may occur very soon, even less than an hour, after the reception of a wound, or not for several Aveeks; usually, in temperate climates, from the fifth to the tenth day. The earlier the disease is developed, the more likely is it to prove fatal, cases occurring after the third week offering a comparatively favorable prognosis. Acute tetanus is much more fatal than the chronic form of the disease: of 1 According, however, to Marion Sims and P. A. AVilbite, of South Carolina, tetanus nascentium is a traumatic affection resulting from displacement of the occipital or of one of tbe parietal bones. 2 363 cases to 87,822 wounded. (Circular No. 6, S. G. 0., 1865, p. 6.) PATHOLOGY OF TETANUS. 517 327 cases of death from tetanus, analyzed by Poland, 79 occurred within two days, 104 in from two to five days, 90 in from five to ten days, 43 in from ten to tAventy-tAvo days, and 11 after twenty-two days. The most rapid death occurred in from four to five hours, while the longest duration of a fatal case Avas thirty-nine days. Symptoms—The symptoms of tetanus may come on suddenly, or may be gradually and insidiously developed ; occasionally a feeling of general dis- comfort precedes for some time the characteristic manifestations of the disease, or there may be gastric and intestinal derangement, or the wound (if it have not healed) may become dry and unhealthy-looking. The first decided symptom is commonly a feeling of stiffness, Avith pain on motion, affecting the muscles of the loAver ja\v and tongue, and those of the back of the neck ; in other cases, however, the cramps are first manifested in the muscles of the wounded limb. In a short time, great difficulty in cheAving or sAvallowing is felt, and trismus soon becomes fully developed, with intense pain and slight tendency to opisthotonos; violent pain reaching from the precordial region to the spine, and doubtless due to spasm of the diaphragm, is now experienced, and forms a very characteristic symptom of the disease ; the abdominal mus- cles become tense, hard, and board-like, and all the Aoluntary muscles, except those of the hand, eyeball, and tongue, become more or less involved. The countenance assumes a peculiar, old-looking expression, being pale, anxious, and distorted into the so-called risus sardonicus or tetanic grin. This dis- tortion of face sometimes persists after recovery, and Poland refers to a case in which it Avas still apparent after eleven years. During the height of the disease, the body is often arched backwards, so that the patient is supported merely by his occiput and heels; Avhile the muscular spasm is tonic, and never entirely disappears, it is paroxysmally aggravated—and the cramps are occa- sionally so violent as almost to hurl the patient from his bed ; the pain is greatest during the cramps, which are also accompanied by profuse perspira- tion and great heat of skin (105°-110.75° Fahr., according to Dr. Radcliffe).1 As the disease advances, the reflex excitability is much increased, the slightest touch or the least current of air being sometimes enough to bring on a paroxysm of cramp. Dyspnoea and Avant of sleep combine to render the condition of the patient still more deplorable. There is no delirium, and little or no fever, the heat of the skin being chiefly confined to the paroyxsms, and the rapidity of the pulse being due to exhaustion rather than to febrile disturbance. Among the symptoms of less importance are constipation, retention of urine, priapism (probably due to spinal meningitis), aphonia, accumulation in the mouth and fauces of viscid saliva, self-inflicted lacerations of the tongue or cheek, and permanently dilated or contracted pupils. Death may occur in a paroxysm, from apnoea ; or, at a later period, from simple exhaustion. There may be a certain degree of muscular relaxation previous to death, or tetanic rigidity may be, as it Avere, directly transformed into rigor mortis. Pathology___The pathology of tetanus is involved in much obscurity. I have called it a disease of the ner\ous system, because it is through the medium of the nerves and spinal cord that its phenomena are manifested, and because the nervous system alone has as yet been found to present post- mortem changes with sufficient constancy to be considered significant. It is, 1 The temperature may continue to rise even after death; thus, in a case recorded by Wunderlich, the thermometer marked 108° before death, 112.5° at the time of death, and 113.5° a short time subsequently. Dr. Ogle, of London, and Dr. Keen, of this city, have recorded cases in which the evening was higher than the morning temperature. 518 SURGICAL DISEASES OF THE NERVOUS SYSTEM. however, quite possible that, as suggested by Travers, J. A. AA'ilson, Richard- son, and others, tetanus may eventually prove to be a blood disease, due to the absorption of some septic material. The nerve or nerves, in the imme- diate neighborhood of the wound, are commonly, though not invariably, found to be inflamed, lacerated, or contused, and it is at least possible that, even in those cases in which the nerves appear healthy, they may have been temporarily diseased, and that a nerve lesion has been really the starting- point of the affection. The muscles have frequently been found ruptured, and are, according to L. Conor, the seat of granular and fatty changes such as have been observed in cases of typhoid fever. Duclaux has seen tetanus prove fatal through rupture of the heart. The most important post-mortem changes of tetanus are found in the spinal cord, and have been particularly investigated by Lockhart Clarke, Dickinson, Charcot and Michaud, Aufrecht, and Coats, of Glasgow. The former writer ascertained, from an examination of six specimens, that there were, in several portions of the cord, marked patches of softening and disintegration affecting the gray matter, the cord itself being altered in shape. The structural change varied from mere gran- ular softening to absolute fluidity, and was accompanied by numerous extrava- sations of blood. " In the Avails of the bloodvessels, there was no morbid deposit nor any appreciable alteration of structure, except Avhere they shared in the disintegration of the part to Avhich they belonged ; but the arteries were frequently dilated at short intervals, and in many places were seen to be surrounded ... by granular and other exudations, beyond and amongst which the nerve-tissue . . . had suffered disintegration. We have reason, therefore, to infer that the lesions of structure had their origin in a morbid condition of the bloodvessels, resulting in exudations with impairment of the nutritive process."1 The folloAving are Mr. Clarke's conclusions as to the pathology of tetanus: (1) it is probable that these lesions are not present in cases Avhich recover, or, if present, are so in but a slight degree ; (2) these lesions are not the effect of excessive functional activity of the cord, but result from a morbid state of the bloodvessels ; (3) these lesions are not the sole cause of the te- tanic spasms, as similar lesions exist in cases of paralysis unaccompanied by tetanus ; and (4) the tetanic spasms depend, first on an abnormally excitable state of the gray nerve-tissue of the cord, induced by the hyperaemic and morbid state of its bloodvessels, with the exudations and disintegrations re- sulting therefrom (this state of the cord being either an extension of a similar state along the injured nerves from the periphery, or resulting from reflex \ action on its bloodvessels excited by those nerves), and secondly, on the per- sistent irritation of the peripheral nerves, by Avhich the exalted excitability of the cord is aroused—the same cause thus first inducing the morbid suscep- tibility of the cord to reflex action, and subsequently furnishing the irritation by which reflex action is excited. Dr. Dickinson's2 observations tend to confirm those of Mr. Clarke, and add the interesting fact that the situations of the various lesions correspond ana- tomically Avith the side on which the injury exists. " The irritation from the left hand, conveyed, as we must suppose, by certain of the left posterior roots, occasioned especial congestion of the left posterior horn, and further changes in the Avhite matter in contact with it—that is, in the left posterior and lateral columns. The central and anterior parts of the gray matter were most extensively affected on the side opposite to that of the injury, as might have been anticipated from the decussation in the cord of the sensory fibres. 1 Med.-Chir. Trans., vol. xlviii., p. 264. 2 Ibid., vol. li., pp. 265-275. TREATMENT OF TETANUS. 519 The irritation having reached any column or sagment of the cord, appeired to diffuse itself throughout its whole length Avith undiminished intensity. Although the cervical region must have been the first recipient of the morbid influence, the lumbar part of the cord, both in the Avhite and gray matter, Avas at least as severely affected." Charcot and Alichaud note the same appear- ances that are described by Lockhart Clarke, but believe them to be due to exudation from the bloodvessels, and not to degenerative changes. It is in the posterior commissure of the gray matter of the cord, and especially in the lumbar region, that they have found Avhat they regard as the " essential alteration" of tetanus ; this consists in the development of a large number of nuclei Avhich are variously disposed, and many of which are flattened from mutual compression ; the changes are in fact the same as, though perhaps more marked than, those described by Fromman as occurring in cases of subacute myelitis. Coats has observed the morbid changes in the medulla oblongata, as Avell as in other portions of the spinal cord. Ringer and Mur- rell controvert the ordinary view that tetanus is due to increased excitability of the spinal cord, and believe that it is due to a diminished " resistance" of the cord, Avhich allows impressions conveyed by the afferent nerves to spread through the reflex portion of the central nervous system. Diagnosis___Tetanus may be distinguished from spinal meningitis by the early fixation of the jaAV, and by the occurrence of paroxysmal spasms, with permanent muscular rigidity in the intervals—the rigidity of spinal me- ningitis being, in a great degree, voluntarily assumed in order to prevent pain of motion. From hydrophobia, the diagnosis may be made by observing that, in the latter disease, the spasmodic movements are clonic, not tonic, that the face is convulsed and restless (no risus sardonicus), and that deli- rium is as common as it is rare in tetanus. From poisoning by strychnia, the diagnosis is sometimes very difficult, particularly if comparatively small quantities of that drug have been repeatedly administered. It is to be ob- served, hoAvever, that in strychnia-poisoning there maybe complete intermis- sions between the paroxysms, and that (according to Poland) there is spasm of the muscles of respiration, Avith early and marked laryngismus, but no fix- ation of the jaAv—the patient being able to open the mouth and SAvallow. Tetanus has been mistaken for rheumatism, and, on the other hand, hysteria has not unfrequently been mistaken for tetanus; the diagnosis could, however, scarcely be very difficult, unless (as in a case mentioned by Copland) tetanus and hysteria actually coexisted in the same patient. Prognosis___The prognosis of acute tetanus is invariably unfavorable. It is doubtful whether there be any authentic case of recovery under such circumstances. In the subacute or chronic cases, the disease being developed at a comparatively late period, and running a less violent course, there is more hope of a successful issue, and by prompt treatment life may occasion- ally be preserved. It may be said in general terms that the later the develop- ment of the disease, the more chance is there of recovery. Treatment___This should be both general and local. The General Treatment should consist in the administration of such remedies as may diminish the morbid excitability of the spinal cord, and at the same time lessen the irritation of the peripheral nerves—it being probably to a combi- nation of these tAvo elements, that the production of the tetanic spasm is due. At the same time, concentrated nutriment in a fluid form should be given as freely as practicable, for death frequently results, as has been seen, from pure exhaustion. The modes of treatment which have been proposed for tetanus 520 SURGICAL DISEASES OF THE NERVOUS SYSTEM. are almost countless, including such diverse remedies as venesection, active stimulation, profuse purgation, and the induction of narcotism with opium. All means fail in acute cases—each has been occasionally successful in those of the chronic variety. The drugs Avhich have obtained most reputation of late years, have been opium, conium,1 belladonna, cannabis Indica, woorara, bromide of potassium, hydrate of chloral, and the Calabar bean. Of these the first and the two last are those upon Avhich I should, at present, be dis- posed to place most reliance, and of Avhich I Avould therefore recommend the employment. Eighteen cases collected by Dr. Eben AAktson, in Avhich the Calabar bean Avas used, gave ten recoveries and eight deaths ; upon the whole, a favorable record. The bean may be given in large doses (Holt- house gave 4^ grains of the extract at once, the patient recovering), the only limit to its administration being the effect produced in controlling the spasms. It appears to act as a direct sedative to the spinal cord, and it has the addi- tional advantage that it enables the patient Avhile under its influence to take food Avith facility. It may be given by the mouth or rectum, or by hypo- dermic injection, a third of a grain of the extract being probably a large enough dose for the latter mode of administration. Opium in large doses may be properly given at the same time, as suggested by Holthouse, on ac- count of its Avell-known sedative effect upon the jieripheral nerves. Demar- quay recommends the hypodermic injection of morphia into the masseter, or Avhatever muscle may be chiefly affected. A cathartic may sometimes be required at the beginning of the treatment, to remove any irritating matters from the boAvels, and concentrated food and stimulus must be given, through- out the case, in as large quantities as the patient can be induced to take. The inhalation of ether or chloroform may be occasionally resorted to with temporary benefit, and the application of an ice-bag to the spine might be tried, though its use should be watched, lest it induce too great depression. Tracheotomy has occasionally been resorted to, and, according to Richet, may be expected to be of service Avhen spasm occurs in expiration. The inhalation of nitrite of amyl has been successfully employed by Foster, Curtis, Funkel, and Forbes, of this city. The Local Treatment is likewise of importance : the wound should be ex- plored, and any foreign bodies carefully removed. The afferent nerve or nerves (if any can be recognized) should be divided or partially excised, or, if the operation be otherwise indicated, amputation may be performed, if a limb be the seat of injury. Nerve-stretching, as suggested by Niissbaum and Callender, has been successfully resorted to by Arerneuil, A'ogt, and other sur- geons, but in my OAvn hands, as in those of AVatson, has failed to give even temporary relief. Though section of the nerve will promise best if resorted to at an early period, it should not be neglected even at a later stage of the case. If no special nerve-lesion can be detected, a \ incision down to the bone may be made, as advised by Liston and Erichsen, so as to insulate the part. The Avound itself should be dressed with narcotics—particularly opium, in the form of laudanum, or a solution of sulphate of morphia (gr. v-f^j), or, if the wound is sloughing, poAvdered opium with charcoal OJ-Sj)—and in cases of burn or scald, this Avill often be the only local treatment which can be employed. The application of atropia to the end of the divided nerve, or by hypodermic injection, has occasionally been found useful. If the Avound Avere already healed, it would be proper to dissect out the cicatrix, as the entanglement of a nerve filament in the scar might prove to have been the starting-point of the disease. 1 Hypodermic injections of conia have been used Avith some success by Prof. C. Johnston, of Maryland. DISEASES OF VEINS. 521 Laurent has collected 54 cases of operation for the relief of tetanus, with 29 recoveries, classified as follows : neurotomy, 13 cases and 7 recoveries ; minor amputation, 17 cases and 11 recoveries; and major amputation, 24 cases and 11 recoveries. Letievant reports 16 neurotomies with 10 recov- eries. But, as justly remarked by E. Labbee, the recoAeries have usually been in chronic cases, in which equally good results may often be obtained by internal treatment alone. During the Avhole course of treatment, the patient should be kept in a rather dark, warm, and dry room, and should be carefully guarded from cur- rents of air. CHAPTER XXIX. SURGICAL DISEASES OF THE VASCULAR SYSTEM. Diseases of Veixs. Phlebitis___Phlebitis, or Inflammation of a Vein, may result from in- jury, or from the absorption of septic material. It is probably (as mentioned at page 170) by means of local inflammatory changes, in conjunction with coagulation of the contained blood, that veins are repaired after division or rupture ; and this clotting or thrombosis of the venous contents, is the most important element in connection with inflammation of a vein. It may be either a primary or a secondary phenomenon, either the cause or the conse- quence of the changes in the venous coats, to which the term phlebitis is applied; thus the phlebitis of pyaemia, and that seen after parturition (phleg- masia dolens), are the results of previous venous coagulation, while in many cases of lacerated wound, fracture, etc., the changes in the venous walls pro- bably precede the formation of a clot. It is in the outer coats of a vein, according to H. Lee,1 who has particularly investigated the subject, that the changes of phlebitis are chiefly found. The cellular coat becomes preter- naturally vascular and reddened, and is at the same time distended Avith serum, lymph, or pus, either separately or commingled. The circular fibrous coat is similarly affected, but in a less degree, becoming injected and thick- ened. The inner coat loses its normal transparency, becoming Avrinkled or fissured, of a dull Avhitish color, and more or less stained by the venous contents, its hue Allying with that of the contained coagulum. The inner and outer coats of an inflamed A^ein may be separated by the products of in- flammation, the various layers of the inner coat becoming disintegrated, or flakes of its lining membrane being cast off into the interior of the vessel. Phlebitis destroys the natural pliability of the venous coats, so that, Avhen divided, an inflamed vein remains patulous like an artery. The formation of a clot in an inflamed Arein, is caused, as pointed out by Schmidt, by the union of tAvo substances ahvays found in the blood, which he calls fibrinogen and fibrinoplastin; it is obviously designed by nature to prevent the entrance of morbid materials into the general circulation, and hence, when the clot is well formed, and in a healthy person, the disease is local and unattended with any particular danger. Dr. Nancrede, of this city, has ingeniously suggested that the extension of the clot depends upon the communication of lateral veins bringing fibrinogenetic material which results ' Practical Pathology, vol. i., Lectures II.-IV. 522 SURGICAL DISEASES OF THE VASCULAR SYSTEM. from the disintegration of tissue, and that hence Avhen, in traumatic cases, the clot has reached beyond the point at which veins carrying such impure blood from the seat of disease reach the main cliannel, the process of coagulation is arrested. The clot undergoes changes, becoming partially organized, and converting the vessel into a fibro-cellular cord ; or may contract so as to alloAv the partial resumption of the circulation ; or may perhaps undergo a sIoav process of solution, and ultimately entirely disappear. Under other circum- stances, the result is not so favorable: a large fragment of clot may become mechanically loosened and dislodged, and, being carried into the general cir- culation, may plug an important vessel (embolism), occasionally even causing a fatal termination, as has happened in cases of phlegmasia dolens; or, if the blood be in an unhealthy condition (as in pyaemia), and the clot imperfectly formed, disintegration may follow, with capillary embolism, leading to the formation of pyaemic patches, or the so-called metastatic abscesses (see page 408). Symptoms___An inflamed vein becomes hard, somewhat swollen, painful, and cord-like; it has, besides, a peculiar knobbed feel and appearance, the knobs corresponding to the positions of its valves. The course of the vein is marked by a distinct, dusky-red line, and the whole limb becomes somewhat stiff, and may be the seat of intense pain, sometimes of an intermittent or neuralgic character. There is always some oedema, along the course of the vein and in the parts below, owing to the obstructed circulation and the con- sequent effusion of the fluid portion of the blood. This oedema may be soft, allowing pitting on pressure, or may be hard and tense. If the vein be deep- seated, the occurrence of tumefaction and pain may be the only evidences of phlebitis. The oedema usually subsides with the restoration of the circulation through the natural or collateral channels, though it may persist for a con- siderable period. The constitutional disturbance attending phlebitis is rarely of a grave character. The conditions described by many writers as suppurative and diffuse phle- bitis appear to be really examples of diffuse inflammation of the areolar tis- sue, or of cellular erysipelas, wliich often extend rapidly in the course of the veins, and which are apt to terminate in pyaemia. (See pages 385, 400, 407, and 505.) Diagnosis.—The affection with which phlebitis is most likely to be con- founded is angeioleucitis, which, however, may be distinguished by observing the brighter redness Avhich it presents, and its invariable complication Avith adenitis. Deep-seated phlebitis may be mistaken for neuralgia, but the diagnosis may be made by observing that the pain of the latter affection is rather relieved than aggravated by pressure, and is not accompanied by oedema. The latter circumstance may also serve to distinguish inflammation of a vein from neuritis. Prognosis—Phlebitis in itself is rarely attended with risk to life; Avhen, however, inflammation of a vein is a mere concomitant of pyaemia, or other grave constitutional condition, the question is very different; and even trau- matic phlebitis, occurring in a person who is broken down in health, should be looked upon as a grave affection. Treatment—In the treatment of phlebitis, all depressing measures should be avoided, the chief risk of the affection being from deterioration of the general health and consequent disintegration of the venous coagulum. If the tongue be heavily coated, with fever and anorexia, half a grain of blue mass witb tAvo grains of quinia may be given every tAvo or three hours, until about three grains of the mercurial have been taken, hut beyond this, the remedy should not, usually, be pushed. The quinia may be continued, eight or VARICOSE VEINS. 523 tAvelve grains being given in the course of twenty-four hours; and the muri- ated tincture of iron may be added, in combination Avith the spirit of Minde- rerus if the use of a diaphoretic be indicated. In milder cases, of course, less energetic measures will be required. The diet should be nutritious and easily assimilable, and stimulus may be given or withheld, according to the general condition of the patient, who should be kept in bed and at perfect rest. The local treatment, in mild cases, may consist merely in the use of warm fomen- tations or evaporating lotions, as mo9t agreeable to the patient; but if the -inflammation appear disposed to extend upwards, with severe constitutional disturbance, an effort may be made to prevent its spread by the operation proposed by H. Lee, which consists in acupressing a healthy portion of the vein at two points about three-fourths of an inch apart, and then dividing the vessel subcutaneously betAveen them. The oedema may be relieved by position, by gentle friction, and by the subsequent use of an elastic bandage. Varix, Varicose Vein, or Phlebectasis, consists in a morbid dila- tation of a vein, usually accompanied by thickening of its walls. Any veins may become A'aricose, but those most commonly affected are the veins of the lower extremity, scrotum, and rectum. The varicose condition may be limited to the principal venous trunks of the part, or may affect the subcuta- neous venous plexus, giving the appearance of a netAvork of a purple hue. The branches of the internal saphena are most frequently affected among the superficial veins, but it is probable that in the majority of cases the deep vessels are likewise more or less in\rolved. The anatomical conditions of varicose veins vary in different cases: thus, together Avith the dilatation, there is often elongation, rendering the vessel tortuous; or the walls may be thinned instead of thickened; or the dilatation may be sacculated, forming pouches Avhich generally correspond to the points of intercommunication with other veins. The causes of varicose veins are twofold: (1) such as pump into the veins an abnormal quantity of blood, as unusual muscular exertion, walking, etc.; and (2) such as mechanically impede the venous circulation, as the pressure of a tumor, or that of the pregnant uterus. A depressed or feeble state of health appears sometimes to act as a predisposing cause, Avhile in some cases, the occurrence of varicosity has been attributed to the effect of hereditary influence. Any occupation which requires the maintenance of the erect posture, predisposes to varix. Varicose veins are rare in early life, and are rather more frequent in women than in men. The symptoms of superficial varix are easily recognized, the dilated and tortuous condition of the affected veins being quite characteristic. The patient often has a sensa- tion of weight and fulness in the part, with some numbness, and occasionally loss of power, and frequently a dull, aching pain Avhich is aggravated by exercise. The limb is sometimes oedematous. Deep varix is more difficult of recognition, the subjective symptoms commonly existing for some time before the implication of the superficial veins renders the nature of the dis- ease apparent. Muscular cramps are, according to Mr. Gay, quite signifi- cant of a varicose condition of the deeper veins. Akricose veins are liable to be attacked by phlebitis and thrombosis, while inflammation of the surround- ing tissues may lead to various troublesome conditions, such as the occurrence of eczema, or of ulceration (giving rise to the varicose ulcer), or to a sclere- matous condition of the part analogous to the Arabian elephantiasis. A varicose vein occasionally gives way by rupture or by ulceration, the accident leading to profuse, or even to fatal, hemorrhage. The Treatment of varicose veins may be either palliative or radical, the 521 SURGICAL DISEASES OF THE VASCULAR SYSTEM. former being alone proper in the large majority of cases. The Palliative Treatment consists in giving support to the part, Avith gentle and equable pressure, by means of a carefully applied flannel bandage, or an elastic stock- ing—the general health being maintained by the use of laxatives to prevent constipation, with tonics, especially the muriated tincture of iron, if, as usually happens, the patient be in a feeble and relaxed condition. Hemorrhage from a varicose vein may be checked by elevating the limb and applying a firm compress. The Radical Treatment may be employed, if the varicose a ein Fig. 243. Application of pins to varicose veins. (Miller.) be evidently so altered in structure as to be useless for carrying on the circu- lation (particularly if it be also painful), if its coats be so attenuated as to threaten hemorrhage, or if it be connected with an ulcer which cannot be induced to heal. This mode of treatment consists in the obliteration of a portion of the vein, and it is radical as far as that portion is concerned, though it by no means insures a cure of the general disease, Avhich, indeed, in most instances, must be looked upon as incurable. Various means have been proposed for the obliteration of varicose veins, such as (1) the applica- tion of caustic, so as to form eschars over the line of the vessel, or, as recently suggested by Linon, the application of a strong solution of the sulphate of iron; (2) the injection of coagulating agents (chloral is particularly'recom- mended by Porta, and other Italian surgeons); (3) the hypodermic injection of ergotin or alcohol; (4) the passage of an electric current through the vessel; (5) the subcutaneous section of the vein; (6) its compression at various points by means of a pin passed beneath the vessel, with a compress or piece of bougie above, the two being fastened together Avith a thread, or wire, in the form of a figure-of-8 (Fig. 243) ; (7) the application of a metallic ligature; (8) simply denuding and isolating the vein, as recommended by Rigaud, Cazin, and Bergeron; and (9) excision of a part of the vein, a Cel- sian mode of treatment recently revived by Marshall, Steele, Howse, and Davies-Colley. Probably the best plan is that recommended by H. Lee, which consists in (10) securing the vein at two points, about an inch apart, by passing acupressure-needles beneath, but not through the vessel; applying, over the ends of the needles, elastic bands or figure-of-8 ligatures; and then subcutaneously dividing the vein at an intermediate point. The needles, which are removed in three or four days, serve to approximate, Avithout injuring, the sides of the vein, Avhile obliteration of the vessel takes place at the point of subcutaneous section, the parts healing in about a week. ANEURISM BY ANASTOMOSIS. 525 AVASCULAR TlMOKS OR AxGEIOMATA.1 (Arterial Varix, Aneurism by Anastomosis, Nevus.) Arterial Varix or Cirsoid Aneurism is a disease Avhich consists in the simultaneous elongation and dilatation of an artery. AVhen, as is fre- quently the case, the capillary net- Avork is also involved, the disease receives the name of Aneurism by Anastomosis or Race- mose Aneurism, but the tAvo affections are, in every essential re- spect, the same. The vessels be- come tortuous, and in parts saccu- lated, their coats (especially the middle) being thin, and causing the artery to resemble a vein. This affection is most common about the scalp and face, but may occur in other parts, as the tongue, extre- mities, internal viscera, and bones ; it is chiefly met with in early adult life, and its development is often attributed to a bloAV or other injury. Aneurism by anastomosis forms a tumor or outgroAvth, of Aariable size and shape, usually of a bluish hue, compressible, and communicating to the touch a spongy or doughy sensa- tion, accompanied by a Avhiz or Aneurism by anastomosis. (Fergusson.) thrill, sometimes amounting to pul- sation, and synchronous with the cardiac impulse. This thrill disappears when the arteries leading to the tumor (which are themselves usually dilated and tortuous) are compressed, and returns with an expansive pulsation when the pressure is removed. Auscultation gives usually a loud, superficial, cooing bruit, though occasionally a softer blowing sound. The temperature of the part is somewhat elevated. The diagnosis from ordinary aneurism may be made by noting the position of the growth (probably at a distance from any large artery), its doughy and compressible character, and the thrill, rather than distinct pulsation, Avhich accompanies the re-entrance of the blood, Avhen, after compression of the neighboring arteries, the pressure is removed. The bruit is more superficial than that of aneurism, and compression of the arterial trunks does not so completely mask the physical signs of the disease, as in that affection, blood still entering the part from other sources. AVhen occurring in bone, aneurism by anastomosis may be mistaken for encephaloid, with which, indeed, it may coexist. The treatment should vary with the size and position of the growth. Ex- cision or Ligation, in the Avay Avhich will be described when we come to speak of naevus, is the mode of treatment to be preferred when the affection is not very extensive, and suitably situated, as on the lip, scalp, or extremi- ties. If excision be employed, the knife must be carried wide of the disease, in order to avoid profuse or possibly fatal hemorrhage. If the tumor be too large for ligation or excision, it will usually be prudent 1 See page 477. 526 SURGICAL DISEASES OF THE VASCULAR SYSTEM. not to interfere, unless the integument be so thinned as to threaten rupture. "When it is decided to operate, several methods are open to the surgeon, the most promising being electro-puncture, the injection of coagulating fluids, and deligation of the main artery of the part. The use of coagulating in- jections is generally preferred by French surgeons ; Broca has reported a case in which, after the failure of acupressure to the nutritive arteries, he effected a cure by injections of perchloride of iron, the passage of the styptic being limited by surrounding the points of injection with rings of lead, and the tumor being attacked in sections by dividing it into lobes by means of tubes of caoutchouc. Bigelow has succeeded by the injection of a saturated solution of nitrate of siher. Heine, from a study of sixty cases, concludes that for small tumors, simple excision is the best remedy, while for those which are larger, preliminary ligation of the carotid or nutrient arteries, and subsequent excision at one or more sittings, are to be preferred. Ligation of the main artery is the plan which has been most frequently employed, par- ticularly when the affection has involved the oibit. In such a case the primi- tive carotid is the vessel to be tied ; but if the disease were limited to the scalp, it might be better to adopt Bruns's suggestion, and tie one or both ex- ternal carotids instead. Thirty-one cases of ligation of the common carotid for erectile tumor, etc., tabulated by Norris, gave eighteen recoveries and eight deaths. In other cases, again, it might be preferable to tie the various arteries in the immediate vicinity of the vascular growth, surrounding the latter at the same time by deep incisions, as was successfully done by Gibson. The only treatment to be recommended for aneurism by anastomosis occur- ring in the long bones, is amputation. Naevus is an affection very analogous to the preceding, but differs from it in involving chiefly the capillaries or veins. AVhen congenital, naevus con- stitutes the so-called mother's mark. 1. Capillary Nevi, which are commonly, if not always, congenital, occur as flattened elevations, of a red or purple hue, usually upon the face or upper part of the trunk, but occasionally in other situations. They may involve a considerable extent of surface, but rarely give any annoyance except from the attendant deformity. Sometimes, hoAvever, they ulcerate and bleed. They consist of a congeries of capillary vessels, and may accompany the aneurism by anastomosis on the one hand, or the venous naevus on the other. 2. Venous Nevi occur as prominent tumors or outgrowths, of a reddish- purple hue, smooth or lobated in outline, and somewhat compressible, doughy, and inelastic to the touch ; they are less exclusively confined to the upper part of the body than the capillary naevi, and, in their structure, consist of thin, tortuous, and sacculated veins, often interspersed with cysts. A'enous naevi may occur subcutaneously, when they form tumors Avhich may be par- tially emptied by pressure, sloAvly filling again Avhen the pressure is removed, and becoming distended by violent exertion or struggling on the part of the patient. Treatment—Cutaneous naevi which are small and not disposed to spread, may often be left without treatment—when they may disappear spontaneously; and, on the other hand, a naevus may involve such a large extent of surface as to forbid any attempt at its removal. The shrivelling of small cutaneous navi may sometimes be hastened by the application of tincture of iodine. Bradley, of Manchester, recommends tattooing with carbolic acid. For the treatment of the diffused form of naevus known as "port-wine stain," Squire recommends linear scarification with a frozen scalpel, followed by compression, the part itself being first frozen with the ether-spray apparatus, and has devised an ingenious instrument for the purpose, consisting of a number of N.EVUS. 527 thin knife blades placed closely together. Moderately large, or subcutaneous, or even small cutaneous nawi, if they are so placed as to cause disfiguration, may be removed byseA-eral methods. A'arious plans have occasionally proved successful, such as vaccination over the growth, the use of a seton, the appli- cation of styptics or vesicants, the introduction of heated wires, electro- puncture, or subcutaneous discission with compression; the best modes of treatment, hoAvever, are commonly the application of caustics, the use of coagulating injections, excision, and ligation. (1.) AYhen the naevus is superficial, and so situated that the presence of a scar will not be particularly objectionable, the application of nitric acid or the Vienna paste may suffice to effect a cure, the application being repeated if there be any tendency to a recurrence of the affection. (2.) Injection of a solution of the perchloride or persulphate of iron, by means of an ordinary hypodermic syringe, may be employed for small naevi in certain situations, as the eyelid or orbit, where other modes of treatment Avould be inapplicable ; the quantity injected should be very small (not more than two or three drops at a time), and compression should be made upon the returning veins, lest some of the injected fluid should enter the general cir- culation, and perhaps cause death, as has actually occurred in cases recorded by Kesteven, Bryant, AY est, and others. (3.) Excision may be practised when the naevus is of large size, and in the form of a distinct tumor, the incisions being carried wide of the disease, except when, as occasionally happens, the groAvth is surrounded by a capsule, and Avhen therefore, as advised by Teale, enucleation may be safely practised. This condition is, according to Erichsen, most common in cases of naevus associated Avith fatty or cystic growths. (4.) Ligation is in most instances the best mode of treatment, and may be applied in several ways. If the naevus be small, it may be sufficient to pass harelip pins in a crucial manner beneath the growth, and throw a ligature around their ends, or a double ligature may be introduced, and the naevus tied in two halves. In other cases the quadruple ligature should be employed. This may be applied by passing beneath the naevus two strong needles, eyed at the points, and crossing each other at right angles—the skin over the groAvth being, if healthy, previously reflected in flaps by means of a crucial incision (Fig. 245). The needles may be passed unarmed, the ligatures— which may be of strong silk or whipcord—being introduced as they are with- draAvn. The nooses are then cut, and an assistant holds six ends firmly, Avhile the surgeon knots the other tAvo, this process being repeated until the Avhole naevus is strangulated in four sections. Another method is to apply the ligature subcutaneously, as shown in Fig. 246, taken from Holmes. AVhen the naevus is flat or elongated, a better plan is that described by Erichsen, which consists in passing a double ligature of whipcord, three yards long and stained black for half its length, in such a way as to have a series of double loops, about nine inches in length, on each side of the tumor (Fig. 217). The black loops being then cut on one side, and the white on the other, the ends are secured as in Fig. 248, so as to strangulate the groAvth in numerous sections. After the operation, the tumor sloughs, and comes aAvayinafew days, leaving an ulcer wliich heals by granulation. Akrious modifications must be adopted, according to the locality of the disease. In dealing with a naevus over the fontanelle, there might be some risk, if the ordinary needles were used, of puncturing the membranes of the brain ; and hence in this situation, after incising the skin Avith a lancet, the ligature should be carried beneath the groAvth by means of an eyed probe. The scalp is so adherent to a naevus in the cranial region, that no attempt should usually be made to preserve the skin in this locality. For naevus of the tongue, the 528 SURGICAL DISEASES OF THE VASCULAR SYSTEM. use of the ecraseur maybe advantageously substituted for that of the ligature. H. Lee has recently recommended, in cases of vascular tumor of the face and Fisr. 245 Fig. 246. Subcutaneous ligature of naevus. The upper figure shows a single ligature carried round the tumor. The lower (in which no tumor is depicted) shows a double string carried below the centre of the base, then divided into two, a a' and b b', and each of the two carried subcutaneously round half of the nssvus, and Na:vus ; application of the quadruple ligature. (Liston.) then tied. (Holmes.) neck, the use of India-rubber thread, instead of the common ligature, the elastic contraction of this agent serving to divide the tissues without hemor- rhage, and thus effecting rapid and painless removal of the morbid growth. Barwell suggests subcutaneous strangulation with a Avire, tightened every Fig. 247. Fig. 248. Diagram of ligature of flat and elongated neevus. Diagram of tied flat and elongated naevus. (Erichsen.) (Erichsen.) three or four days, so as to cut through the base of the naevus Avithout loss of any skin. Strangulation with acupressure pins has been successfully employed DISEASES OF ARTERIES. 529 by BontfloAver, of Manchester. Though ligation is the safest mode of treat- ing naevus, I have once met with a fatal result from the operation, apparently due to embolism of the pulmonary artery. Moles___A mole may be considered as a superficial variety of nanus, and is usually covered with hair. Excision may be practised, if the disease be not too extensive, or Morrant Baker's plan may be adopted, the surface of the mole being shaved off, and the part alloAved to heal under a scab. Hem- orrhage during and after the operation may be controlled by pressure. Diseases of Arteries. Arteritis and Arterial Occlusion___Arteritis, or Inflammation of the Arterial Tunics, may occur as a primary affection, the result of injury or exposure to cold, but in the immense majority of cases is secondary to Arterial Occlusion, the result of thrombosis, or more frequently of embolism, the plug being derived from a fibrinous heart-clot. The repair of arteries after divi- sion is, as has been already mentioned (p. 176), due to the formation of a clot, together with the union of the cut edges by means of local inflammatory changes. The alterations in the arterial coats produced by inflammation, are analogous to those Avhich AA-e have studied in the Avails of a vein, as the result of phlebitis. Thus the external coat and sheath become vascular, pulpy, and distended with the products of inflammation ; the middle coat contracted, thickened, and softened ; Avhile the inner loses its smooth and polished ap- pearance, and becomes pulpy and stained from contact Avith the coloring matter of the blood. The clot Avhich forms in cases of arteritis, and Avhich indeed, as has been said, is commonly the cause of the arterial inflammation, may consist merely of masses of a fibrinous substance, Avhich do not com- pletely occlude the vessel—or may form a complete plug, usually of a conical form, the loAver part of Avhich consists apparently of white blood-corpuscles and fibrin, and often adheres to the sides of the artery, Avhile the upper part is of the color of ordinary clotted blood, and projects tail-like into the upper part of the vessel. The symptoms of arterial occlusion consist of acute pain in the course of the affected artery, and in the parts Avhich it supplies, Avith a feeling of ten- sion, great hyperaesthesia, and loss of muscular power. If the artery be superficial, it can be felt as a cord, and is either pulseless, or the seat of a sharp and jerking, pulsation, according to the degree of its obstruction. If the artery be one of importance, gangrene may result, though, in young and healthy subjects, the collateral circulation may be established with sufficient promptness to avoid this result. The arterial clot may become organized, the vessel being conA'erted into a fibro-cellular cord; or a fragment may be detached and plug the artery at a lower point (this double occlusion almost invariably producing gangrene) ; or the clot may become completely disin- tegrated, and capillary embolism (arterialpyemia) result. The treatment consists in the administration of opium to relieve pain, and of tonics, stimulants and concentrated food to maintain the patient's strength, with application of external warmth to the affected part in order to avert mortification. The subject of gangrene as the result of arterial occlusion, and the question of amputation under such circumstances, have been sufficiently considered in previous chapters (pages 91, 193). Chronic Structural Changes in Arteries—The most important of these are Fatty Degeneration, Atheroma, Ossification, and Calcification. 34 530 SURGICAL DISEASES OF THE VASCULAR SYSTEM. ■A k I, \ & Fatty degeneration in inner coat of aorta. (Green.) Fig. 249. 1. Fatty Degeneration occurs in the inner coat of arteries, especially the aorta, carotids, and cerebral arte- ries, giving rise to small, rounded or angular, whitish spots, which project slightly above the surface ; the fatty change takes place in the connective- tissue corpuscles of the part, and at a later period, the intermediate sub- stance softening, the masses of fat granules fall apart, and, the current of blood carrying aAvay the fat particles, velvety-looking depressions are produced, Avhich constitute a form of what A irchow calls fatty usure.1 2. Atheroma, which is usually accompanied by the fatty change of the internal coat above described, appears to occur primarily in the external layer of the inner coat, at the junction of the latter Avith the middle coat, and forms a pultaceous (or atheromatous) mass, consisting of granular matter, fat globules, plates and crystals of cholestearine, and half-softened fragments of tissue wliich have not yet undergone degeneration. During the early stage of atheroma, the appearance presented is that of a whitish, someAvhat elevated spot, projecting into the ATessel, but still covered by a portion of the inner coat of the latter8 (Fig. 250). As the process continues, the inner coat Fig. 250. Atheroma o the Aorta, showing the new growth in the deeper layers of the inner coat, and the consequent internal bulging of the vessel. The new tissue has undergone more or less fatty degene- ration. There is also some cellular infiltration of the middle coat. i. internal, m. middle, e. external coat of vessel. (Green.) becomes perforated, the atheromatous mass is e\~acuated into the vessel, and the so-called atheromatous ulcer results (Fig. 251), just as in the affection knoAvn as ulcerative endocarditis. AVhile this change is occurring betAveen the inner and middle coats of the artery, its outer coat becomes thickened and indurated, thus tending to maintain the strength of the vessel, Avhich at the 1 Cellular Pathology, Chance's transl., pp. 339-340. 2 Mr. Moore, in his essay in Holmes's System of Surgery, ato1. iii., adopts tbe view formerly held by Rokitansky, that atheroma is a deposit on the lining membrane of the artery, derived from the blood. CHRONIC STRUCTURAL CHANGES IN ARTERIES. 531 Fig. 251. Atheromatous ulcer of aorta. (Liston.) When in the super- same time becomes comparatively rigid and inelastic. Atheroma is usually spoken of as a degenerative change, but, according to Virchow, Billroth, .Nie- meyer, AV. Moxon, and others, should be considered a result of inflammation. Atheroma is often sup- posed to occur as a sequel of syphilis, but, according to Heubner and Ewald, the syphilitic degeneration met Avith in arteries is a distinct affection (see page 450). 3. Ossification is a rare, but, according to A'irchoAV, an occasional change met with in the inner arterial coat. It may coexist with or may take the place of the atheromatous change (atheromasia), and, like that, results, according to A lrchow, from inflam- matory proliferation. 4. Calcification is frequently met Avith, and, unlike atheroma, often in the peripheral arteries ; it occurs chiefly in the middle coat of the vessel, and has no necessary connection Avith the atheromatous change. It consists in the deposit of earthy matters, principally phosphate, Avith a little carbonate, of lime, and occurs in the form of plates, rings, or tubes, constituting the several varieties of the affection known as laminar, annular, and tubular, calcification. ficial arteries, it is readily recognized by the touch. These various structural changes may exist independently, or, as is more common, may coexist in the same person. They may occur at any age, but are by far most frequently seen in those Avho have passed the period of middle life. They are more frequent in men than in Avomen, and are said to be pre- disposed to by intemperate habits and by syphilis ; when occurring in the limbs, they are usually symmetrical. The effect of these structural changes is, in the first place, to diminish thfe calibre of the affected artery, and secondly, by lessening its natural resiliency, to lead to its irregular dilatation and elongation ; hence, an atheromatous or calcified artery may become tor- tuous, and is peculiarly apt to become the seat of aneurism. Rupture may take place through an atheromatous ulcer, and lead to fatal hemorrhage, as has been occasionally seen in the aorta ;J while both atheroma and calcifica- tion render an artery more apt to be ruptured by external violence, and inter- fere with the success of haemostatic measures—a ligature perhaps cutting through at once, or becoming prematurely detached and leading to secondary hemorrhage. Finally, the loss of smoothness in the lining surface of an atheromatous or calcified artery, hinders the circulation, and offers a nidus for the occurrence of arterial thrombosis, thus leading indirectly to occlusion and perhaps gangrene, as in several cases collected by H. Lee ; or, on the other hand, particles detached from an atheromatous ulcer may produce capil- lary embolism, and give rise to one form of arterial pyaemia. Little can be done in the way of treatment for these structural changes, beyond attention to the general health of the patient; if Avide-spread, they Avould of course render the surgeon cautious in recommending any cutting operation that Avas not imperatively required. Should occlusion and gangrene occur, the case should be treated on the principles laid down in previous portions of the work. 1 Similarly, fatty degeneration of the cerebral arteries is a very common antece- dent to the occurrence of apoplexy. (See Paget, Lectures on Surgical Pathology, 3d edit., p. 106.) 532 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Aneurism. Aneurism, as the term is used in this Avork, is a disease of the arteries, consisting in a circumscribed dilatation of one or more of the arterial coats. Varieties___AVe have already considered those forms of aneurism wliich result from wounds (see page 194), as well as the general dilatation of an artery which constitutes the disease known as arterial varix or cirsoid aneu- rism; there remain for discussion three varieties of aneurism, which may be called respectively: 1, the tubular or fusiform ; 2, the sacculated; and 3, the dissecting aneurism. 1. Tubular or Fusiform Aneurism—This is a circumscribed dilatation of all the coats of an artery, in its whole circumference. It is ac- companied by elongation of the vessel, with thickening and structural change of its coats. It is most common in the aorta, but also occurs in the iliac and femoral arteries, and has been seen in the basilar artery. Several fusiform aneurisms may coexist in the course of the same vessel, the intervening por- tions of the artery remaining healthy. Tubular aneurisms of the aortic arch may attain a very large size, running a chronic course, and doing-harm chiefly by pressure on important parts. They may cause death by impeding the circulation, and thus causing syncope ; or by compressing other parts, as the oesophagus or bronchi; or, Avhen occurring in the intra-perieardkl portion of the aorta, by bursting into the pericardial sac (Figs. 252, 256). More commonly, however, a sacculated aneurism forms upon one or other side of the tubular dilatation, and, becoming the more important disease, leads more rapidly to a fatal result. 2. A Sacculated Aneurism is a sac-like dilatation which forms upon one side of an artery, or of a previously existing fusiform aneurism, and Avhich communicates with the interior of the vessel by means of a comparatively small orifice, called the mouth of the sac. Sacculated aneurisms are divided into true and false; the true sacculated aneurism being one in which all the arterial coats enter into the formation of the sac-Avail, and the false sacculated aneurism (which is by far the more common) being one in Avhich, the inner and part of the middle coat having given Avay, the sac-wall is formed by the thickened outer coat of the artery, with perhaps the external layers of the middle coat. A true sacculated aneurism must be of small size, and with a large mouth to its sac; for it is scarcely conceiAable that a large sac could be formed from the portion of arterial wall corresponding to the area of a small sac-mouth. It is very probable, however, that a considerable number of sac- culated aneurisms are at first-fme, and subsequently, as they increase in size, become false by rupture of the inner coats of the sae-Avall. False sacculated aneurisms are further classified by surgical Avriters as circumscribed and diffused, the aneurism being circumscribed as long as its sac remains entire, and becoming diffused when its sac gives Avay—the contained blood being then either widely spread among the adjoining tissues, or being still confined by an adventitious envelope of condensed connective tissue. The subdivision of aneurisms into true and false, is not of much practical importance—the fact being that it is often impossible, even after careful dissection, to distinguish one from the other ; Avhile a diffused aneurism is in reality nothing more than an aneurism the sac of which has given way. 3. Dissecting Aneurism is almost exclusively met with in the aorta, and is a rare form of the disease, in which the blood makes its way betAveen CAUSES OF ANEURISM. 533 the coats of the artery itself; a sac may thus be formed in the arterial Avail; or the blood may dissect up the coats of the vessel for some distance, at last bursting through the external tunic, and probably causing death by syncope ; or, finally, the blood may re-enter the artery tlirough a softened patch of the Fig. 252. Fig. 253. Large fusiform aneurism of ascending aorta, Sacculated aneurism of ascending aorta. bursting into pericardium. (Erichsen.) (Erichsen.) inner coat, thus giving the appearance of a double aorta. The only contin- gency in Avhich a dissecting aneurism Avould be likely to demand the special attention of the surgeon, would be in case the pressure of the effused blood should threaten gangrene, by occluding the trunk of the affected vessel. Causes of Aneurism.—The chief Predisposing Cause is unquestion- ably the existence of structural changes (particularly fatty degeneration and atheroma^ in the arterial Avails. Calcification does not directly tend to cause aneurism, but rather lessens the dilatability of the artery Avhich it affects; it has, hoAAreArer. an indirect influence, the want of elasticity which it produces tending to increase the strain upon other portions of the vessel, and thus pre- disposing them to aneurismal disease. Age has been looked upon as a pre- disposing cause, aneurism usually occurring during the middle period of life ; the explanation is, that at this age, Avhile atheromatous changes have begun, the laborious occupations of youth are commonly still continued. Similarly, though aneurism is unquestionably much more frequent in the male sex than in the female (about seven to one1), it is probably not more so than might be expected from the greater liability of men to structural arterial changes, and from their being more commonly engaged in occupations Avhich themselves predispose to aneurismal disease. Any occupation which requires intermit- tent violent muscular exertion, predisposes to aneurism, by inducing occasional violent action of the heart, and consequent OA^er-distension of the arteries; 1 In the internal aneurisms the proportion is four to one, and in tbe external (ex- cluding carotid aneurism, which affects both sexes equally) it is thirteen to one; dis- secting aneurism is twice as frequent in women as in men (Crisp, Structure, Diseases, and Injuries of Bloodvessels, p. 115). 534 SURGICAL DISEASES OF THE VASCULAR SYSTEM. thus hotel-porters, soldiers, and sailors, or those who, usually leading sedentary lives, indulge occasionally in athletic sports, are said to be more liable to aneurism than those Avhose occupation is uniformly laborious. Climate ap- pears to exercise some predisposing influence, aneurism being probably more common in the British isles, and particularly in Ireland, than in any other portion of the world. The disease is comparatively rare in this country. Anything Avhicli tends to obstruct the arterial circulation, may predispose to aneurism, by increasing the tension of the arterial Avails ; it is thus, as we have seen, that calcification produces its effect, and it is thus that aneurism may be developed above the seat of occlusion of an artery by embolism,1 or above the point of application of a ligature. The position of an artery may itself predispose the vessel to aneurism ; thus the exposed situation of the popliteal artery renders it peculiarly liable to the development of aneurismal disease. The Exciting Causes of aneurism are wounds, bloAvs, and sudden strains. The effect of wounds has already been considered (see page 194) ; Woavs and strains, which may cause rupture of a healthy artery, may still more readily induce partial dilatation of one wliich is Aveakened by disease, thus giving rise to a tubular, or to a true sacculated, aneurism; or (Avhich is commoner) may cause the giving way of the portion of the inner coat Avhich covers an atheromatous patch, leading to the evacuation of the latter, and the conse- quent formation of a false sacculated, or of a dissecting, aneurism, according to the particular circumstances of the case. Number, Size, and Structure of Aneurisms—Aneurisms are usually single, but tAvo or more may coexist in the same person. AVhen an- eurisms are multiple, they may affect one or different arteries ; thus there may be an iliac and a femoral, or a femoral and a popliteal aneurism in the same limb, or, on the other hand, a popliteal aneurism may coexist Avith one of the subclavian or carotid artery, or Avith one of the aorta. Popliteal an- eurism is frequently symmetrical. AVhen a large number of aneurisms coexist, as in cases recorded by Pelletan and Cloquet, the patient is sometimes said to suffer from the aneurismal diathesis. Aneurismal tumors vary in size, from that of a pea,2 to that of a child's head; the size varies in different situations, according to the degree of resist- ance offered by surrounding parts, and the force of the distending blood cur- rent. The largest aneurisms are hence commonly those which occur in the aorta, or, externally, in the axilla, neck, groin, and ham. If a sacculated aneurism is laid open, its structure, going from without inAvards, is found to be as folloAvs : (1) an investment of condensed areolar tissue, forming an adventitious sac; (2) the true aneurismal sac, consisting either of the thickened external, with, perhaps, part of the middle, coat (false aneurism), or of all the coats (true aneurism), in which case the inner and middle coats may sometimes be recognized by the atheromatous and calca- reous patches Avhich they contain ; (3) concentric layers or laminae of decol- orized fibrinous clot, which appear to have been successively separated from the blood, as if by Avhipping,3 and of Avhich the inner layers are softer and redder than the outer; and (4) an ordinary loose " currant-jelly" coagulum, 1 According to Church, embolism is the most frequent cause of intracranial aneurism in young persons {St. Bartholomew':s Hosp. Reports, vol. vi., p. 99). 2 The miliary aneurisms found by Charcot, and others, in the capillary vessels of the brain, in cases of apoplexy, are much smaller, the diameter of these aneurisms rarely exceeding a millimetre, or about ^ of an inch. 3 This is denied by W. Colles, who believes that the laminated coagulum is formed by the walls of the sac itself. SYMPTOMS OF ANEURISM. 535 which may be either of ante-mortem or of post-mortem formation. The laminated fibrinous coagulum serves an important purpose in strengthening the sac-A\all, lessening the containing capacity of the sac itself, and, by its tough and inelastic character, diminishing the force of the arterial current in the sac, thus, in every way, tending to limit the spread of the disease, and even to lead to its spontaneous cure. The mouth of the sac, which is round or oval in shape, is of variable size, but always of much less area than a sec- tion of the sac itself; in a false aneurism the inner and usually the middle coat cease abruptly at the mouth of the sac, and even in a true aneurism they can rarely be traced for more than a short distance beyond the same point. The structure of the tubular, and that of the dissecting, form of aneurism, have already been referred to (page 532) ; another point in Avhich these differ from the sacculated aneurism, is in containing little or no laminated fibrinous clot. Symptoms of Aneurism—Patients are sometimes conscious of the formation of an aneurism—experiencing a distinct sensation of somethino- having given Avay, or a sharp pain, as if from the stroke of a Avhip—or (as in the case of intra-orbital aneurism) hearing a sudden sound, as of the explosion of a percussion-cap—a small, pulsating tumor being, perhaps immediately, or soon after, discovered upon examining the part. In other cases, the develop- ment of an aneurism is very gradual, the patient perhaps not becoming aAvare of its existence until it has attained a considerable size. The symptoms of aneurism may be divided into those Avhich are peculiar to the aneurismal nature of the affection, and those which depend merely upon its size or posi- tion—its presmre effects—and wliich might equally be due to any other tumor of the same bulk, and in the same locality. The peculiar symptoms of aneu- rism are made apparent by auscultation and manual examination, and depend upon the Aoav of blood through the aneurismal tumor, and, in the case of the ordinary sacculated form of the disease, upon the communication which exists betAveen the sac and the artery upon Avhich it is developed; in certain inter- nal aneurisms, the auscultatory signs alone are available for diagnosis. General Characters—An external aneurism presents the appearance of a rounded or oval tumor, situated in the course of a large artery, someAvhat compressible and elastic, and becoming flaccid by pressure on the artery above, and tense by pressure on the artery below the tumor. If the aneurism contain but little laminated clot, it will be quite soft and compressible, but if, on the other hand, the sac contain a large amount of fibrinous clot, it will be comparatively hard and inelastic; the skin over an aneurism is usually healthy, though stretched; as the tumor groAvs it may, however, become discolored, thinned, or even ulcerated, and suppuration may occur in the subcutaneous areolar tissue. Muscular weakness of the part, stiffness, and a tired feeling, are frequent accompaniments of aneurism. Pulsation___The pulsation of an aneurism is peculiar, being of an eccentric, expansive character, separating the hands Avhen placed on either side of the tumor—the fluid pressure of the blood entering the sac being, according to a Avell-knoAvn law of hydraulics, exerted equally in all directions. This pulsa- tion is most marked Avhen the mouth of the sac is large, and when the sac contains but a small quantity of laminated clot—the pulsation of a partially consolidated aneurism, if at all perceptible, being comparatively obscure, and sometimes scarcely distinguishable from that transmitted to a solid tumor by a subjacent artery. The characters of the pulsation are rendered less distinct by pressure above, and more distinct by pressure below the aneurism, or by elevating the part in which the tumor is seated. By firmly compressing the artery above the sac, the pulsation in the latter ceases, and it becomes flaccid; 536 SURGICAL DISEASES OF THE VASCULAR SYSTEM. if noAv the hands be placed on either side of the tumor, and the compression be suddenly removed, the entering blood redistends the sac, with a forcible, expanding beat which is almost pathognomonic. The pulsation of the artery below the tumor is sometimes greatly dimin- ished ; this is a sign of considerable value in certain cases of intrathoracic aneurism, in Avhich the radial pulse of the affected side may be much weaker than on the sound side, or altogether absent. This, in particular instances, may be due to arterial occlusion from arteritis, to the rigidity produced by calcification, or to external pressure, but, in the majority of cast's, is probably OAving to the mechanical action of the sac-walls in equalizing the blood current and thus lessening pulsation, just as the air-chamber does in the ordinary " hydraulic ram." Bruit.—This is the name given to the intermittent sound which is heard by applying the ear to an aneurismal tumor, and which is due to the rush of blood from a narrow into a dilated cavity: the bruit varies a good deal in different cases, being usually of a rasping or saAving character, and most dis- tinct in tubular aneurisms, and in those Avith large sac-mouths. It may be scarcely perceptible, or entirely absent, in an aneurism with a very small mouth, or which is nearly filled with laminated coagulum'; in cases of femoral or popliteal aneurism, the bruit may often be rendered more distinct by caus- ing the patient to lie down, and by elevating the limb. The bruit, Avhich is often accompanied Avith a peculiar thrill, is synchronous Avith the aneurismal pulsation, and ceases with the latter, if the artery be compressed above the tumor—returning immediately Avhen the pressure is removed. According to Savory, the thrill is most marked Avhen the aneurism projects from the poste- rior surface of the artery, so that the vessel lies betAveen the sac and the sur- geon's hand. Pressure Effects__Among the more common pressure effects of aneurism, are venous congestion and oedema, from compression of the deep-seated veins. In some cases a varicose condition of the superficial veins may result from the same cause, and gangrene may even follow from the obstruction to the returning circulation. The risk of gangrene may be further increased by pressure of the aneurismal sac upon its own or neighboring arteries, thus leading to an insufficient vascular supply to more distant parts. Pressure upon nerves, gives rise to intense pain, usually of a lancinating character, and, in certain situations, may lead to serious consequences by interfering with the functions of important parts : thus hoarseness and spasmodic dyspnoea may result from compression of the recurrent laryngeal nerve, dyspn&a, or (as in a case recorded by AV. F. Atlee) uncontrollable eructation, from pres- sure on the pneumogastric, and, in cases of intra-cranial aneurism, facial paralysis, deafness, ptosis, strabismus, or blindness, from compression of vari- ous cerebral nerves. Pressure upon secreting glands, or their ducts, may cause trouble by interfering Avith the functions of the part. Pressure upon bones and joints, often leads to serious consequences, the flat bones (as the sternum or ribs) becoming eroded and perforated, or caries and disorganiza- tion of articulations ensuing, and seriously complicating the treatment of the case. The erosion of bone by the pressure of an aneurismal tumor, is often attended by a distressing sensation of burning or boring pain, as in the verte- bral column in cases of aneurism of the aorta. Finally, serious consequences may result from pressure on important viscera: thus dyspnoea may be due to compression of the trachea, bronchi, or lungs; dysphagia to compression of the oesophagus; and progressive emaciation to pressure on the thoracic duct —while hemiplegia may result from the compression exercised by an intra- cranial aneurism on the brain. DIAGNOSIS OF ANEURISM. 537 Symptoms of Diffused Aneurism—AT hen the aneurism becomes diffused by rupture of its sac, the symptoms undergo a certain change. The tumor loses its definition of outline, Avhile it becomes rapidly very much larger; the pulsation, bruit, and thrill, become faint, or entirely disappear; the part be- trachea to the left side. (Erichsen.) comes oedematous, and often cold and livid, from A-enous congestion ; the pain is suddenly increased, and syncope may occur; the swelling becomes hard, from coagulation—and, in some rare cases, a boundary of clot and condensed areolar tissue serves to limit the further spread of the disease, which may possibly in these circumstances undergo a spontaneous cure. Usually, Iioav- ever, the swelling continues to increase, Avith or Avithout pulsation, or evi- dence of inflammation, and the case ends in gangrene, from conjoined arterial and Aenous obstruction ; or, the clot becoming disintegrated, with suppuration and ultimate giving way of the skin, death follows from external hemorrhage. In some cases, rupture of the aneurismal sac leads to wide extravasation of blood among the tissues of the part, the accident being accompanied Avith much shock and pain, faintness perhaps resulting from the loss of blood from the general circulation, and gangrene ensuing at no distant period. Diagnosis.—The affections with which aneurism is most likely to be confounded, are various forms of tumor, abscess, and simple arterial dilata- tion. Internal aneurism may be mistaken for rheumatism or neuralgia, but if the disease be situated externally, such an error could scarcely be made, except from Avant of care in the examination of the case. From Pulsating Tumors of a vascular or encephaloid nature, aneurism may usually be distinguished by its more circumscribed form, its more forci- ble and distinct pulsation (which is of a peculiar, eccentric character), its louder, deeper and more defined bruit, and its situation in the course of a large artery. If, however, a vascular or encephaloid groAvth occur in a locality in which aneurism is common, as in the popliteal space, the diagnosis may become extremely difficult—and the most experienced and careful surgeons have, under these circumstances, occasionally been led into error. 538 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Cysts, or Solid Tumors, seated over an artery, may have a pulsation com- municated from the latter, and may thus simulate aneurism ; the diagnosis may usually be made by observing that the growth can be lifted from, or pushed to one side of, the vessel, Avhen the pulsation will diminish or disap- pear; that the pulsation itself is not of an eccentric or expansive character; that there is no bruit, or at least merely a dull, beating sound, such as may be produced by compressing an artery with a stethoscope ; and that the degree of tension of the tumor is not affected by compressing the artery at a point nearer the heart. In some cases, however, a tumor may be connected Avith several arteries which surround or penetrate its substance, and the diagnosis in such a case might be impossible. Non-Pulsating Tumors, of a glandular or cancerous nature, may be mis- taken for aneurisms in Avhich consolidation has progressed so far as to obscure their pulsation—though the mistake is more apt to be the other way, such an aneurism being taken for a solid tumor. The diagnosis may be sometimes made by observing the mobility of the tumor; thus, by its moving with the larynx in the act of deglutition, a lobular enlargement of the thyroid gland may be distinguished from a carotid aneurism. Aneurisms have not unfrequently been mistaken for Abscesses, and have been hastily opened in consequence ; the error may arise from an aneurism becoming diffused, ceasing to pulsate, and exciting inflammation and suppu- ration in the surrounding tissues, or from the formation of an actual commu- nication betAveen an aneurism and the cavity of an abscess. Errors of diagnosis, under these circumstances, have been made by no less eminent surgeons than Desault, Dupuytren, and Liston. It is probable that, in some of these cases, careful auscultation might reveal a bruit, even if all the other signs of aneurisms Avere absent. General Dilatation of an Artery may simulate aneurism, especially one of the tubular variety ; the diagnosis is made by observing the absence of the characteristic symptoms of the latter disease. For illustrations of the difficulty of diagnosis in cases of aneurism, the student may advantageously consult several papers by Dr. Stephen Smith, of NeAV York, in the American Journal of the Medical Sciences for April and October, 1873, and January, 1874. Terminations of Aneurism__An untreated aneurism may termi- nate in a spontaneous cure, or may cause death by pressure on important parts, by inducing syncope, by rupture and consequent hemorrhage, or by causing gangrene. 1. Spontaneous Cure__This, Avhich is unfortunately a rare termina- tion, may be effected in several Avays ; and it is to be observed that the modes of treatment which will be presently discussed, are but imitations of nature's methods of effecting a cure. (1.) Gradual Consolidation by Deposit of Laminated Coagulum—This is the most frequent mode of spontaneous cure, and is seen almost exclusively in sacculated aneurisms and those occurring in arteries of the second or less magnitude. A case, however, occurred to Stanley, in which an aortic aneur- ism was spontaneously cured in this way. Tbe sac of the aneurism, acting as a diverticulum, alloAvs contraction of the artery beloAV, Avhich, together with the enlargement of the collateral branches given off above, tends to lessen the force of the current through the aneurism, and thus to encourage the separa- tion of fibrin and consequent formation of the laminated clot. This mode of cure is imitated in the medical treatment of aneurism, as well as in the surgi- cal treatment by compression on the cardiac side of the sac, by flexion, by the TREATMENT OF ANEURISM. 539 Hunterian mode of ligation, and to a certain extent by AAkrdrop's operation. A modification of this mode of spontaneous cure is that which is said to occur from the compression of the artery by the aneurism itself, or by another aneurism or solid tumor. (2.) Occlusion of the Artery below or above the Sac by Means of a Fibrin- ous Plug—This mode of spontaneous cure is occasionally seen ; the artery beloAV the sac may be plugged by the detachment of a fragment of the lami- nated clot; or, possibly, the artery above the sac, by a similar fragment derived from the heart or a higher aneurism. The former occurrence is imitated in the treatment by manipulation and in Brasdor's operation, and the latter in Anel's method. (3.) Inflammation of the Sac may possibly cause coagulation, and conse- quent cure of the aneurism, though the soft clot formed in this Avay is more apt to become subsequently disintegrated, leading to suppuration and rupture of the sac. This mode of cure is imitated by the use of direct pressure, gah-ano-punctuxe, the injection of coagulating fluids, etc. (4.) Finally, a spontaneous cure may. perhaps, occasionally result from Suppuration and Gangrene, leading to the extrusion of the aneurismal sac as a slough, Avhile hemorrhage is prevented by the occlusion of the artery by inflammation. This mode of cure is imitated in Avhat is called the " old operation," or that of Antyllus, Avhich is practically equivalent to an excision of the sac. The eA'idence of the occurrence of a spontaneous cure, consists in the more or less gradual disappearance of the aneurismal pulsation and bruit, the sac at the same time becoming firm and contracted, and the circulation being carried on by means of collateral branches. 2. Modes of Death__An aneurism may prove fatal by (1) pressure on important parts, as the phrenic or pneumogastric nerve, the trachea, heart, or lungs; (2) syncope, which may occur from a large aneurism becoming sud- denly diffused, and is sometimes the imme- diate cause of death in cases of aortic aneu- rism ; (3) rupture of the sac and hemorrhage —which may be internal, into the brain or spinal canal, pleura, pericardium, trachea, oesophagus or abdominal cavity—or external, as Avhen an aortic aneurism perforates the sternum and bursts upon the surface of the body; and (4) gangrene, which is apt to occur when an external aneurism becomes diffused, and Avhich is usually complicated with hemorrhage. The rupture of an aneurism on the cuta- neous surface, is commonly effected by the occurrence of suppuration and pointing, with the formation of a small slough, as in an abscess ; on a mucous surface, by the occur- rence of a small circular ulcer; and on a serous surface, by the formation of a fissured or star-like opening Stellate rupture of an aortic aneurism into the pericardium. (Erichsen.) Treatment of Aneurism. y- This may be com-eniently divided into the medical or non-operative, and the surgical or operative, treatment of aneurism. The former is the only 540 SURGICAL DISEASES OF THE VASCULAR SYSTEM. mode generally applicable to aneurisms of the thoracic aorta, and is the safer mode in certain other cases—Avhile it may be used as a valuable adjuvant to the surgical treatment of aneurism in any situation whatever. Medical Treatment__This aims to promote the cure, or at least retard the progress, of aneurism, by inducing, if possible, a deposit in the sac of laminated, fibrinous coagulum. To effect this, the patient should, in the first place, be kept at perfect rest—in bed, if possible—and should limit his diet, particularly avoiding irritating or indigestible food, stimulants, and large quantities of liquid. The treatment by position and restricted diet has been very successful in the hands of the Irish surgeons, particularly Belling- ham and Jolliffe Tufnell. Small but-repeated bleedings wove highly com- mended by Aklsalva, and form a prominent feature of the method of treatment which bears his name. They have been likewise employed with success by Pelletan, Hodgson, and others. Aknesection has also been advantageously resorted to by Porter, Broadbent, and others, for the relief of dyspnoea, in cases in Avhich this has been a troublesome symptom. Holmes has suggested the AvithdraAval of blood directly from the aneurism by means of an aspirator; but the plan seems to me a very unsafe substitute for venesection, and I have heard of one case in which it Avas the immediate cause of death. Akrious drugs have acquired a certain reputation in the treatment of aneurism, espe- cially the acetate of lead and the iodide of potassium, which is very highly spoken of by Balfour, of Edinburgh. Speir, of Brooklyn, recommends the employment of gallic acid and the subsulphate of iron. Digitals, veratrum viride, and aconite have also been used with ad\rantage, Avhile Langenbeck, Dutoit, Plagge, and others, have lately employed with success hypodermic injections of erqotine. The local application of ice has been of use in some cases, but is a dangerous remedy, having, according to Broca, induced gan- grene of the skin. The pain of a growing aneurism may sometimes be relieved by the use of anodyne plasters or embrocations, Avhile a hemlock or lead plas- ter may be used to give external support, in a case in Avhich rupture of an aneurism is impending. Surgical Treatment__This embraces a number of different methods which may be considered in succession. I. Ligation___Ligation may be employed on both sides of the aneurismal sac, constituting what is knoAvn as the " Old Operation;" on the Cardiac Side, as in Hunter's and Anel's methods; and on the Distal Side, as in the plans of Brasdor and AAkrdrop. 1. The " Old Operation."—This, which until the early part of the last century, Avas, with the exception of amputation, the only operation em- ployed in the treatment of aneurism, is also spoken of as the Antyllian method, from Antyllus, who Avas one of the first, if not the first, to employ it. It consists in opening the sac, and applying ligatures above and beloAV, as Avas directed in speaking of traumatic aneurism (see page 191), though it would appear that by the older surgeons the ligatures were sometimes applied first, and the sac subsequently kid open, or even totally excised. The opera- tion is often a very severe one, and is more liable to be followed by hemor- rhage than the Hunterian operation, on account of the artery being tied in immediate proximity to the sac, and where, therefore, it may probably be diseased. In certain situations, hoAvever, as in the axilla, root of the neck, or gluteal region, this operation may be sometimes properly employed, and was, under such circumstances, several times resorted to by the late Prof. LIGATION ON CARDIAC SIDE OF TUMOR. 541 Syme, with the most brilliant and gratifying success ; it may also be practised in cases of diffused femoral aneurism, as a substitute for amputation; and in any locality, if an aneurism have burst or have been accidentally laid open, it may often be the most eligible mode of treatment. A modification of this method, attributed to Guattani and recently revived by AVatson, of Jersey City, consists in plugging the sac, and, if possible, the opening of the artery from Avhich it arises. Fig. 257. Fig. 258. Hunter's operation. 2. Ligation on the Cardiac Side of the Tumor__The method of ligating an artery for aneurism Avhich, Avhen practicable, is now employed in preference to any other, is that knoAvn as the Hunterian Method (Fig. 258), from the illustrious John Hunter, by Avhoni it Avas first resorted to in 1785. In this operation, the vessel is tied at a distance from the sac (Avhich is not opened), thus securing a healthy portion of the artery for the application of the ligature, and still allowing a certain amount of blood to pass through the sac by means of the collateral circulation ; the cure is thus effected by the deposition of lami- nated coagulum, and not by the sudden clotting of the Avhole contents of the tumor. Anel's Method (Fig. 257), Avhich is spoken of by most French writers as identical with Hunter's, con- sists in the application of a proximal ligature immediately above the sac: it Avas employed by Anel in 1710, in a case of traumatic aneurism of the brachial artery, and apparently as a mere experimental variation upon the old method.1 It does not "seem to have been repeated, except once by Desault, and fell into oblivion until after the promulgation of Hunter's plan of operation. Anel's method is defective in not alloAving any current through the sac, except from the distal end—imperfect coagulation and suppuration being therefore apt to folloAV—and in requiring the ligature to be applied to a part of the vessel which is Aery liable to be diseased, thus exposing the patient to a consider- able risk of hemorrhage ; the operation is, moreover, difficult, on account of the displacement of the artery by the tumor, and not free from danger. In performing the Hunterian operation, those precautions are to be observed Avhich were mentioned Avhen speaking of ligation in the continuity of arteries (page 185); before tightening the ligature, it is well to make distal com- pression for a feAV seconds, so as to insure the distension of the sac. The immediate effect of deligation is to arrest the aneurismal pulsation and bruit, the limb below the ligature rising in temperature,2 and often be- coming painful and hyperaesthetic; loss of muscular poAver is also occa- 1 Keyslere subsequently (in 1774) modified the old operation by substituting com- pression for the distal ligature, retaining, however, the incision of the sac (Pelletan, Clinique Chirurgicale, t. i., p. 144). 2 This statement is in accordance Avith the result of my own observation, and cor- responds witb the doctrine of Holmes ; most writers, hoAvever, teach that the tempera- ture at first falls, and subsequently rises when the collateral circulation is established. But, according to Broca, as quoted by Holmes, this rise of temperature does not take place in animals, although in these the collateral circulation is most rapidly estab- lished. The increased temperature is apparently due to capillary congestion, caused by the sudden removal of tbe vis a tergo of the heart's action, aided perhaps by a positive dilatation of the capillaries, brought about through the agency of the nervous system. 542 SURGICAL DISEASES OF THE VASCULAR SYSTEM. sionally met with. The consolidation of the aneurism usually begins at once, and in favorable cases is commonly completed in the course of a few days— the tumor gradually contracting subsequently, though it often remains quite perceptible to the touch for weeks or even months. The establishment of the collateral circulation, after the Hunterian operation, usually requires the en- largement of two sets of anastomosing vessels—one around the seat of liga- tion, and another around the aneurism itself—unless in the rare cases in which the sac becomes obliterated, still leaving a channel for the normal Hoav of blood. If, however, the artery be tied near the sac, as in aneurism of the primitive carotid or external iliac—or in any case by Anel's method—but one set of collateral vessels is needed. If the collateral circulation above the sac be too rapidly established, the operation may fail, the pulsation of the aneurism being reneAved as forcibly as at first; in most cases, however, enough coagulation takes place Avhile the circulation is temporarily arrested, to insure the continuance of the clotting process, and the attainment of ultimate suc- cess. AVhen tAvo sets of collateral branches are enlarged, the loAver arch of anastomosis is commonly first developed, owing to the aneurismal SAvelling itself having led to previous dilatation of the neighboring vessels. If the lower anastomosis be defective, consolidation of the tumor may not take place, and suppuration of the sac, or even gangrene, may folloAV. Causes of Failure after the Hunterian Operation___There are several cir- cumstances Avhich may lead to failure after the Hunterian method of ligation ; these are, (1) hemorrhage from the point of ligature, (2) return of pulsation from too free development of the upper collateral circulation—that above the sac, (3) suppuration and sloughing of the sac, often accompanied by hemor- rhage, and (4) gangrene of the limb from the combined influence of arterial occlusion and venous congestion. (1.) Secondary Hemorrhage from the Point of Deligation___This (which, according to Crisp, usually occurs from the seventh to the fifteenth day) is more frequent in the upper, than in the loAver extremity, on account of the greater freedom of arterial anastomosis in the former situation, but is apt to occur in any locality in which large branches are given off in close proximity to the point of ligation—the clots, upon which arterial occlusion after the use of the ligature depends, being, under such circumstances, insufficient to resist the force of the circulation. In order to diminish the risk of hemorrhage, Holmes recommends the employment of carbolized catgut ligatures, and re- ports a case in which he thus secured the carotid and subclavian arteries, the patient dying from other causes, and the autopsy shoAving that both vessels had been successfully occluded. Callender, hoAvever, from a series of experi- ments made Avith catgut ligatures, concludes that they disappear so rapidly (in 50 to 60 hours) in the fluids of a Avound as not to give time for the firm occlusion of the vessel, and cases of secondary hemorrhage after the use of carbolized catgut have been reported by the same Avriter and by Mr. Holden and Dr. Humphry. My OAvn experience in this direction is limited to two cases in Avhich I tied (successfully as regarded recovery from the operation) the common carotid artery for aneurism; as the external coat of the vessel is not divided, I do not see why there should be any special risk of hemorrhage from the disappearance of the ligature, though failure may occur from the artery remaining pervious and thus permitting a return of the blood-current, as indeed actually happened in one of my cases and in others recorded by Heath and T. Smith. The treatment of hemorrhage from the point of ligation, in a case of aneu- rism, is the same as for bleeding after ligation in the continuity of an artery in any other case, and is to be conducted as directed at page 193. LIGATION ON CARDIAC SIDE OF TUMOR. 543 (2.) Recurrent Pulsation is met with when the upper anastomotic arch allows an unusually free Aoav of blood into the artery, betAveen the sac and point of ligation, and is proportionally most frequent in cases of carotid aneu- rism, for in these the circle of AVillis allows the collateral circulation to be very quickly established. In many cases, the recurrent pulsation consists of a mere thrill, Avithout any bruit; but it is occasionally as distinct as before the operation. It usually occurs within twenty-four hours after the tighten- ing of the ligature, though sometimes not for four or six Aveeks, and more rarely at an intermediate period. The prognosis of these cases is usually favorable, the pulsation again disappearing as consolidation is completed— though, occasionally, a fatal result ensues from suppuration and sloughing of the sac. Pulsation sometimes recurs several months after the consolidation and contraction of the aneurismal tumor, and the case is then properly called one of secondary aneurism, though it is probable that in most instances the new tumor is developed at a slightly higher point of the artery than the seat of original disease. Enlargement of the sac after ligation, without pulsation, is due to the reflux of blood from the artery on the distal side. If excessive, it may lead to serious consequences—inducing gangrene, by obstructing the venous circulation. Usually, h.OAAreAer, as pointed out by Pemberton, coagu- lation occurs, and the aneurism is thus converted into a solid, fibrinous tumor. Treatment—Before tightening the ligature, in an operation for aneurism, the surgeon should ascertain, by pressure Avith the finger, that doing so Avill entirely arrest the pulsation in the sac. By neglect of this precaution, the aneurismal current might be kept up by means of a vas aberrans or unusual arterial distribution, and the success of the operation might be in consequence prevented. The treatment of recurrent pulsation may usually be satisfactorily conducted by ele\Tating the limb, making moderate compression upon the sac, and perhaps cautiously applying cold. If the pulsation persist, a ligature may be applied loAver doAvn, as in Anel's method; but if sloughing of the sac be imminent, the surgeon's only resources Avill be amputation and the "old ope- ration"—the former being indicated in cases of popliteal or axillary, and the latter in those of cervical or inguinal, aneurism. (3.) Suppuration and Sloughing of the Sac___This may occur as a con- sequence of recurrent pulsation—or may result from imperfect development of the lower collateral circulation (preventing consolidation of the tumor), from the size of the sac itself and the thinness of its Avails, from the circula- tion through the sac being completely arrested (leading to coagulation en masse, instead of to the deposit of laminated clot), or from external violence, or even careless handling of the tumor before or after operation. The symp- toms are those Avhich characterize the occurrence of suppuration in general, the sac finally giving Avay, and (in about tAventy-five per cent, of the cases in Avhich this accident happens) death resulting from hemorrhage. Bleeding is particularly apt to occur in those cases which have been marked by recurrent pulsation, and then follows immediately upon the giving way of the sac ; in other cases it may not occur for several days ; Avhile if suppuration takes place at a late period, the arteries communicating with the sac may be suffi- ciently occluded not to allow any hemorrhage at all. Suppuration of the sac is most common in cases of axillary and inguinal aneurism, though it may occur in other situations. The treatment consists in laying open the sac, eATacuating its contents, and promoting healing by granulation, a provisional tourniquet being applied as a matter of precaution : should hemorrhage occur, an attempt must be made to secure the bleeding orifice with a ligature, or by the application of the actual cautery—and, if these fail, amputation should be practised, provided that the situation of the aneurism admits of such a course. 544 SURGICAL DISEASES OF THE VASCULAR SYSTEM. (4.) Gangrene of the Limb usually results, as has been mentioned, from the combined effects of arterial occlusion and venous congestion ; it is par- ticularly apt to occur in cases of very large or of diffused aneurism, and is predisposed to by loss of blood, by erysipelas, or by the exposure of the limb to undue pressure, cold, or excessive heat. It is most frequent in the loAver extremity, and occurs usually from the third to the tenth day, being invaria- bly of the nature of moist gangrene from implication of the veins. In order to prevent the occurrence of gangrene, those measures should be adopted which Avere advised in speaking of gangrene from arterial occlusion (page 193) ; in some cases it may be proper (in order to relieve the venous trunks from pressure) to lay open the sac and evacuate its contents—and indeed it is one of the recommendations of the old operation, over that of Hunter, that it is less apt to be folloAved by mortification. If gangrene have actually oc- curred, amputation must be performed, usually at the shoulder-joint, in the case of the upper limb, and at the junction of the upper and middle thirds of the thigh, in that of the lower extremity. Beside the above, Avhich are the common causes of death after ligation for aneurism, there are certain special risks in particular situations. Thus Cere- bral Disease causes more than one-third of the deaths after ligation of the common carotid (ninety-one out of two hundred and fifty-nine, according to Pilz), and Intra-thoracic Inflammation about two-fifths of the deaths after ligation of the third part of the subclavian (ten out of tAventy-five, according to Erichsen). Indications and Contra-indications for Ligation___The application of the ligature, in the treatment of aneurism, Vindicated (1) in cases in Avhich the disease is acth'e and advancing, and so situated that, Avhile pressure, flexion, etc., are not applicable, the use of the ligature is not attended with unusual risk, (2) in any case in which less dangerous modes of treatment have been tried and failed, (3) in case an aneurism has burst into an articulation, (4) in case an aneurism has become diffused, and yet not so widely diffused as to require amputation, and (5) in case an aneurism has burst or is about to burst externally, and in case, therefore, the operation is imperatively required to prevent death from hemorrhage. The use of the ligature is, on the other hand, contra-indicated (1) by the presence of any complication—such as ex- tensive arterial or cardiac disease, the existence of internal aneurism, old age, or the prevalence of erysipelas—which would probably render .the operation peculiarly dangerous, (2) by the locality of the aneurism being such that pressure or flexion would probably be sufficient to effect a cure, as in many aneurisms of the brachial, femoral, and popliteal arteries, and (3) by the locality of the aneurism being such that, from the proximity of anastomosing branches, or from any other cause, the operation Avould almost certainly ter- minate unsuccessfully—the imminence of rupture being in such a case the only circumstance that could justify operative interference. Multiple aneurism is usually, though not ahvays, a contra-indication ; thus, if two aneurisms exist on the same limb, they may both be cured by the same operation ;l or double popliteal aneurism by ligation of both femoral arteries ; in most cases, how- ever, the existence of more than one aneurismal tumor contra-indicates, though it may not positively forbid, ligation. Though I have said that ligation is contra-indicated in many cases of pop- liteal aneurism, yet I believe that in other instances it is the best mode of 1 Pemberton has recorded a case in which three aneurisms on the same limb were aured by ligation of the external iliac artery. LIGATION ON DISTAL SIDE OF TUMOR. 545 Fig. 260. treatment. The operation, however—which, though delicate, is not in itself very dangerous—should not, of course, be indiscriminately resorted to. If the aneurism be quite small, pressure Avill probably suffice for a cure, and even if it fail, will do little or no harm ; and hence, in such a case, should certainly be tried. If, on the other hand, the tumor be very large, or if it have become diffused, the risk of gangrene may be so great as to render am- putation preferable to either compression or ligation. There is, however, an intermediate set of cases, in Avhich pressure would not be likely to succeed, and in which, if persisted in, it Avould certainly increase the obstruction to the venous circulation, and thus lessen the chances from subsequent ligation. In such cases, compression should be employed, if at all, with great caution, and ligation should be promptly resorted to, if pressure be not quickly produc- tive of benefit. The surgeon will in this, as in other instances, advance both his OAvn reputation and the interests of his patients, rather by adapting his remedies to the exigencies of each particular case, than by advocating and invariably employing any exclusive mode of treatment. 3. Ligation on the Distal Side of the Tumor__This operation is attributed to Urasdor, whose name it bears. It was recommended by Desault, but first practised by Deschamps, and subsequently by AAkrdrop—being indeed often spoken of as ATardrop's method. Though this surgeon, Iiowca er, successfully employed Brasdor's operation, the plan which he himself suggested, and which properly bears his name, is someAvhat different. In Brasdor's operation, the Avhole circulation on the distal side of the sac is arrested—in Wardrop's, only a part of the distal circu- lation, by the application of a ligature to a branch of the main trunk, or to one of several arteries proceeding from the aneurism. Thus distal ligature of the carotid for carotid aneurism, would be an example of Brasdor's method, but the same operation for innomi- nate aneurism, Avould be properly called AVardrop's. The former aims to produce entire, and the latter partial, arrest of the circulation tlirough the sac. The risks, be- side those incident to the Hunterian mode of ligation, are that the sac, being still dis- tended by the cardiac impulse, may con- tinue to increase in size, the operation thus failing, even if suppuration and sloughing do not lead to a fatal termination. Hence, except in particular cases, as of aneurism of the root of the carotid, or of the innominate, the distal ligature is not to be recommended. II. Acupressure has been successfully employed in a few cases of aneurism, but does not appear to present any particular advantages over the use of the ligature. Various modifications of this method, under the name of temporary ligature, filopressure, etc., have also been employed by Stokes, Dix, and others, but not often enough to enable us to say whether they will ultimately be found any better than the methods of treatment which have been longer before the profession. (See page 188.) 35 546 SURGICAL DISEASES OF THE VASCULAR SYSTEM. III. Compression___Compression may be made directly upon the aneu- rism, or indirectly upon the artery at a point above or below the tumor (proximal or distal compression) ; it may be effected by the hands of the surgeon or his assistants (digital compression), or by means of instruments (instrumented, compression). Direct Pressure upon the aneurismal sac, was introduced by Bourdelot, in the seA-enteenth century, and has since been suc- cessfully employed, from time to time, by various surgeons, but is so uncer- tain, and occasionally so dangerous, a method, that it is iioav generally aban- doned as an exclusive mode of treatment—Avhile Distal Compression, Avhich was proposed by A'ernet, in the last century, failed in its author's own hands, and is rarely employed at the present day. Both direct and distal compres- sion may, however, prove valuable adjuvants to pressure on the proximal side of the sac, as in the plan recently adopted by Reid, AVagstaffe, Tyrrell, Syd- ney Jones, F. A. Heath, AVright, T. Smith, and others, avIio have cured pop- liteal aneurisms by pressure with Esmarch's bandage. The treatment of aneurism by Compression on the Cardiac Side of the Tumor, was employed by Hunter, Blizard, and particularly Freer, in England, and by Pelletan, Dupuytren, and others, in France, but did not attain the position wliich it noAv occupies in the estimation of the profession, until it Avas, about thirty years ago, revived and systematized by the Irish school of surgeons, particu- larly by Hutton, Bollingham, Tufnell, and Carte. It is not necessary, as was formerly supposed, to make such firm pressure upon an artery which is the seat of aneurism, as to entirely interrupt the flow of blood—and still less to excite such a degree of inflammation as might lead to the obliteration of the vessel; on the contrary, the object being to imitate nature in her mode of effecting a spontaneous cure, by inducing the gradual deposition of laminaj of fibrinous clot, it is sufficient to exercise enough compression to simply arrest the pulsation of the sac, Avithout preventing the Aoav of blood through it. This mode of treatment is particularly applicable to sacculated aneurisms, though it may also succeed in cases of the tubular variety, in Avhich, how- ever, the cure is effected rather by the gradual contraction of the aneurismal dilatation, than by the deposit of fibrin. The chances of success by compres- sion are greatest Avhen the sac contains only fluid blood, coagulation in an already partially consolidated aneurism being apt to occur suddenly, and in an imperfect manner. After recovery, the sac is commonly entirely filled up, but in some cases a channel remains, through Avhich the normal circulation is carried on. During the treatment by compression, the patient should of course be con- fined to bed,1 and the hygienic and other means spoken of under the head of Medical Treatment, put in force. Nervous irritability and pain should be controlled by the free use of opium, and in certain cases, in which the needful pressure cannot be otherwise borne, ether or chloroform may be administered .by inhalation. .1. Instrumental Compression may be effected by the use of various forms of apparatus, such as a Signoioni's or a Skey's tourniquet (Figs. 20, '11), Lister's compressor (Fig. 28), Beade's or Carte's apparatus (in the latter of ■which (Fig. 261) elastic force is applied by means of vulcanized India-rubber bands), or a simple conical weight, held in position by means of a leather socket, or, as successfully employed in Bellevue Hospital, New York, a bag of shot suspended from the ceiling. In situations in Avhich a considerable extent of artery can be dealt with (as in the thigh), alternate pressure upon 1 Dr. Buckminster BroAvn has, however, reported a case in Avhich direct compression effected a cure while the patient continued to walk about. DIGITAL COMPRESSION. 547 several points may be practised, by means of an instrument such as that represented in Fig. 202, Avhich was modified from one of Charriere's, by Fig. 261. Fig. 262. Gibbons's modification of Charriere's com- pressor. Dr. Gibbons, of this city. The points Avhich require special care, in the application of instrumental compression, are to see that the artery is fairly pressed against the bone, while the pressure is not so Avidely diffused as to cause great venous congestion from implica- tion of the deep-seated veins, and to guard against excoriation of the skin by carefully shaving and powdering the part, and by occasionally changing the point of pressure. In situations in which very deep pressure is necessary to control the circulation, and in Avhich, therefore, the treatment becomes very painful (as in compress- ing the aorta, common iliac, or subclavian), anaesthesia may be previously in duced, as proposed by Murray, and may be steadily kept up for as many hours as may be thought safe. Rapid Pressure Treatment of Aneurism.— Murray, Heath, Mapother, Levis, AgneAV, and other surgeons, have succeeded in curing aneurisms of the iliac and femoral arteries, and even of the abdominal aorta, by completely arresting the flow of blood through the sac by means of instrumental com- pression, applied above or on both sides of the tumor, and kept up in some cases for many hours, the patient meanwhile being under the influence of an anaesthetic. The mechanism, by Avhich the cure is effected in these cases, seems to be the coagulation en masse of the contents of the aneurismal sac, the mode of treatment being thus assimilated to Anel's and Brasdor's opera- tions. "Wliile "the rapid pressure treatment" is unquestionably a valuable addition to the surgeon's means of dealing with aortic and inguinal aneurisms, it cannot, in my judgment, replace, in the treatment of aneurisms in other situations, the ordinary mode of making instrumental compression—which aims to effect a cure by inducing a gradual formation of laminated coagulum, and Avhich I believe to be safer, if less brilliant, than the rapid method, Avhich has already led to five fatal results in the hands of British surgeons. 2. Digital Compression, Avhich Avas first proposed by Vanzetti, of Padua, about twenty-five years ago, and which has been successfully resorted to by Knight, of New Haven, Parker and Wood, of NeAv York, S. AV. Gross and Agnew, of this city, and many others, may be employed as an exclusive measure of treatment, or as an adjuvant to compression by means of instru- ments. For its use in the former mode, constant relays of skilled assistants are usually required, and these can frequently not be obtained ; hence, though its statistical results are very favorable (the average duration of treatment in Carte's compressor for the groin. 548 SURGICAL DISEASES OF THE VASCULAR SYSTEM. successful cases being, according to Gross and Fischer, about three days), it is principally as an aid to instrumental compression that it is likely to be gene- rally resorted to. The employment of digital compression can be much facili- tated by Holden's plan of superimposing a weight upon the finger, Avhich can thus keep up the pressure for a considerable length of time Avithout fatigue. The statistics of digital compression have been particularly studied by Fischer, of Hanover, avIio finds that 188 cases (in all situations) gave 121 successes, and 07 failures. In 17 of the successful, and in 33 of the unsuccessful cases, instrumental compression and other means were also employed. Death oc- curred in 19 instances, once after digital compression alone (from gangrene), three times after digital and instrumental compression, ten times after subse- quent ligation, three times after amputation, and twice after opening the sac. Digital compression is estimated by Fischer to be five per cent, more successful than instrumental compression, and is considered by him superior to any other mode of treatment except flexion, which he thinks should be preferred in any case in which it is applicable. AA nen it is resolved to attempt the cure of an aneurism by pressure, the patient being prepared as has been directed, and the circulation through the aneurism controlled by the application of a suitable instrument, compression should be steadily maintained, if possible, until consolidation is complete, or at least measurably advanced. This may usually be accomplished by using an instrument such as that of Dr. Gibbons, or by employing digital compres- sion during the intervals in which the pressure of the instrument is relaxed. A cure has, indeed, been obtained in cases in Avhich pressure has occasionally been intermitted for several hours at a time, but it seems probable that, Avhen applicable, moderate but continuous pressure is more likely to prove beneficial than that which is more forcible but not steadily maintained. It is Avell, before applying compression to the cardiac side, to insure the complete distension of the sac by the use for a few minutes of distal com- pression. The contraction of the aneurismal sac may also be promoted by making gentle direct pressure upon the tumor, during the whole course of treatment, by means of a carefully-applied bandage, the action of which may be aided by Corradi's plan of interposing an air-ball between this and the aneurism. Advantages and Disadvantages of Compression___The advantages of this mode of treatment are very obvious ; it is certainly, though not entirely free from risk, far safer (in most cases) than ligation of the artery, and, in cases in which it proves successful, is not materially more tedious. In many in- stances, a cure has been effected in from a few hours to three or four days, and the average duration of treatment, in successful cases, is, according to Hutchinson's statistics (for popliteal aneurism), about nineteen days, or about the same time as is commonly required for the separation of a ligature from the femoral artery. Its disadvantages are that it often fails—124 cases of pop- liteal aneurism thus treated gave, according to Holmes, only 60 cures—and that when it fails, the chances of subsequent successful deligation are less than they Avould have been, had the latter operation been primarily employed. This fact is, indeed, denied by many surgeons, and it is even claimed that previous compression, by favoring the establishment of the collateral circula- tion, lessens the chance of gangrene after the use of the ligature ; but, as long ago pointed out by Porter, the risk of gangrene after operations for aneurism, is more from \enous congestion than from arterial deficiency; and that com- pression tends rather to increase than to diminish venous congestion, will pro- bably not be doubted. Nor is it fair to assert that the long list of failures FLEXION AND MANIPULATION. 549 after compression, is entirely due to Avant of care in its application ; for the advocates of the ligature might as justly respond, Avith the late Mr. Syme, that most of the untoward results of that operation Avere due to the operator's Avant of skill—Syme himself, as is well knoAvn, having tied the femoral artery thirty-five times, Avith but a single death. In what cases, then, should compression be used ? The answer should, 1 think, be someAvhat as folloAvs: Compression should be employed, by prefer- ence (1) in all cases in Avhich, from the age or general condition of the patient —from the existence of heart disease, of other aneurisms, or of marked struc- tural change of the arterial coats—or from the prevalence of erysipelas, pyae- mia, etc., the operation of ligation would be attended by particular risk ; (2) in all cases in Avhich the aneurism, being detected at an early stage, Avould be in the most favorable condition for the use of compression, and in Avhich the pressure treatment, if eAren it failed, would not seriously lessen the pros- pect of benefit from subsequent ligation ; and (3) in all cases, on the other hand, in Avhich the aneurism, from its locality or size, Avould not probably be amenable to the ligature, and in Avhich, therefore, pressure should be at least tried before resorting to such formidable measures as amputation or the "old operation." Finally, compression may be tentatively employed in almost every case— even in popliteal aneurisms of moderate size, which are those specially adapted to the use of the ligature. If, hoAATever, decided benefit be not obtained in a short time—three or four days,1 or after a still shorter trial, if venous conges- tion, oedema, and pain are markedly increased by the treatment—the surgeon should, I think, unhesitatingly abandon compression and resort to the Hun- terian operation, Avhich, under such circumstances, I cannot but believe to be a preferable mode of treatment. IAT. Flexion___This mode of treatment was introduced by Mr. Ernest Hart, in lcSo.s,2 and has since been successfully employed by Shaw, Pember- ton, and several other surgeons. Its efficacy depends chiefly upon the inter- ference with the arterial circulation caused by bending the vessel to an acute angle, but is assisted by the direct compression exercised upon the sac by the contiguous surfaces betAveen Avhich it is thus placed. Flexion is applicable in cases of popliteal aneurism, and of aneurism at the bend of the elbow, or in the axilla. Its application is very simple, consisting merely in the re- tention of the limb in the flexed position by means of a double collar or figure of 8 bandage. If flexion is to be employed by itself, the limb should be bent so as to completely check the aneurismal pulsation. In most cases, however, it is preferable to employ moderate flexion, using it as an adjuvant to digital or to mild instrumental compression. The statistical results of the flexion treatment have been studied by Stapin and by Fischer; the former writer finds that 49 cases gave 26 successes and 23 failures, 11 of the successes having been due to flexion alone, and 15 to this in combination with other methods ; while Fischer finds that o7 cases gave 28 successes (20 by flexion alone) and 29 failures. It is probable that a combination of flexion with alternate instrumental and digital compression, Avould be found in many cases as satisfactory as it Avould be certainly a less irksome mode of treatment than either plan by itself. Ar. Manipulation.—This method consists in squeezing or kneading the aneurismal sac, in such a way as to break up the contained laminated coagu- 1 Holmes gives a week as the proper limit. 2 It is said to have been previously employed both by Fergusson and by Maunoir, of Geneva. 550 SURGICAL DISEASES OF THE VASCULAR SYSTEM. lum—a fragment of which it is hoped may plug the artery at the distal side, and thus lead to the consolidation of the tumor. This plan Avas introduced by Fergusson, and has been successfully employed by Little, Teale, and Blackman, of Cincinnati, having been combined by the last-mentioned sur- geons with proximal compression. According to Akn Buren, this is the true explanation of the cures reported from the use of Esmarch's bandage, as of many other recoveries attributed to compression alone. The dangers of this mode of treatment are that rupture of the sac and consequent diffusion of the aneurism, or inflammation and gangrene, may be caused by the application of too much force ; and that (in cases of subclavian or carotid aneurism, for the former of which Fergusson employed it) a fragment of clot may occlude the carotid or vertebral artery, and thus lead to grave if not fatal cerebral disturbance. Cases are mentioned by Esmarch and Teale, in which death followed the occurence of this accident, during the mere preliminary exami- nation of patients suffering from carotid aneurism, and Tillaux' has recently recorded a case of paralysis and aphasia resulting from embolism similarly occurring during the examination of an aortic aneurism. VI. Galvano-puneture Avas first employed by B. Phillips in 1838, and has since been resorted to in a number of cases of aneurism, by Petrequin, Ciniselli, Duncan, Althaus, and others. Both poles of the battery should, as a rule, be introduced into the sac. The great risks of the operation are that coagulation en masse will probably occur, and that sloughing of the aneu- rismal wall may take place at the points of puncture—an accident which would be apt to be folloAved by hemorrhage. Embolism of the carotid proved fatal in a case referred to by AVheelhouse. The statistics of this mode of treatment are not very favorable ; eighty-nine cases collected by Duncan gave twelve deaths, and only thirty-one recoveries. The only cases, therefore, to which galvano-puneture seems appropriate, are such as forbid either compres- sion or ligation, and yet require active treatment. Guimaraez has reported a case of carotid aneurism cured by the external application of electricity. VII. Injections of Coagulating Liquids, and especially of the perchloride of iron, have been practised upon several occasions, and some- times with success. This is, however, a very dangerous method of treatment (the principal risks being from inflammation, gangrene, rupture, and embo- lism), and its use is rarely justifiable except in localities in Avhich both cardiac and distal compression can be maintained until coagulation is complete—in localities, in fact, in which either compression or ligation would be equally applicable, and certainly preferable. VIII. Acupuncture, and the Introduction of Foreign Bodies, such as fine wire (Moore, Domville, Murray), watch-spring (Montenovesi and Bacelli), horsehair (LeA'is, Maury), and catgut (Bryant), have been tried—each aiming to effect a cure by furnishing a starting point for coagula- tion ; acupuncture, in conjunction with proximal compression, proved suc- cessful in a case of ilio-femoral aneurism reported by Dr. William Macewen, but the introduction of foreign bodies has proved utterly useless in every case in which it has thus far been employed.1 IX. Strangulation has been successfully employed for very small aneurisms, two needles or harelip pins being passed beneath the tumor, and a ligature throAvn around their extremities, as in cases of naevus. 1 Dr. Horace Dobell recommends the injection of melted spermaceti. TREATMENT OF PARTICULAR ANEURISMS. 551 X. Caustic has likeAvise been used Avith success as an application to very small aneurisms. XL Amputation___Finally, amputation might he required, if an aneurism in a limb should become diffused and threaten gangrene, if the pressure of the tumor should cause extensive caries of the neighboring bone, or if hemorrhage should occur from external rupture. Amputation may also be required in the event of the failure of ligation. Arterio-Venous Aneurism__As the result of ulcerative action, a preternatural communication may occasionally be formed between an artery and a contiguous vein, constituting a non-traumatic varii'ty of aneurismal varix. The symptoms and treatment do not differ from those of the trau- matic form of the disease, Avhich has been already described (see page 195). Treatment of Particular Aneurisms. From a consideration of the principles laid down in the preceding pages, and from an examination of the statistical results, as far as they can be ascer- tained, of various modes of treatment, Ave may arrive at the folloAving con- clusions as to the best course to be adopted in dealing Avith aneurismal disease in various parts of the body. Thoracic Aorta__Permanent benefit can seldom be hoped for from operative treatment in aneurism of the aortic arch. Ligation on the cardiac side of the sac is evidently out of the question, and hence the choice as re- gards operations is limited to tying the carotid alone (and, unless the innomi- nate be also involved, the left carotid is, as pointed out by Dr. Cockle, the one to be chosen), or to tying this and the subclavian artery as well. The former plan has been adopted in twelve cases, and the latter in six, temporary relief having been afforded in several of each category; the most successful operations haAre been those of Mr. Heath, one of Avhose patients lived four and a half years after ligation of the carotul only, and another four years after the simultaneous ligation of the carotid and third part of the sub- clavian.1 Still less success has attended the treatment by coagulating injections, and that by the introduction of a coil of Avire or Avatch-spring, Avhich was first tried by the late C. H. Moore, and which has been more recently employed by Domville and Murray, and in tAvo cases by Bacelli; no benefit resulted to the patient in DoniAille's case, while the other four all terminated fatally, as did the case in which the introduction of horsehair Avas tried by Maury, of this city. Distal pressure proved of benefit in cases recorded by Dr. Lyon and Mr. Edwards, and referred to in Air. Heath's pamphlet, as did Galvano- puneture in 13 out of 36 cases referred to by Dr. Bowditch, of Boston. The only treatment, hoAvever, to be ordinarily recommended, in a case recognized a6 aneurism of the thoracic aorta, is the medical and hygienic treatment de- scribed at page 540. 1 In another case, however, Air. Heath failed in attempting the same operation, on account of the aneurism extending much further than had been anticipated. This patient died. b.ri SURGICAL DISEASES OF THE VASCULAR SYSTEM. Cases of Aortic Aneurism, treated by Ligation of Carotid Artery. No. Operator. Result. Remarks. 1 Tillanus, Relieved. Died suddenly, five months subsequently. 2 Rigen, Relieved. Died in three months, from strangulated hernia. 3 Montgomery, Died in four months ; sac suppurated. 4 O'Shaughnessy Died. Died in seven days ; galvano-puneture also used. 5 Knowles, a Died of apoplexy. t> Heath, Relieved. Died 4^ years afterwards, from external rupture. 7 Annandale, Relieved. Tumor still pulsated. 8 Holmes, Relieved. Doing well eighteen months after operation. 9 Callender, Died in twelve months. 10 Bryant, Died. Died in ten days ; pyaemia ; no clot in sac. 11 Barwell, Wound healed. 12 Ashhurst, Relieved. Died in seven weeks, from suffocation. Cases of Aortic Aneurism, treated by Ligation of both Carotid and Subclavian Arteries. No. Operator. Result. Remarks. 1 Hobart, Died. Subclavian tied in frst portion ; hemorrhage from carotid on sixteenth day. 2 Heath, Relieved. Life prolonged for four years. 3 Maunder, Died. Died on sixth day, from occlusion of aorta. 4 Sands, Relieved. Hemorrhage from carotid on 43d and 48th days checked by pressure; not much benefit from operation. 5 Maury, Died. Ligatures came away Avithout bleeding ; aneurism grew Avith increased rapidity. Introduction of horsehair tried. Death from external rupture of aneurism. 6 Speir, Died. Carotid constricted Avith artery constrictor ; tAvo flays afterwards, subclavian tied; nohemorrhage from either wound, but death on 34th day from external rupture. Innominate Artery.—The chief operative treatment applicable to innominate aneurism, is the distal ligature, applied to the carotid, to the sub- clavian or axillary, or to both vessels, consecutively or at the same time. The carotid alone appears to have been tied for innominate aneurism twenty- two times, with five more or less permanent recoveries, and seventeen deaths. The subclavian or axillary alone has been tied five times, with at least tem- porary benefit in three instances. The double ligature has been employed in sixteen cases, the arteries having been tied consecutiAely in four, and simul- taneously in tAvelve, only one of the former category and two of the latter proving permanently successful. In four cases Avhich have been already re- ferred to (Hobart's, Heath's, Maunder's, and Sands's), the aneurism Avas eventually found to have been aortic, Avhile in Cuvillier's case (avIuCIi Avas likewise supposed to be one of innominate aneurism) the affected artery was found after death to have been the subclavian. Hodges, of Boston, employed the double ligature in a case of supposed innominate or aortic aneurism, but after the_ death of the patient, wliich occurred on the eleventh day, no aneu- rism at all Avas found, though both vessels Avere dilated; on the other hand, Cheever, likewise of Boston, in a case of innominate aneurism made an un- INNOMINATE ANEURISM. 553 successful attempt to apply the double ligature ; the position of the carotid artery could not be detected, and, in endeavoring to secure the subclavian artery, the accompanying vein Avas ruptured, death following in two hours. It is thus seen that, as far as statistics bear upon the question, the ad\antage is, upon the Avhole, with ligation of either vessel alone ; hence, if the ligature is to be used at all, that artery should be first tied in the direction of Avhich the aneurism appears to be chiefly disposed to spread, the ligation of the other vessel being reserved for a subsequent occasion, if it should be found necessary; as to the part of the subclavian to which the ligature should be applied, I would decidedly recommend the third portion, or that beyond the scaleni; though it is but right to add that Mr. Holmes is disposed to think that, by employing a ligature of carbolized catgut, the risk of hemorrhage would be so much lessened1 that the question of tying the first portion of the artery might properly be entertained. But as the operative treatment by any plan is so unsatisfactory, a fair trial should ahvays be first given to the effect of rest and medical treatment, aided, perhaps, by distal pressure, wliich proved of benefit in a case under the care of Mr. Syme. In a case of Luke's, repeated bleedings and the use of digitalis effected a cure, while Coote ob- tained an equally happy result by the enforcement of rest and the application of ice. Cases of Innominate Aneurism, treated by Ligation of Carotid Artery. Xo. Operator. Result. Remarks. 1 Evans, RecoA-ered. Li\*ed twenty-eight years subsequently. 2 Mott, RelieA'ed. Died seven months subsequently, from asphyxia. 3 Key. Died. Died in a feAV hours. 4 Morrison, Recovered. Lived twenty months subsequently. 5 Fergusson, Died. Died on seventh day, from pneumonia. 6 Hutton, a Died on sixty-sixth day ; suppuration of sac. 7 Campbell, a Died on nineteenth day, from pneumonia. 8 Wright, ti Died on sixtieth day ; hemiplegia. 9 Broadbent, i i Died in fourth month, from hemorrhage. 10 Hewson, " Died on eleventh day. 11 Is'euraeistcr, " Died on fifth day ; hemiplegia. 12 Scott, " Died from rupture of sac. 13 Dohlkoff, " Died on sixth day ; paralysis. 14 Porta, u Died in forty hours, from erysipelas. lfj Villardebo,2 Died on twenty-first day, from hemorrhage. 16 Ordile, u 17 Pirogoff, Relieved. 18 Pirogoff, " 19 Pirogoff, Died. Hemiplegia. 20 Nussbaum, " Died from rupture of sac. 21 Nussbaum, " Died from rupture of sac. 22 Heath, Mistaken for aortic aneurism, and left carotid tied. Death almost immediate, from anaemia of brain. 1 The use of carbolized catgut has, however, been followed by secondary hemor- rhage in cases of ligation of the femoral artery recorded by Mr. Holden, Mr. Callender, and Dr. Humphry. 2 This appears to be identical with the case attributed to Rompani. Erichsen mentions other unsuccessfulfcases attributed to Knowles and O'Shaughnessy. 554 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Cases of Innominate Aneurism treated by Ligation of Subclavian or Axillary Artery} No. Operator Result. Remarks. 1 2 3 4 5 Wardrop, Labgier, Broca, Blackman, Bryant, Relieved. Died. Relieved. Died. Relieved. Died two years subsequently, from dropsy. Died in a month, from asphyxia (axillary tied). Died in six months, from gangrene of lung. Died in eight days, from hemorrhage. Improvement continued at last report. Cases of Innominate Aneurism treated by Consecutive Ligation of Carotid and Subclavian Arteries. No. Operator. Result. Remarks. 1 o 3 4 Fearn, Wickhaui, Malgaigne, Bickersteth, Recovered. Died. Died from causes unconnected with operation. Died in two and a half months ; rupture of sac. Died on twenty-first day, from erysipelas. Died in three months. Cases of Innominate Aneurism treated by Simultaneous Ligation of Carotid and Subclavian Arteries. ro. Operator. Result. Remarks. 1 Rossi, Died. Died in six days. 2 Hutchison, " Died in forty-one days. 3 J. Lane, a Rupture of sac. 4 McCarthy, u 5 Durham, " Died on sixth day, from shock. 6 Holmes, " Died in eight Aveeks ; galvano-puneture also used. 7 Ensor, u Died in nine Aveeks. 8 Weir, u Died in fifteen days ; rupture into trachea. 9 Barwell, Recovered. Operation by antiseptic method. 0 Kelburne King, Relieved. Temporarily relieved ; died in 111 days from he-morrhage; aorta also involved. 1 Eliot, Died. Died on twenty-fifth day, from hemorrhage. 2 Barwell (2d case), Recovered. Died subsequently, from bronchitis. Carotid Artery and Branches__Carotid aneurism is usually looked upon as specially adapted for the treatment by ligation. The operation of tying the common carotid is, however, attended in itself by very considerable risk—the mortality being, according to Norris's statistics, over thirty-six per cent., and according to those of Pilz, over forty-three per cent.2 Of Hi cases in which the common carotid Avas tied during our late war, no less than 63 (7"> per cent.) terminated fatally, and 101 cases collected by Mr. Maunder, of ligation for wound or traumatic aneurism, gave but 34 recoveries. I have 1 Dupuytren's case, usually placed in this category, was one of subclavian aneurism. 2 Both carotids have been tied in twenty-seven cases—Dnce simultaneously (fatal in twenty-four hours), and tAventy-six times with greater or less interval between the operation; only five of the latter cases proved fatal. SUBCLAVIAN ANEURISM. 555 myself tied the common carotid in two cases, and both times successfully, as regarded recovery from the operation. As more than one-third (ninety-one out of tAvo hundred and fifty-nine) of the deaths after this operation have resulted from cerebral disease due to the interference Avith the circulation of the brain, it is evident that in any case in Avhich it is practicable to do so, ligation of the external should be substituted for that of the common carotid. If, hoAve\-er, as is usually the case, the aneurism involves the common trunk itself, and pressure proves unavailing, ligation of the primitive' carotid must be resorted to. Ligation by the Hunterian method has, according to Pilz, been done in eighty-seven cases, with fifty-five known recoveries and thirty- one deaths, the result of one ease not having been ascertained. For traumatic aneurism at the root of the carotid, the surgeon may choose betAveen Brasdor's and the ** old operation," Avhich has been successfully employed by Syme and Frothingham. For non-traumatic aneurism, the " old operation " Avould be unsuitable, for the surgeon could not be absolutely sure that the disease might not involve the innominate, or even the aorta; and hence, in such a case, the distal ligature (first practised by Wardrop) is the plan of treatment most to be recommended. Of seven cases in which this operation has been performed, four recovered (Wardrop, Bush, Colson, Wood), and three died (Lambert, Demme, Lane)—a sufficiently favorable record to encourage a resort to the operation under suitable circumstances.1 Internal Carotid and Branches___Aneurisms of the internal carotid and its branches, including intra-cranial and intra-orbital aneurisms, may require ligation of the common carotid artery, though digital compression Avith medical treatment should always be first tried in these cases. The results of carotid ligation for intra-orbital aneurism are very faAorable, twenty-nine cases, col- lected by Xoj«s, having given tAventy-five recoveries and but one death. The internal carotid artery has been successfully tied in cases of hemor- rhage by Keith, Buck, Briggs, Sands, S. Smith, and Barba, but does not appear to have been tied in cases of aneurism. Vertebral Artery.—This vessel has, according to Prof. Gross, been tied on five occasions, and four times successfully; but it does not appear that the operation has ever been attempted for aneurism of the vertebral artery itself. Compression and styptics, after laying open the sac, proved successful in a case of traumatic aneurism of the vertebral, recorded by Kocher, of Bern. Subclavian Aneurism__The statistics of this serious affection have been particularly investigated by Sabine, of New York, Koch, and Poland. The following table sIioavs the results of various modes of treatment, in 1"22 cases collected by the last-named Avriter:— 1 Pilz gives thirty-eight cases of ligation of the common carotid by Brasdor's method, for all aneurisms, recovery having been obtained in twelve, Avith twenty-five deatlis, and one unaccounted for {Half-Yearly Abstract of Med. Sciences, vol. xlviii., p. 158). 556 SURGICAL DISEASES OF THE VASCIIL AR SYST EM. Mode of treatment. 10. 11. 12. 13. 14. 15. 16. 17. 18. None, or medical treatment only..... Moxa and hypodermic injection of ergot1 Direct compression2......... Compression on cardiac side3...... Injection of coagulating fluids4...... Acupressure of axillary and innominate . Manipulation........... Galvano-puneture.......... Operation for ligation of innominate or subcla- vian, begun, but not completed .... Ligature of subclavian (3d portion) embracing rases of subclavio-axillary aneurism5 Ligature of subclavian (1st portion), subclavio- axillary in one case........ Ligature of innominate........ Ligature of innominate, carotid, and vertebral Ligature of subclavian and carotid5 .... Ligature of subclavian, carotid, and \*ertebral Ligature of axillary j .B asjd y Ligature of carotid )K ' Amputation at shoulder-joint8...... 49 1 3 1 ■2 1 4 1 21 11 12 1 1 1 4 1 1 122 Recovered, or in process of recovery. 13 1 3 1 33 Died. Uncer- tain. 31 6 12 11 12 84 From the above figures it will be seen that the most promising methods of treatment are the medical and hygienic, Avith compression in suitable cases. Manipulation and galvano-puneture are also worthy of further trial. The Hunterian operation is justifiable in cases in Avhich the aneurism is situated in the third portion of the vessel, so that a ligature can be applied outside of the scaleni muscles, or even between them—the case under such circumstances approximating to one of axillary aneurism. When, hoAvever, the disease involves the second portion of the artery, the surgeon can only choose between ligation of the innominate (first practised by Mott), ligation of the first part of the subclavian, and some form of the distal operation. The innominate artery has, in all, been tied in tAventy cases, of which nineteen proved fatal. The only instance of recovery is that in Avhich Dr. Smyth, of New Orleans, tied also the carotid and vertebral, the patient sur- viving ten years and then dying from hemorrhage from the sac, into which the blood had found its Avay through the subscapular artery. 1 Dutoit has recently reported a case successfully treated by hypodermic injections of ergotine, supplemented by digital pressure on the cardiac side of the sac ; Gay has also recently recorded a case in which compression Avas employed with marked ad- vantage. 2 Direct compression has proved successful in a fourth case reported by Mr. Holmes. 3 A case cured by distal compression has been recently recorded by Warren Stone, of New Orleans. 4 Dr. Levis, of this city, tried the introduction of horsehairs with a fatal result. 5 Another (fatal) case has recently occurred in the practice of Sir W. Fergusson. 6 A successful case has been since recorded by Dr. Little, of New York. i Successful cases have since been reported by Prof. Toland, of San Francisco, and Dr. Forbes Moir, of Aberdeen. 8 An unsuccessful case since recorded by Mr. Holden. SUBCLAVIAN ANEURISM. 557 Cases of Ligation of the Innominate Artery. No. Reporter. Result. No. Reporter. Result. 1 Mott, Died. 11 Gore, Died. 2 Graefe, " 12 Pirogoff, " 3 Norman, " 13 Bujalski, << 4 Arendt, " 14 Id. << 5 Hall, " 15 Bickersteth, " 6 Bland, " 16 O'Gradv,1 11 7 Lizars, •' 17 Smyth,2 Recovered. 8 Dupuytren, " 18 Porter,3 Died. 9 Cooper, " 19 Hutin,4 " 10 Id. 20 Lynch,5 " The first portion of the subclavian has, including McGilPs case of tem- porary occlusion, been tied nineteen times, and in every instance Avith a fatal result. Seventeen of these operations Avere upon the right side, and two (Rodgers's and Me( Jill's) upon the left. Cases of Ligation of the first portion of the Subclavian Artery. No. Reporter. Result. No. Reporter. Result. 1 Colles, Died. 11 Bayer, Died. 2 Mott, " 12 Liston,7 '< 3 HaA'den, " 13 Parker,8 " 4 O'Reilly, " 14 Hobart,9 " 5 Partridge, 15 Cuvillier,'" " 6 Liston, " 16 Kuhl," " 7 Rodgers, " 17 Ayres,12 u 8 Auvert, " 18 Becker,12 t i 9 Id.6 19 McGill,13 '< 10 Arendt, " 1 i We thus have 39 cases of ligation of either the innominate or the first part of the subclavian, or, considering cases of subclavian aneurism only, 31 in- stances of the proximal operation, with only one recovery—surely not enough to justify a repetition of the proceeding unless in very exceptional circum- stances. If the operation is to be done at all, Dr. Smyth's example should be followed, and the A7ertebral and carotid secured, as avoII as the innominate. The distal operation has been somewhat more successful, but is still un- promising. What course there is to be pursued for an aneurism which involves the first or second portion of the subclavian, and Avhich resists bloodless treat- 1 In this case the carotid also was tied. 2 Carotid and vertebral also tied. 3 Modified acupressure employed in this case. 4 Operation for secondary hemorrhage. 5 Operation for hemorrhage after gunshot wound. B Case of axillary aneurism. 7 Carotid also tied. 8 Carotid and vertebral also tied. 9 Distal operation for aortic aneurism ; carotid also tied. 10 Traumatic aneurism from bayonet wound ; carotid also tied. 11 Operation for malignant tumor of head. 12 For secondary hemorrhage following gunshot injury. 13 First part of left subclavian temporarily compressed with torsion forceps ; pleura wounded ; death on sixth day. 558 SURGICAL DISEASES OF THE VASCULAR SYSTEM. ment? Amputation at the shoulder-joint (which Avould act as a modified distal operation) would under such circumstances probably be the best pro- cedure. It Avould, as pointed out by Fergusson, avIio suggested the plan, have the advantage over the ordinary distal method, of diverting the force of the circulation by removing the part which previously demanded an arterial supply. This method has been put in practice by Prof. Spence and Mr. Holden, and in the first-named surgeon's case Avith very gratifying results; it might also be properly adopted in cases of aneurism of the third portion of the artery, in wliich, from any circumstance, the vessel could not be reached beyond the scaleni muscles. Axillary Aneurism—This, which is a less frequent affection than subclavian aneurism, admits of several modes of treatment. Compression upon the third portion of the subclavian, either by the finger, or instrument- ally (the patient being anesthetized), should be tried, and may sometimes prove successful, as in a case recorded by Lund, of Manchester; advantage might also be obtained from the flexion method, the arm being bandaged across the chest. If it be determined to resort to severer measures, the sur- geon must choose between ligation of the axillary below the clavicle, ligation of the third portion of the subclavian, the old operation, and amputation at the shoulder-joint. Ligation of the axillary below the clavicle, has been done for aneurism (as a Hunterian operation) in 21 cases,1 Avith 8 deaths, giving a mortality of 38 per cent. The statistics of ligation of the third part of the subclavian, for axillary aneurism, are slightly more favorable, 67 cases, accord- ing to Koch, gi\Ting but 23 deaths—a mortality of only 34 per cent. Hence, the latter operation should, I think, be preferred, particularly as on theoreti- cal grounds it Avould seem to be safer—ligation below the clavicle being of the nature of Anel's, rather than of Hunter's method. Ligation of the third portion of the subclavian is, liOAveA'er, in itself a Arery serious operation,2 and it is, therefore, Avorth Avhile to inquire, with Mr. Syme, Avhether the old ope- ration might not in some cases be preferable. Statistics are as yet wanting to decide this question, but the operation, Avhich Avas tAvice successfully re- sorted to by Syme himself, is at least worthy of further trial. Amputation at the shoulder-joint for axillary aneurism Avas successfully performed by Syme, and likewise by Morton, of this city, for hemorrhage and gangrene after liga- tion of the second portion of the subclavian. Either this, or the " old opera- tion," would be necessarily indicated in any case of axillary aneurism Avhich had become diffused, or Avhich threatened external rupture or gangrene of the limb. Amputation would probably be the safer proceeding, but Avould of course have the disadvantage of necessarily sacrificing the upper extremity. Hemorrhage during either operation might be prevented by compressing the subclavian over the first rib, through a preliminary incision above the cla- vicle. Aneurisms of the Arm and Forearm__Aneurism of the upper- most part of the brachial artery, immediately beloAV the axilla, may be treated by direct compression or by flexion, and, if these fail, by the " old operation" or by amputation, either of which Avould probably be safer than ligation of 1 Koch gives 26 cases, of which, however, 5 appear to have been for subclavian aneurism (distal operation) ; one of these was the case in which Porter acupressed the axillary artery, and subsequently the innominate. 2 The mortality for all causes is, according to Norris's statistics, 43^ per cent. (Am. Journ. of Med. Sciences, July, 1845), and according to Koch's, no less than 51 per cent. Of 48 cases recorded during our late war, 37 terminated fatally, a mortality of over 77 per cent. ABDOMINAL AND INGUINAL ANEURISMS. 559 the axillary, whether in the armpit or beloAV the clavicle. For aneurism of the brachial at a lower point, or of either of its branches, if compression fail, the Hunterian operation should be employed. The traumatic and arterio- venous aneurisms met with at the bend of the elboAv, as the result of vene- section, are best treated by the "old operation" (see pages 195, 196). Abdominal and Inguinal Aneurisms__Dr. Murray, of NeAvcastle- on-Tyne, cured an aneurism of the abdominal aorta by instrumental compres- sion above the sac, in five hours (the patient being under the effect of chloro- form) ; and Dr. Heath, of Sunderland, is said to have been equally successful by using pressure, without anaesthesia, continued for twenty minutes—irre- gular compression for ten hours, Avith chloroform, having previously failed. A third successful case has been reported by Dr. Moxon and Mr. Durham, a fourth by Dr. Greenhow, and a fifth by Dr. Philipson. This mode of treat- ment is, however, not entirely free from danger; a patient of Bryant's died eleven hours after the removal of the clamp (which in this instance Avas ap- plied over the aorta on the distal side of an aneurism of the cceliac axis), an autopsy revealing extensive peritonitis due to the pressure of the instrument; a second case, under the care of Paget and Bloxam, terminated fatally in eight days from peritonitis and visceral infarctus ; a third case is mentioned by Holmes as having proved fatal in the practice of Mr. Durham ; a fourth (in a case of varicose aneurism of the aorta and left common iliac vein) ter- minated fatally from gangrene of the intestine under the care of Mr. Simon ; and a fifth, from rupture of the sac, in a patient treated by distal compression by Dr. Skerritt, of Bristol. Still, the successful result in the first-mentioned cases, undoubtedly brings Avithin the range of surgical treatment an affection otherwise almost hopeless. The instrument to be employed may be either Skey's or Lister's (Figs. 27, 28), and the pad must be accurately held in place over the aorta, as complete interruption of the circulation is required. The distal ligature has proved futile in cases of aneurism of the aorta, or of its abdominal branches, while the Hunterian operation is manifestly out of the question. Aneurism of the common iliac artery may be treated by compression on the cardiac side of the sac, the patient being in a state of anaesthesia. Cases are recorded by Mapother, Heath, Eck, and others, in Avhich satisfactory cures have been in this Avay obtained. If possible, the compressing pad should be applied over the iliac artery itself, but if the size of the tumor will not per- mit this, over the aorta. Ligation of the abdominal aorta for inguinal aneurism, Avas first performed by Sir Astley Cooper,1 in 1817, and has been since repeated by James, Mur- ray, Monteiro, South, McGuire, of Richmond, Va.,2 Stokes, of Dublin (by Porter's method of modified acupressure), and Watson, of Edinburgh.3 Czerny, of Vienna, has also tied the aorta for hemorrhage following a gunshot Avound, after previous ligation of the external and common iliacs. All of these cases 1 Sir Astley Cooper's operation, perhaps the boldest in the history of surgery, has been much criticized—many surgical writers following Guthrie in believing that it is always possible to secure the common iliac, through an incision on tbe opposite side of the abdomen. That this is not ahvays so, is shown by Stokes's case, in wliich the incision was made on the left side for a right iliac aneurism, and yet " any attempt to deligate the common iliac would," it was found, " be impracticable," on account of the overlapping and adhesion of the aneurismal tumor. {Dub. Quart. Journal of Med. Sciences, Aug. 1869, p. 5.) 2 In this case, it was intended to tie the common iliac, but the aneurism was found to involve the aorta, and burst during the examination. (.1///. Journal of Med. Sciences, Oct. 1868, p. 415.) 3 For secondary hemorrhage, after previous ligation of the common iliac. 560 SURGICAL DISEASES OF THE VASCULAR SYSTEM. proved fatal, though Monteiro's patient survived until the tenth day. In Cooper's, James's, and Wktson's cases, the incision was made through the linea alba, and in all the others on the left side, as in ligating the common iliac. The uniformly fatal result of this operation should forbid its employ- ment, unless under very exceptional circumstances. If, hoAvever, the patient Avere dying from hemorrhage, and the common iliac could not be secured, as happened in the cases of Cooper, McGuire, Watson, and Czerny, ligation of the aorta would seem to be not only justifiable, but absolutely necessary. Ligation of the common iliac artery (Avhich was first practised, in LSI 2. by Gibson, of this city, in a case of gunshot injury) may be required in cases of aneurism involving the common iliac artery, or either of its branches. To the 32 cases collected by Dr. Stephen Smith, of New York, may be added 31 since reported, viz., the successful cases of Bickersteth, Brainard, Luzen- burg, Cock, McKinky, and Caldas, and the fatal cases of Gurlt, Biinger, Hammond, Hargrave, Maunder, AVatson, Delisle, Baxter, Czerny, Busch, McKee, Isham, Cutter, Hamilton, Baker, Ingram, Barral, D'Almeida, Pitta, Barbosa, Ladureau, Gouley, Carr, C. T. Hunter, and A. B. Mott. Of the whole 63 cases, but 13 terminated successfully—a gloomy record wliich hardly Avarrants a resort to this proceeding unless in very exceptional cases. It is probable that the old operation would, in some cases of aneurism of the common iliac, be preferable to ligation of that vessel, as it certainly would be to ligation of the aorta. This procedure has, however, not yet been em- ployed ; it Avas attempted by Cooper in the case in Avhich that surgeon tied the aorta, and Avas believed to have been performed in a case of iliac aneurism operated on by the late Mr. Syme. In this instance, the loss of blood Avas pre- vented by the use of Lister's aortic compressor, and the patient recovered from the operation, but died about three months afterwards from pleurisy—when an autopsy showed the aneurism to have been of the external iliac, the ligatures having been really applied beloAV the bifurcation of the common trunk. Aneurisms of Internal Iliac and Branches__Aneurisms of the internal iliac, and of the pudic artery, are extremely rare, there being, accord- ing to Erichsen, but one case of each known. Aneurisms of the gluteal and ischiatic arteries are more common, and may be treated in a Arariety of ways. Fischer,1 of Hanover, has particularly investigated the statistics of these affections, and from an analysis of 3o cases (14 of traumatic, and 21 of spon- taneous aneurism), concludes that the injection of the perchloride of iron is the best mode of treatment. If this method fail, or if it be not thought pro- per to employ it, it Avould further appear that for traumatic aneurisms the " old operation," as practised by Bell, Syme, Bickersteth, Hussey, and Darby, of New York, and for those of a non-traumatic nature ligation of the internal iliac, are the measures to be preferred. The following table is com- piled from Fischer's paper :— 1 Archiv fur kliu. Chirurgie (Langenbeck), xi. Band, 3 Heft, S. 827. ILIAC AND FEMORAL ANEURISMS. 561 Traumati c. Sp 0NTANE0US. Aggregate. Mode op Treatment. ~3 5 2 z; * 19 Syme, " 6 Coluzzi, << 2d Thomas, Died. 7 Oalozzi, Recovered. 21 Thompson,' " 8 Higginson, Died. 22 Torracchi, u 9 Kimball, " 23 Tripler,' *3). In some cases, adAantage may be derived from washing out the joint by injecting diluted tincture of iodine, or a Aveak solu- tion of carbolic acid. In favorable cases, especially in children, recovery by anchylosis may be obtained ; but should the strength of the patient begin to flag, no time should be lost in resorting to excision or amputation—the former operation being, under these circumstances, as a rule, applicable to the upper, and the latter to the lower extremity. Death after pyarthrosis may result from simple exhaustion, or from the development of pyemia. Arthritis. By Arthritis is meant inflammation of a joint as a whole; Avhichever tissue may have been first attacked, the remainder are sooner or later implicated. Arthritis usually begins Avith inflammation of the synovial membrane, or of the articulating extremities of the bones; more rarely the ligaments and sur- rounding soft parts, are first involved, but it is doubtful whether the articular cartilages are ever affected, except secondarily. Gelatinous Arthritis___The origin of arthritis in ordinary Synovitis, has already been considered ; there is, however, a form of chronic synovitis, called by BarAvell strumous, and by Athol Johnstone scrofulous—but Avhich, as justly remarked by SAvain, may exist without any evidences of a scrofulous diathesis—in which the synovial membrane is found in a pulpy or gelatinous condition, and Avhich almost invariably ends in destructive disorganization of •the joint. This condition of the synovial membrane is described by Brodie and SAvain as a peculiar form of degeneration, called by the former pulpy, and by the latter gelatiniform degeneration; BarAvell, on the other hand, regards it as essentially the same as the granulation change referred to in speaking of the pathology of synovitis in general, the difference being that, in ordinary synovitis, this granulation tissue undergoes further development, while in the cases now under consideration it remains in a rudimentary state. Godlee has studied the granulation tissue from these cases of " white savcII- ing," and finds it to consist of cells and nuclei embedded in a trabecular meshwork with which " giant-cells" are connected by processes. In fact the appearances closely resemble those of miliary tubercle, and tend to confirm the view that tubercle is of inflammatory origin; similar observations have been made by Friedlander. As the disease progresses, the articular cartilages undergo a somewhat analogous change, the disease finally reaching the bones, 584 DISEASES OF JOINTS. which become softened and carious. The symptoms of this peculiar form of disease, Avhich may be appropriately called Gelatinous Arthritis, and which is rarely seen except in the knee and elboAV, and in adults, differ from those of ordinary synovitis in several-particulars. Thus the swelling is more dif- Fig. 276. Gelatinous arthritis of elbow. (Barwell.) fused, and comparatively unattended with fluctuation, being of a doughy and somewhat elastic type—this elasticity, as pointed out by Fergusson, causing the bones, if pressed together, to resume their former position when the pres- sure is removed. The SAvelling is often accompanied, and partially masked, by general oedema of the limb. The pain is less marked than in synovitis, and of a dull, gnawing character, differing both from the acute pain of ordi- nary synovitis, and from the "jumping" pain Avhich attends exposure of the bone by ulcerating cartilage. There is little or no heat, and if the part be at first red, the surface soon loses its color, often becoming eventually positively blanched—an appearance so characteristic as almost to justify the name of white swelling formerly given to these cases. Another point, to which SAvain /calls attention, is that considerable mobility of the joint often remains, even vwhen the disease has reached an advanced stage. Arthritis from Bone Disease, etc__Arthritis begins, in many cases, with a morbid condition of the bones Avhich enter into the formation SYMPTOMS OF ARTHRITIS. 585 of the joint—this condition consisting of diffuse periostitis (subperiosteal ab- scess), osteo-myelitis, necrosis, caries, tuberculous deposit, or (Avhich is prob- ably the most common) a low form of osteitis of the articulating extremities, which is often described as strumous, but Avhich has no necessary connection with the scrofulous diathesis (see page 115). Arthritis may likewise begin with inflammation of the Ligaments and other peri-articular structures (as after sprains), and it may possibly (in cases of wound, for instance) originate in primary inflammation of the Articular Cartilage. Causes of Arthritis.—Among the causes of arthritis may be enu- merated wounds (see page 210), sprains, contusions, exposure to cold and moisture, pyemia, the puerperal state, scarlet fever, the scrofulous diathe- sis, etc. Symptoms.—The symptoms of arthritis are those of deep-seated inflam- mation ; they often begin very insidiously, but when fully established are easily recognized. The swelling is more uniform than in synovitis, and doughy rather than fluctuating to the touch ; the pain, which is specially re- ferred in the case of the knee to the inside of that joint, and in the case of the hip to a point above and behind the great trochanter, is excessive, worst at night, aggravated by the slightest touch, or by motion of the part, and accompanied (Avhen the disease is fully deA'eloped) by spasmodic contractions of the adjoining muscles, giving it the peculiar "jumping" or " starting" character which has been already referred to. These spasms occur particu- larly at night, coming on when the muscular system is relaxed by sleep, and often causing the patient to Avake Avith a scream. These "jumping" pains haATe long been associated with ulceration of the articular cartilages, and Avere formerly supposed to be due to the condition of those structures ; it is noAv, however, generally acknoAvledged that inflammation and ulceration of carti- lage is not, in itself, attended Avith pain (cartilage containing no nerves), and that the peculiar starting pains of arthritis are really due to the condition of the plate of bone immediately beneath the seat of ulceration. When the cartilaginous disintegration has gone so far as to lay bare opposing surfaces of bone, they Avill rub together when the joint is moved, and distinct grating may thus be produced. The position assumed by the patient, in a case of arthritis, is quite characteristic : the affected joint is so placed as to enable it to be kept fixed, and to be most thoroughly relaxed ; thus, in the case of the knee, the patient lies on the affected side, with the outside of the joint rest- ing on the bed, the leg flexed on the thigh and the thigh on the pelvis—tlie opposite knee draAvn up so as to serve as a guard, and to keep off the Aveiglt of the bedclothes—and the Avhole attention apparently concentrated and di- rected to shield the diseased part from injury. The inflammatory fever is severe, assuming a typhoid type if suppuration occurs, and perhaps yielding to hectic in the advanced stages of the disease. The symptoms Avhich accompany the occurrence of suppuration in cas :s of arthritis, are very much the same as Avere described in speaking of pyar- throsis from synovitis. Pointing sometimes takes place at a comparatively early period, but in other cases the pus, after escaping from the cavity of the joint, dissects up the muscular interspaces of the limb for some distance be- fore making its appearance on the surface. Occasionally many of the symp- toms of suppuration may have been present, including even absorption of the cartilages and relaxation of the articular ligaments (as shown by unnatural mobility, or the occurrence of dislocation) and distinct grating on motion, and yet recovery may ensue under judicious treatment, Avithout any discharge 586 DISEASES OF JOINTS. Arthritis of knee-joint, in an ad- vanced stage. (From a patient in the Children's Hospital.) of pus, though with more or less complete anchylosis. In these cases the pus, or at least its fluid portion, has probably been absorbed, the pus cor- puscles undergoing fatty or calcareous degen- eration. It is in such cases as these that re- sidual abscesses are sometimes obserATed after considerable intervals of time (see p. •)«!). When arthritis of a large joint, as the hip or knee, has advanced to the stage of abscess, the prospects of spontaneous recovery are usually very limited. In some cases, partic- ularly among those whose social condition secures to them careful nursing, abundant nutriment, opportunity for change of air, and other favoring circumstances, a cure by an- chylosis may be obtained, the opposing joint surfaces becoming united by granulations which are subsequently organized into a fibrous or imperfect bony tissue ; but in most instances, and as a rule with hospital patients, unless rescued by operation, such cases eventu- ally terminate in death, from exhaustion, diarrhoea, or pyemia, or from phthisis, or other disease of internal viscera. Arthritis of the smaller joints offers a much more favorable prognosis. Elongation of the affected limb is occasionally observed in arthritis as the result of irritation of the epiphyseal cartilages, but in most cases the disease ultimately leads to shortening and withering of the part. Acute Arthritis of Infants___T. Smith has described under this name a very severe form of the disease met with during the first year of life. The affection, which is not dependent upon the presence of a syphilitic taint, is a very fatal one, thirteen out of twenty-one cases, recorded by Mr. Smith, having ended in death. When recovery occurs there is little risk of anchylosis, but the joint may be Aveakened by the loss of portions of bone. Amputation has been successfully employed by G. Brown. Treatment—The Constitutional Treatment of arthritis consists pretty much in the administration of anodyne diaphoretics, with occasional mild laxatives, during the acute stage—followed by tonics, especially iron and cod-liver oil, at a later period. Mercurials, which may be proper in trau- matic arthritis, should be used, if at all, with great caution in these cases— medicines of any form being, indeed, of less importance than nutriment, Avhich should be given abundantly and in an easily assimilable form. The most important part of the Local Treatment is to place the joint in a state of complete and long-continued rest, and in a favorable position. If the shoulder be affected, the arm should be kept to the side, and directed somewhat forwards, while the elbow, if diseased, should be maintained in a flexed, and the wrist, hip, or knee in a straight or extended position. In all cases in which the lower extremity is involved, the foot should be properly supported, so that Avhen recovery is obtained the patient may not be left Avith a pes equinus. It is recommended by many excellent authorities, that if the limb be found in a vicious position, it should be forcibly placed right, wliile the patient is under the influence of an anesthetic, any resisting muscles or tendons being subcutaneously divided if necessary. I think, however, that the object may be, in many cases, quite as well and more safely accomplished TREATMENT OF ARTHRITIS. 587 Fig. 278. I by the use of continuous extension, applied by means of elastic bands, or, which is more convenient, by means of the ordinary Aveight-extension appa- ratus (see Fig. 126). When the limb has been brought into the proper posi- tion, it should be fixed, with Avell-padded splints or fracture-boxes, or, if the surgeon prefer, with some form of immovable apparatus, an aperture being cut so as to allow of inspection and topical medication of the joint. In many ca-es of arthritis, particularly if affecting the knee or hip, the greatest ad- vantage may be derived from the use of conthuious extension, which may be applied with Barwell's splint, in which the extension is effected by an India-rubber accumulator; with a spiral Avire spring surrounding the limb, as suggested by Holt- house ; or (wliich I prefer) with the ordinary weight-ex- tension apparatus—a mode of treatment which aa as used by Brodie, and which has been since successfully resorted to by numerous surgeons. The efficacy of this simple apparatus may be still further increased by the applica- tion of lateral long splints or sand-bags. The relief from pain afforded by continuous extension in cases of joint disease is very marked. It appears to act by counter- acting the tendency to muscular spasm, and thus pre- venting the inflamed ends of bone from being pressed together. With regard to topical medication in cases of arthritis, the best application during the acute stage is, I think, usually a warm poultice, though in some instances, dry cold appears to afford more relief. Leeches may be re- quired in some cases. When the first acute symptoms have subsided, benefit may often be derived from counter- irritation in the form of blisters, or the actual cautery. The cautery should be applied before the occurrence of suppuration (the patient being anesthetized), by draAv- ing the iron, heated to a black heat only, rapidly across the joint, in lines at least an inch apart; it is not neces- sary to produce a slough, and the surrounding parts may be protected (as recommended by Voillemier) by coating the whole Avith collodion, the cautery thus only affecting the part which it absolutely touches. Nekton suggests the use of a metal ruler, as a guide to the lines in Avhich the cautery is to be applied. The hot iron, though doubtless an efficient remedy, is one to which all patients have a feeling of repulsion, and should, therefore, I think, be reserved for verv urgent cases. Blistering I have usually found quite satisfactory; the blister should be placed over the seat of greatest pain, and it is better to use a small than a large blister, repeating it if necessary. In the chronic stages, great advantage may be derived from painting the part with iodine, and from the use of pressure applied by means of a soap plaster and firm bandage. Marshall speaks very favorably of the application of a solution of the oleates of mercury and morphia, in oleic acid, while BarAvell employs, in the gelatinous form of the disease, injections of diluted tincture of iodine (one part to fifteen), not into the joint, but into the thickened sur- rounding tissues. Injections of carbolic acid have been tried, and sometimes with benefit, by Knbrr, Hueter, Petersen, Schmidt, and other surgeons. If suppuration occur, the case must be treated by free incisions, etc., as directed in speaking of pyarthrosis ; if the bones be but slightly invoWed, recovery may still be sometimes obtained by perseverance in conservative treatment, Barwell's splint for making continuous ex- tension. C« T 588 DISEASES OF JOINTS. but under opposite circumstances, excision or amputation will usually be in- dicated, if the joint be so situated as to admit of operative interference. Fitzpatrick, of Dublin, speaks favorably of the application of the potassa- cum-calce, but a case thus treated by Mr. Holmes ended fatally through the development of pyemia. The local use of sulphuric acid has proved success- ful in cases reported by J. W. HaAvard, and other surgeons. In cases of gelatinous arthritis, the chances of spontaneous recovery are so slight that excision is indicated at a comparatively early period. The account Avhich has been given above of arthritis in general, Avill suf- fice for a description of the affection as met with in most of the articulations, as the shoulder, elbow, Avrist, knee, ankle, tarsal joints, etc. There are, however, two situations in which arthritis occurs, Avhich impress certain pecu- liarities on the disease, requiring more detailed consideration ; these are the hip, and the sacro-iliac articulation. Arthritis of the Hip-joint, Morbus Coxarius, Coxalgia, or Hip Disease, is an affection of early life (more than two-thirds of all cases occurring in persons under fifteen years of age), and is much commoner in boys than in girls.1 Three varieties of the disease are recognized by Erich- sen, according as it begins in the head of the femur, the acetabulum, or the proper structures of the joint (especially the synovial membrane) ; and this division being, in some respects, convenient, I shall folloAV that author in speaking of femoral, acetabular, and arthritic coxalgia. Nature.—The nature of hip disease has been a matter of much dispute, many distinguished surgeons looking upon it as almost ahvays, if not inva- riably, a constitutional affection, depending upon a tuberculous or scrofulous diathesis. The remarks made in a previous chapter upon struma, are par- ticularly applicable here ; while it is probable that, in a few cases at least, a deposit of tubercle does lead to hip disease, and Avhile there can be no doubt that the scrofulous diathesis does act as a predisposing cause of the affection, there can be as little doubt, I think, in the light of modern pathology, that many if not most cases are simply of an inflammatory nature; and that, in a majority of instances, the disease is to be looked upon as having a local origin, and (which is of the highest importance, in a practical point of view) as specially demanding local treatment. Causes—The exciting causes of hip disease are usually of an apparently trivial character, such as slight bloAvs or falls, sprains, over-exertion in Avalk- ing, or sitting on cold steps, or in wet grass. Symptoms—The symptoms of the affection vary in its different stages, three of which are commonly described by surgical Avriters. Hip disease usually begins very insidiously, obscure pains, Avhich are probably considered rheumatic, and a limping or shuffling gait, often existing for some time before any deformity is discovered. (1.) Pet in is felt in the affected joint and in the corresponding knee, the latter symptom being most marked in the femoral form of the disease, and apparently due to irritation of branches of the anterior crural and obturator nerves. The pain in the hip is constant in the arthritic form, of a very acute type, and accompanied with a feeling of tension, and with tenderness above the great trochanter. It is increased by motion or exercise, and is, therefore, worse in the evening, but the " starting" pains caused by muscular spasm do not come on until a comparatively late period. In the femoral and 1 Of 100 consecutive admissions for hip disease into the Children's Hospital of this city, 61 were of boys and 39 of girls. Again, of 419 cases of excision for hip disease collected by Culbertson, in Avhich the sex of the patient was ascertained, 297 were in males, and 122 in females. HIP DISEASE. 589 acetabular varieties, the hip pain is of a dull gnawing character, worse at night, often intermittent, and specially elicited by striking on the knee or heel, and thus pressing the joint surfaces together; starting of the limb is devel- oped at an early period. Of course, as the disease advances, in Avhatever form it may have originated, the different symptoms become merged together, so that these distinctions are only available in the earliest stage of the affection. (2.) Swelling is most marked in the arthritic variety, Avhich may be looked upon as the acute form, of the disease. Redness and Heat are rarely observed in any case, on account of the deep situation of the joint. (3.) Deformity—In the first stage of hip disease, the knee is slightly flexed, and the limb usually but not always abducted—this position being involuntarily assumed, as most easy to the patient. Slight limping accom- panies this stage of the disease. The second stage is marked by flattening of the buttock, the fold of the nates on the affected side becoming almost if not quite obliterated ; with this, there is elongation of the limb, Avhich in the large majority of cases is apparent merely, being due to a tAvist of the pelvis, though in the arthritic form of the disease there may possibly be in some instances true elongation, from distension of the synovial capsule. When in this stage the patient stands, the whole AA'eight is borne by the sound limb, that which is diseased being carried forward, flexed, and abducted. If now he be placed in the recumbent posture, the limbs may be brought to the same Fig. 279. Fig. 280. Hip disease in second stage ; showing flatten- Hip disease in third stage ; showing shorten- ing of buttock, with apparent elongation. (Bar- ing and adduction, with obliquity of pelvis. well.) (From a patient in the Children's Hospital.) level, the deformity apparently disappearing; but by careful examination it will be found that the relative position of the thigh and pelvis is the same as in the standing posture, the lumbar spine being unduly arched, and the pelvis distorted into an abnormally vertical position. In this stage there is marked lameness, and it is to this stage also that the pain in the knee particularly be- longs. In the acetabular variety of the disease there is comparatively little 590 DISEASES OF JOINTS. Excised head and neck of femur; showing change in shape of bone in third stage of hip disease (see Fig. 280). (The specimen is in the Miitter Museum of the College of Physicians of Phila- delphia.) deformity, while in the•femoral, there may be, as long as the patient is going about, apparent shortening (due to distortion of the pelvis), which, however, yields to apparent lengthening, after a few days' rest in bed. The deformity of the third stage (between which and the second there may be an interval of comparative comfort) consists in adduction of the limb (Fig. 2K0), lead- ing to shortening, which is greater in appearance than in reality, with undue prominence of the buttock on the affected side, marked obliquity of the pelvis, and a compensatory double lateral curvature of the spine. The rima natium, wliich in the sec- ond stage inclined towards the affected side (Fig. 270), is now directed away from it. The shortening of the third stage of hip dis- ease, is, at the beginning of that stage, merely apparent; as the malady progresses, how- ever, actual shortening occurs, from altera- tion in the shape of the bones which enter into the formation of the joint (Fig. 281), and in some cases, though in feAver than Avas formerly supposed, from positive dislocation taking place. (1.) Dislocation is chiefly confined to the femoral variety of the disease, and its occur- rence is often attended with marked relief from pain ; if, as sometimes happens, it takes place without the previous formation of abscess, a new socket may be devel- oped upon the dorsum ilii, the acetabulum becoming gradually filled up and obliterated. In the acetabular form of the affection the cotyloid cavity may become perforated, the head of the femur perhaps slipping through into the cavity of the pelvis. (5.) Suppuration may or may not occur in the arthritic form of hip dis- ease, but is almost inevitable in the other varieties. It occurs earlier in the acetabular than in the femoral form of the affection. The spot at which pointing oc- curs is often significant; thus an abscess opening on the outer part of the thigh, below the trochanter, indicates disease of the caput femoris, Avhile abscesses opening in the pubic region denote disease of the acetabulum—the abscess being intra- or extra-pelvic according as it opens above or below Poupart's ligament. Abscess open- ing in the gluteal region may indicate either form of the affection. Termination of Hip Disease___The ar- thritic and occasionally the other forms of the disease, if submitted to judicious treat- ment at an early period, may terminate favorably, though in many cases the best that can be hoped for, is a cure by anchy- losis. Even if the joint be anchylosed, provided that the limb have been kept in a straight position, the result will be quite satisfactory, the mobility of the pelvis com- Deformitv resulting from double hip dis- ... , n ,. ,, .,,. ,., • , ., , pensatinrr in a great degree tor the stiffness ease, (from a patient under the care of " . ° ° ° Dr. Hodge, in the Children's Hospital.) of the joint; but unless precautions have DIAGNOSIS AND PROGNOSIS OF HIP DISEASE. 591 been taken Avith regard to position, anchylosis with great deformity will ensue, such distortion as is exhibited in the accompanying cut (Fig. 282), being by no means unfrequently met Avith. If suppuration have occurred, and therefore Ave may say as a rule in cases of acetabular ox femoral coxalgia (particularly if followed by consecutive dislocation), the utmost that can usually be attained by conser\ative measures is recovery with a shortened, deformed, atrophied, and often useless limb. Death may occur from simple exhaustion, diarrhea, tuberculosis, amyloid degeneration, or pyaemia, or from some intercurrent affection Avhich Avould have been successfully resisted but for the constantly depressing influence of the joint affection. Diagnosis—Hip disease may be distinguished from rheumatism by observ- ing the limitation of the affection to one joint, and by noting the character- istic deformity. This may be readily made apparent, as pointed out by Prof. Sayre, by placing the patient upon a perfectly hard plane surface, when, if the knee of the affected limb be brought down, the lumbar spine instantly becomes arched. From lateral curvature of the spine with neuralgic tender- ness, it maybe distinguished by the pain being increased by pressing together the joint surfaces, and by the existence of painful nocturnal spasms, Avhile the diagnosis from antero-posterior curvature of the spine may be made by observing the mobility of the hip in that disease, and the different seat of pain—though if the abscess in spinal disease point on the outer side of the thigh, pressing on filaments of the obturator nerve, there will be pain referred to the knee, just as in hip disease. Morbus coxarius could only be mistaken for abscess external to the joint, for disease of the knee, or for caries of the great trochanter, by neglect of careful examination. From sacro-iliac dis- ease, the diagnosis may be made by observing that in that affection the seat of greatest tenderness is different, that there is no shortening, and no pain on moving the hip if the pelvis be fixed, and that the pelvic distortion is perma- nent and absolute, not, as in hip disease, temporary and relative. The diag- nosis from separation of the upper epiphysis of the femur Avith abscess, is difficult, if not impossible—a matter which, fortunately, is of no practical moment, as excision would be equally indicated in either affection. Prognosis___Statistics are wanting to show the mortality of hip disease, it being but seldom, from the chronic nature of the affection, that the surgeon has the opportunity of watching a case to its termination. My own impres- sion is very decided, that, when suppuration has occurred, the bones being involved, recovery without operation is an extremely rare occurrence : this impression is confirmed by the results of 9 terminated cases observed by Gibert, which gave 8 deaths and but 1 recovery. It is true that hip disease does not appear \rery frequently in our mortuary records, but this is owing to the fact that the patients are carried off by secondary complications or inter- current affections, to which the death is attributed—no reference being made to the chronic condition, Avithout Avhich those affections would not have occurred, or would not have proved fatal. Femoral, and still more acetabu- lar, coxalgia, may be therefore looked upon as extremely grave diseases; the arthritic form of the affection, hoAvever, offers, as already mentioned, a much more favorable prognosis. Treatment___It is Aery important that early treatment should be adopted in every case of hip disease, and accordingly a rigid examination of the case should be instituted on the slightest suspicion of the existence of this serious affection. During the first stage of the disease, the patient should be put to bed, and the joint kept in a state of complete rest by the use of extension, and, if needful, the adaptation of a suitable splint. I myself employ an ordinary long splint, well padded, or sand bags, as in the treatment of fractured thigh, but the surgeon may use Avith equally good results the carved splint of Dr. Physick, or one moulded from gutta-percha, leather, or pasteboard, or splints made 592 DISEASES OF JOINTS. from wire gauze, as recommended by BarAvell and Bauer, or finally any of the forms of immovable apparatus which were described at page 82. The particular form of splint used is a matter of indifference, provided that the limb be kept in a proper position, and the joint in a state of absolute rest. To relieve pain, especially the starting pain which is one of the most distressing symptoms of the affection, continuous extension is the most valuable agent Avhich we possess. The ordinary weight-extension apparatus may be used, as in cases of fractured thigh, or Barwell's elastic "accumulator" maybe employed instead. The simple weight is the most convenient means, and is, according to my experience, very efficient. I have not, myself, found it necessary to resort to subcutaneous division of the tendons or spasmodically contracted muscles, an operation which has, however, been successfully employed by Bonnet, Bauer, Sayre. and other surgeons. If the affection have run on to the second stage, the same treatment is to be employed, together with counter-irritation by blisters or the cautery, applied to the seat of greatest pain, usually a little above and behind the great trochanter; the general condition of the patient must at the same time receive attention, the state of the digestive organs being looked to, and the strength maintained by the administration of food and tonics, especially iron and cod-liver oil. In most cases of arthritic coxalgia, and in some at least of the femoral variety, if the treatment above described be earl)' adopted and strictly carried out, a marked improvement will soon be manifested, the pain and tenderness gradually disappearing, till at length motion of the joint is no longer pro- ductive of suffering, and the patient feels and considers himself Avell. The time required for this favorable evolution of events, is of course variable, six Fig. 283. Fig. 284. Sayre's short splint applied. (Sayre) Sayre's long splint applied. (Sayre.) or eight weeks being probably a minimum period. If now all further treat- ment be neglected, the disease will in a short time almost inevitably recur, and probably in an aggravated form; and yet it is very important that the patient should be no longer confined to bed, but should be enabled to take SACRO-ILIAC DISEASE. 593 exercise in the open air. It is in these circumstances, I think, that the inge- nious forms of apparatus devised by Davis, Sayre, Andrews, Agnew, Taylor, Thomas, of Liverpool, and other surgeons, are particularly serviceable : they act by keeping up extension and counter-extension, while the patient is enabled to walk about and lead a comparatively active life. In the third stage of the disease, the treatment already advised is still applicable, extension being here particularly indicated, in order to prevent or counteract the tendency to shortening. If abscess form, the same plan may still be continued, counter- Fig. 285. irritation being, hoAvever, iioav abandoned as useless. If the abscess originate within the synovial capsule. distending and threatening to rupture the latter, the pus may be evacuated by means of an aspirator, or simple trocar and canula, Avith precautions against the entrance of air, as advised by Dr. Bauer. Under other circumstances, the abscess should, I think, be treated on the general principles laid doAvn at page 381. It is rarely possible to effect the absorption of pus under these circumstances, but the attempt is Avorth making, and Avill occasionally succeed—as in a case mentioned by BarAvell, and as in one under my oavii care in Avhich absorption occurred under the influence of dry cold. After abscesses have opened in cases of hip dis- ease, leaving sinuses Avhich lead doAvn to carious bone, it is still possible in some instances to obtain a cure by anchylosis, and, in cases not admitting of operation, this is the best termination that can be hoped for. Little can be done, under these circum- stances, beyond keeping the limb straight, moderately extended, and with the foot Avell supported, Avhile the strength of the patient is maintained by appropriate constitutional and hygienic treatment. In many of the cases, however, Avhich reach this condition (at least among the class of children that come into our city hospitals), excision, or possibly amputation, may afford a better chance of life than perseverance in Agnew's apparatus for cox- expectant treatment. algla- Arthritis of the Sacro-iliac Joint (Sacro-iliac Disease)__ This affection, Avhich is extremely fatal, is fortunately rare, though probably not quite so rare as is commonly supposed—being sometimes not recognized by practitioners, as indeed it has, until comparatively recently, been com- monly ignored by systematic Avriters. It has been particularly studied bv Nekton and Erichsen. Sacro-iliac disease is an affection of early adult life, and usually begins with a condition analogous to, if not identical with, that form of arthritis Avhich has been called gelatinous, though, in other instances, the bones appear to be first affected. The disease can seldom be traced to any definite exciting cause. The Symptoms consist of pain and tenderness, with swelling over the line of the sacro-iliac junction, the pain being aggravated by motion, laughing, coughing, straining at stool, etc., and accompanied by a peculiar sensation, as if the body Avas falling apart. Pain is elicited also by pressing the sides of the pelvis together. The patient is lame from the beginning; and, as the disease adA'ances, becomes completely bedridden, usually lying on the un- 38 594 Diseases of joints. affected side. The limb on the diseased side is commonly extended, elongated from downward displacement of the os innominatum, and ivasted from atrophy of its muscles. It is somesimes markedly adematous from obstruction of the iliac vein. The hip is deformed, from the side of the pelvis being tilted for- wards and rotated dowmvards. Suppuration occurs at a rather late period of the disease, abscesses pointing, according to Erichsen, over the joint, in the gluteal or lumbar regions, within the pelvis, or in connection witli the rectum. In a case Avhich was under my care at the Episcopal Hospital, abscesses pointed in the groin, in the gluteal region, and on the inside of the thigh. The Diagnosis of sacro-iliac disease can usually be made Avithout much difficulty, the affection with Avhich it is most likely to be confounded being hip disease, the diagnostic marks of which have already been pointed out. Disease of the spine may be distinguished, even if there be no posterior cur- vature, by the presence of tenderness in the region of the affected vertebra?, and of stiffness of the Avhole spinal column, with absence of any elongation of the limb, or sign of disease about the sacro-iliac joint. Neuralgia of the hip may be distinguished by the diffused and superficial character of the pain, and by the absence of any real displacement of the os innominatum ; Avhile sciatica may be recognized by the seat of pain being below the sacro-iliac joint and extending doAvn the limb, and by the absence of elongation or other signs of articular disease. The Prognosis of advanced sacro-iliac disease is always unfavorable; Erichsen, avIio has devoted special attention to the subject, says that he has never seen recovery in any case in wThich the disease Avas fully developed, and in which suppuration had occurred. When seen at an early stage, however, there is more hope of successful treatment, and cases of recovery under these circumstances have been reported by McGuire and other surgeons. The Treatment consists in endeavoring to prevent suppuration, by placing the joint at rest by means of the weight extension apparatus, as advised by Prof. McGuire, and at a later period by supporting the part with a leather or pasteboard splint, moulded to embrace the pelvis, hip, and thigh; counter- irritation may be of service in the early stage, and the general health should be sustained by the administration of cod-liver oil and other tonics. The patient should of course stay in bed, and preferably in the prone position. No operation is, for obvious reasons, admissible in this grave affection. Rheumatoid Arthritis. Rheumatoid Arthritis is the name proposed by Dr. Garrod for a peculiar form of inflammation of the joints, Avhich was described by Adams, 11. W. Smith, and Canton, as Chronic Rheumatic Arthritis, and Avhich, in the case of the hip, is sometimes known as Morbus Coxe Senilis. The pathology of this disease is involved in much obscurity; rheumatoid arthritis resembles both gout and rheumatism, and yet does not appear to partake of the nature of either of those affections. It probably begins with hyperemia of the synovial membrane and increased synovial secretion, folloAved by thickening, and sometimes elongation, of the ligaments, gradual absorption or ossification of the inter-articular cartilages, and finally porceknous induration and ebur- nation of the bony extremities. Barwell, however, believes that osteitis is the primary condition, and that the synovial change is entirely secondary. In the case of the hip, Avhich is the joint most commonly affected, the round ligament disappears, and the head of the bone becomes irregularly enlarged, flattened, sometimes elongated, and placed at a right angle with the shaft. RHEUMATOID arthritis. 595 The cervix femoris becomes shortened, apparently by interstitial absorption, and is often surrounded by vascular fringe-like projections of the synovial membrane. The acetabulum becomes enlarged, and sometimes flattened, but in other cases deepened, so as to surround the head of the femur as with a cup. Ex- tensive stakctitic bony outgroAvths often ap- pear about the base of the great trochanter, and especially along the inter-trochanteric line, Avhile similar osteitic formations are developed in the ligamentous and other soft tissues. On section, the bone is found to be rarefied, Avith an excess of oily matter—in a state, indeed, of osteoporosis with eburna- tion. All the joints of the skeleton may be involved, but those in which the disease is most commonly observed, are the articulations of the hip, shoulder, and lovver jaAv. Rheu- matoid arthritis of the shoulder is, according to Canton, the true pathological condition in those cases described by Soden and others as displacement of the long head of the biceps. The joints on either side are often symme- trically affected. Rheumatoid arthritis usually occurs in the male sex, and in persons avIio have passed the middle period of life; Avhen met with at an earlier age, the patients are generally females ; the disease appears in most cases to result from the action of cold in persons of debili- tated constitution, the development of the affection in any particular joint being sometimes hastened by traumatic causes. Appearance of the head of the femur in rheumatoid arthritis. (Druitt.) Symptoms—The disease begins with pain of a rheumatic character, increased, in the case of the hip, by standing or walking, and followed by impaired power of motion, preventing the patient from either standing erect, stooping, or sitting in the ordinary posture. The limb may at first appear lengthened, but subsequently becomes shortened from changes in the shape of the bones, the apparent shortening being still further increased by obliquity of the pelvis. The limb is somewhat flexed and everted, the buttock becom- ing flattened, Avhile the trochanter is unduly prominent and thickened. Crackling, or grating, may be elicited by rotating the limb, being evidently produced by the stakctitic formations already referred to, and by the rubbing together of the eburnated .surfaces of bone. The muscles of the thigh waste, but those of the calf of the leg maintain their nutrition ; the loss of motion in the hip is in some degree compensated for, by increased mobility of the lumbar vertebra?. Suppuration occasionally, but very rarely, occurs, nor, according to Barwell, is there any tendency to the production of anchylosis. Diagnosis___Rheumatoid arthritis is chiefly interesting to the surgeon in a diagnostic point of vieAv, being frequently mistaken for fracture in the neighborhood of the affected articulation. The diagnosis can usually be made by inquiring into the history of the case, and by observing that the affection is not limited to a single joint. The arthropathies, or articular affections which depend upon lesions of the nerves and nerve-centres, present many analogies to rheumatoid arthritis, and, according to Mitchell, are often clini- cally indistinguishable therefrom. 596 DISEASES OF JOINTS. Prognosis.—The disease is very seldom fatal, but, on the other hand, is extremely chronic and intractable, and productive of a great deal of pain and discomfort. Treatment__But little can be done in the Avay of treatment, beyond the employment of ordinary hygienic means and the administration of tonics, especially cod-liver oil, iron, and quinia, the affected joint being, during the acute stage, kept at rest, and occasionally blistered. Iodide of potassium may be sometimes used with advantage, as may be arsenic and guaiacum. R. W. Smith speaks highly of the latter drug, in combination with sulphur, rhubarb, alkalies, and aromatics. Change of air, and a resort to various mineral springs, mav be properly advised in some cases. With regard to motion of the dis- eased joints (in the chronic stage), it may be said that the patient may take as much exercise as can be done, without inducing an aggravation of pain. Erichsen recommends, in the case of the hip, external support by means of lateral irons, jointed opposite the articulations, Avith a pelvic band and leather socket for the thigh and leg. Excision of the hip has been resorted to in this affection, but is not to be recommended ; the prospective benefits of the operation, under these circumstances, are not sufficient to compensate for the risk Avhich Avould necessarily attend its performance. Periarthritis. This name is applied by Duplay and Gosselin to a condition simulating arthritis, but due to inflammatory changes in the neighboring bursae and other periarticular tissues. There is less swelling and constitutional disturbance than in inflammation of the joint itself, and the diagnosis from rheumatism may be made by observing that but one joint is affected, and from neuralgia by noting a peculiar crackling which may be commonly detected by palpation of the affected bursa?. The treatment in the acute stage consists in the en- forcement of rest, Avith the use of cataplasms, or belladonna and mercurial ointment, and at a later period in friction with stimulating liniments, and the employment of passive motion to prevent the occurrence of false anchylosis. Anchylosis. Frequent reference has been made in the preceding pages to the cure of joint-diseases by anchylosis, a word which, as used by surgeons, is equivalent to stiff-joint. Anchylosis, or ankylosis (the latter is etymologically the more correct spelling), may be incomplete or complete. In incomplete or fibrous anchylosis, the stiffness is due to thickening of the joint capsule, Avith the development of bands of fibro-cellular material Avhich cross from one articular surface to the other, and Avhich result from the organization of inflammatory lymph, or of the granulation structure which in joint-diseases replaces the synovial membrane and articular cartilages. The stiffness of the part is further promoted by contraction and adhesion of the neighboring muscles and tendons, the latter being almost exclusively concerned in the production of the so-called false anchylosis, Avhich results from mere disuse. In complete or bony anchylosis the joint may be entirely obliterated, the articulating surfaces being united throughout by bone (synostosis), or (which is probably the more common condition) there may be fibrous anchylosis, with the superaddition of osseous arches or bands, which cross from side to side externally to the joint, and which may be new formations, of the nature of exostoses, or may result from the deposit of ossific matter in ligaments or other pre-existing soft struc- tures. Bony anchylosis is rarely met with except as the result of traumatic arthritis, fibrous anchylosis being more common in the ordinary forms of the TREATMENT OP ANCHYLOSIS. 597 disease, particularly in patients of a strumous diathesis. It not unfrequently happens, indeed, under the latter circumstances, that, Avhile more or less perfect anchylosis is taking place in one part of a joint, caries or necrosis is in Fig. 287. existence at another. In bony anchy- losis there is absolutely no motion of the joint, while in the fibrous variety slight motion may ahvays be elicited by careful examination, particularly if the patient be in a state of anaesthesia. Treatment__The treatment of an- chylosis varies according as it is complete or incomplete, and according to the posi- tion in which the joint has become stiff. 1. Fibrous Anchylosis in a Good Position. — No treatment should be adopted under these circumstances until all acute inflammatory symptoms have subsided; when the disease has become chronic,passive motion may be cautiously employed, being aided by frictions, the salt douche, etc. In fibrous anchylosis of the elbow, the patient may himself practise passive motion by swinging a flat-iron or other Aveight, as advised at page 227. Advantage is occasionally derived from the use of well-padded splints, the angle of Avhich may be varied by means of a Stromeyer's screw or other similar contrivance, or from the use of continuous extension by elastic bands or by a weight. It may be, in some rare cases, justifiable to attempt subcutaneous division of the restraining intra- articular bands, but the operation is not very promising, and is necessarily attended Avith some risk. Fibrous anchylosis of the shoulder is often folloAved by the development of a bursa beneath the scapula, the motions of which bone give rise to a crackling sound, described by Terrillon under the name of subscapular friction. 2. Fibrous Anchylosis in a Bad Position.—If the elboAv be anchylosed in an extended position, or the shoulder, knee, or hip at a right angle, it becomes important to adopt more active treatment, though no operation should be per- formed until acute symptoms have passed away. In many cases, particularly in those of rheumatic origin, it is possible at once to restore the limb to a posi- tion in which it "will be useful, by forcibly flexing and extending the joint, and thus rupturing the intra-articular adhesions, while the patient is in a state of anaesthesia. In other instances, continuous extension, by means of elastic bands (Fig. 290) or a weight, will be safer1 and equally efficient. If resist- ance be made by contracted tendons in the neighborhood of the joint, these should be subcutaneously divided, a few days being then allowed to elapse before the employment of extension. Any inflammation Avhich folloAVS these manoeuvres must be treated upon general principles. In the case of the hip- 1 The humerus has been fractured in attempting forcibly to break up adhesions of the elbow-joint, and Louvricr and Homans have recorded ruptures of the popliteal artery in similar operations for anchylosis of tbe knee. Synostosis of hip-joint. (Pirrie.) 598 DISEASES OF JOINTS. joint, subcutaneous osteotomy, by Adams's or Gant's method, may often be resorted to. The deformity met with in anchylosis folloAving arthritis of the knee-joint, usually consists in flexion, backAvard displacement of the tibia upon the condyles of the femur, and outward rotation of the leg and foot. In these cases, simple extension, even Avith division of the hamstring tendons, is not sufficient, the backward displacement persisting, and rendering the limb weak and comparatively useless ; under such circumstances, the ingenious apparatus of Mr. Bigg (Fig. 291) may be employed, which acts by means of springs, drawing the head of the tibia dowmvards and forwards, Avhile the condyles of the femur are at the same time pressed upwards and backAvards. Subcutaneous division of the adhesions uniting the femur and patella is sug- gested by Mr. Willett, and has been advantageously resorted to by Mr. Maunder. Anchylosis of the knee in a position of over-extension is extremely rare; it is well seen in the accompanying illustration (Fig. 288), from a patient under my care in the Episcopal Hospital. The displacement in these cases is an exaggeration of that which is commonly observed, the head of the tibia slipping entirely behind the femur and projecting in the popliteal space. In cases of partial fibrous anchylosis, complicated by frequently recurring inflammation of the joint (Fig. 289), excision or amputation will not unfre- quently be required. Fig. 288. Fig. 289. Anchylosis of knee-joint in position of over-extension. Chronic arthritis of knee-joint, with (From a patient in the Episcopal Hospital.) partial anchylosis in bad position. (From a patient in the Episcopal Hospital.) 3. Bony Anchylosis in a Good Position___If a joint be affected with bony anchylosis, and in such a position as to retain the usefulness of the limb, pru- dent surgery Avould dictate that no operation should be resorted to; an excep- tion may be occasionally made in the case of the elbow, Avhich may be in some instances advantageously excised under these circumstances. P. H. Watson and Annandale prefer to an ordinary excision of the elbow, a partial operation, in which the lower portion of the humerus only is removed. TREATMENT OF ANCHYLOSIS. 599 4. Bony Anchylosis in a Bad Position..—Various operations have been employed to remedy bony anchylosis under these circumstances. Hip—Dr. J. Rhea Barton, of this city, in the year 1.">, the same surgeon, in a case of fibrous anchylosis, substituted for the removal of a Avedge-shaped mass, an ordinary excision of the knee-joint, the parts being subsequently held together with silver wire. Culbertson has collected fourteen cases of Subcutaneous osteotomy of both thigh bones for anchylosis following hip-disease. (From a patient in the Children's Hospital.) Barton's operation, to which should be added Iavo others (successful) by Blackman, of Ohio, and J. E. Adams, of London, making in all sixteen cases with tAvo deaths, Avhile one or other of Buck's methods appears, accord- ing to the same author, to Ikiac been employed thirty-nine times with five deaths—tbe mortality of the former operation being thus 12.."), and that of the latter about 12.8, per cent. A safer method consists in subcutaneously perforating the anchylosed joint in various directions by means of a suitable drill (Fig. 109), the remaining bony adhesions being then forcibly ruptured, and the limb being, after a few days, gradually brought into a straight position by an extending apparatus. This operation appears to have been first suggested by Malgaigne, avIio pro- posed to use a chisel and mallet (as has since been done by L. S. Little and Maunder), though Diefi'enbach had previously suggested separation of the united joint by means of a chhel and saw—not, however, used subcutaneously. Brainard, of Chicago, in 18.">4, proposed to apply the drill to the bone imme- diately above the joint, and the first operation upon this plan Avas performed by Pancoast of this city, in 18.")9. Brainard subsequently applied the drill to the knee-joint itself, and the operation has since been repeated upon several 602 DISEASES OF JOINTS. occasions by Prof. Gross and others. Nine cases, collected by S. W. Gross in 1868, had proved uniformly successful. This procedure is certainly pre- ferable to any other that has, as yet, been proposed, being not only attended with less risk to life, but having the great adA'antage of not shortening the limb by the removal of any portion of bone. Trochlea of humerus ; showing formation and connection of loose cartilaginous bodies. (Miller.) Loose Cartilages in Joints. The name " loose cartilage" is given to certain bodies Avhich are met Avith in joints, and Avhich are very analogous to the rice-like bodies described as occurring in compound ganglia, and in Fig. 295. diseases of synovial bursa5. These loose cartilages have, according to Rainey, as quoted by Barwell, a distinct investing membrane of a fibro-cellular character, and are found on section to consist of two layers, one fibro-cartilaginous and the other resembling bone. They appear, in most instances, to originate in a transformation of the villous or fringe-like processes of the synovial membrane, being thus at first attached by narroAv pedicles to the parietes of the joint, but, subsequently, often be- coming isolated. They are, according to R. Adams, especially met Avith in cases of rheumatoid arthritis, and are most com- mon in the knee, though occasionally seen in other joints. Usually quite small and round, they are sometimes found as large as a chestnut, and flattened or elongated. They may be single, or may coexist in large numbers. According to Teale and Paget, these bodies are in some cases actually fragments of articular cartilage, Avhich are separated by a sIoav process of exfoliation folloAving necrosis, the result of injury. Symptoms.—If closely attached, these bodies may give rise merely to Aveakness of the joint, Avith a tendency to intra-articular effusion, but if float- ing or loose, they are apt to be caught between the opposing joint surfaces— this occurrence causing intense pain, sometimes accompanied with nausea or syncope, and the patient being unable to move the joint, and sometimes fall- ing, while rapid synovial effusion commonly supervenes. These symptoms, it will be seen, closely resemble those of dislocation of the semilunar cartilages (see page 29G). Treatment___This may be palliative or radical. The palliative treat- ment consists in supporting the joint by means of an elastic bandage, so as to restrain its motions, and lessen the risk of the loose body becoming caught between the articulating surfaces. Hilton advises that the loose cartilage should be fixed in contact with the synovial membrane, by means of adhesive strips applied externally, Avhen absorption of the foreign body may often be obtained. The radical treatment, which consists in removing the foreign body, either by direct or by subcutaneous incision, is attended with consid- erable risk to life, the mortality of the direct operation being, according to H. Larrey's and Barwell's statistics, 18, and of the subcutaneous procedure 8, per cent. Hence neither should be employed, unless the disease be attended with so much suffering as to make interference absolutely necessary. The direct operation consists in making a sufficiently free incision over the loose ARTICULAR NEURALGIA. 603 cartilage, Avhich is firmly fixed between the surgeon's finger and thumb, the skin being draAvn to one side so as to make a valvular opening, as recom- mended by B. Bell. The loose cartilage is then squeezed out through the cut, which is immediately closed, Avhile the limb is kept at rest upon a splint. Any inflammation Avhich may follow is to be treated upon the principles already laid down.1 The subcutaneous operation, which, though much safer, is more difficult and more likely to result in failure, consists in fixing the loose cartilage as before, and dividing the synovial membrane over it Avith a long tenotome passed subcutaneously beneath the skin ; the foreign body is then squeezed into the periarticular areolar tissue, Avhere it may he left to be absorbed, or from Avhence it may be removed by direct incision, after some days' interval, as advised by Goyrand. Another plan, introduced, and suc- cessfully practised in 2."i case's, by Square, of Plymouth,- is to squeeze the loose cartilage into, but not through, the subcutaneous opening in the synovial membrane, fixing the foreign body in that position by means of a compress and adhesive strips. The point at which the incision is to be made, in the case of the knee, which is the joint usually affected, is to the inner side of, and a little beloAV, the patella. If the cartilage cannot be fixed by the sur- geon's fingers, MacCormac's plan may be adopted, and the offending body transfixed with a needle or fine trocar. If there be more than one loose cartilage, it may be necessary to repeat the operation at a subsequent period. Articular Neuralgia. (Hysterical Joints.) Intense pain in a joint may arise from various causes unconnected with disease of the articulation itself. Thus, pain in the knee is, as Ave have seen, a common accompaniment of hip disease, and the same symptom may arise from other circumstances, as the pressure of a tumor or an aneurism. Occa- sionally, however, intense neuralgic pain is felt in a joint, accompanied per- haps with slight SAvelling and redness, and attended Avith spasmodic action or, more often, rigid contraction of the neighboring muscles, and yet not depend- ent upon any perceptible organic change. These cases are chiefly, though not exclusively, met with in women, and usually in those who present other evidences of hysteria. The credit of first forcibly directing the attention of surgeons to the true nature of these cases, is undoubtedly due to the late Sir Benjamin C. Brodie, and the subject has been since ably illustrated by Sir James Paget, who describes these, and similar cases, as instances of neuro- mimesis or nervous mimicry of disease. The joints most often affected are the knee, hip, and ankle, though a similar condition is occasionally seen in the elbow and shoulder, and perhaps in the vertebral column. Diagnosis___The diagnosis from arthritis may be made by observing the diffused and superficial character of the pain and tenderness, Avhich are not increased by pressing together the joint surfaces (as would be the case in arthritis), and are not attended with the other signs of inflammation, and with the constitutional disturbance, Avhich Avould be present in an ordinary case of joint-disease. The rigid contraction Avill often disappear, if the patient's attention be suddenly called away, and if an anaesthetic be given, the motions of the limb will be found to be unimpaired. 1 When performed Avith the precautions of Lister's antiseptic method, the risks of this operation are, according to BarAvell and Barton, reduoed to a minimum. 604 EXCISIONS. Treatment___This consists in the adoption of measures to improve the state of the patient's general health, particularly by attention to the di- gestive functions, and by the use of tonics and antispasmodics, with the cold douche and frictions to the affected joint. If contraction exist, the limb may be straightened while the patient is in a state of anaesthesia, and may be kept for a few days subsequently upon a suitable splint. Moral treatment is quite as important as physical, and the patient should, if possible, be induced to co- operate with the surgeon in the adoption of the means employed to promote recovery. In the belief that the disease is mental, it is sometimes advised to work upon the patient's imagination by pretending to perform an operation for her relief; though such a course may occasionally succeed, I believe the surgeon will do better, in the end, by dealing perfectly honestly Avith his pa- tient, and avoiding even the appearance of deception. It is almost needless to say that such heroic measures as amputation or excision, or even the appli- cation of the actual cautery, would be totally unjustifiable in the cases under consideration. Meyer recommends the application of an induced current of electricity to the affected joint. CHAPTER XXXII. EXCISIONS. Excision ix General. The operation of resection, in cases of compound fracture and dislocation, appears to have been known to the ancients, but subsequently Avas entirely forgotten until revived in the first half of the last century by Cooper, of Bungay, who removed the loAver ends of both tibia and fibula for compound dislocation of the ankle. The first excision for disease of a joint, appears to have been that performed by Eilkin, of Norwich, in 1762, in a case of arthritis of the knee. The history of the introduction of the operation of excision into the practice of surgery, is a subject of much interest, but cannot be entered upon within the limits of this work ; the reader is respectfully referred, for information upon this matter, to the able monograph of O. Heyfelder, and to that of Hodges, of Boston. The applicability of excision to the various trau- matic lesions of bones and joints, and to deformity resulting from anchylosis, has already been considered in previous chapters (see pp. 164, 211, f)98) : and I shall therefore, in the folioAving pages, confine myself to a description of the operative procedure in the different regions of the body, and to a considera- tion of the applicability of excision to diseases of bones and joints, especially to caries and arthritis. Indications for, and Contra-indications to, Excision in General—1. Excision is indicated (1) in case a bone or joint is so exten- sively diseased that its removal is imperative ; here the question is betAveen amputation and excision, and the latter operation should always be preferred, provided that the circumstances of the particular case admit of a choice. (2) Excision is sometimes justifiable, where the amount of disease is not sufficient to Avarrant amputation, and yet Avhere the time Avhich would be re- quired for a spontaneous cure Avould be so long as to render operative inter- ference proper, or Avhere the utility of the limb Avould be less after a sponta- neous cure than it Avould be after removal of the joint ; as in the elbow, Avhere a cure by anchylosis would be particularly undesirable. INDICATIONS FOR EXCISION IN GENERAL. 60") 2. Excision is, on the other hand, contra-indicated by (1) the extent of diseased bone being so great that its removal would render the limb an incum- brance, and less useful than a Avell-formed stump ; this is particularly the case in the lower extremity, but in the arm, provided that the hand be preserved, very considerable portions of bone may often be properly removed. (2) Excision should not as a rule be practised in cases of acute disease, experience showing that amputation is under such circumstances better tole- rated. Hence, if operative interference be necessary to preserve life, in a case of acute bone or joint disease, amputation will usually be indicated : ex- cision of the shaft of a bone may, hoAvever, be occasionally proper in cases of acute necrosis from subperiosteal abscess (see page f>74). (3) If the soft tissues around a diseased bone or joint be extensively dis- eased, infiltrated with loAvly organized lymph, and riddled Avith sinuses, the result of an excision is less apt to be satisfactory than under opposite circum- stances, though the operation is not absolutely contra-indicated by such a con- dition. (1) Either extreme of life is considered unfavorable to excision, on account of the long period required for recovery after the operation, and, in the case of early childhood, on account of the risk of interfering Avith the groAvth of the limb, Avhich is chiefly dependent upon the integrity of the epiphyseal cartilages. Boeckel, of Strasburg, hoAvever, from an examination of over tAventy cases of arrested development,' concludes that the shortening is less due to injury of the epiphyseal cartilages than to disuse of the limb OAving to pain or to muscular atrophy—causes Avhich Avould be equally active if exci- sion Avere not performed. This is confirmed by my OA\n observation in a case of disease of the knee of tAventy-three years' duration, in which the leg Avas by measurement four inches shorter than its fellow; by excising the joint and straightening the limb, Avhich Avas much contracted, though a considerable portion of bone Avas of course removed, I gave the patient a limb Avhich Avas practically two inches longer than it had been before the operation. (.">) A bad state of the general health, particularly if dependent upon or- ganic \isceral disease, as of the lungs, liver, or kidneys, must ahvays be con- sidered a contra-indication to excision. The long confinement which usually folloAvs the operation, with perhaps long-continued and exhausting suppura- tion, will seriously complicate the chances of recovery in such a case. Hence, if any operation at all be required in a patient suffering from advanced phthisis, or from Bright's disease, amputation will usually be the preferable procedure. From the above remarks, it will be seen that, while excision is, in suitable cases, an admirable and truly conservath-e operation, and in every way supe- rior to amputation, yet it is, after all, only applicable in selected cases; hence it is obviously unfair to attempt, as has been sometimes done, to prove that excision is a less fatal operation than amputation, by a comparison of the statistical results of the tAvo procedures—one being habitually reserved for favorable cases, while the other is indiscriminately applied to all the remain- der : greatly as I admire the operation of excision, I cannot but believe that, ceteris paribus, it is, in every region of the body, at least as fatal as the corresponding amputation. Process of Repair after Excision__The groAvth of the long bones in thickness is accomplished by means of the periosteum, and in length by means of the epiphyseal cartilages. Hence, in excising portions of the shafts of bones, it is of the utmost importance to preserve the periosteum, by the 1 Oilier recommends in such cases an excision of the epiphyseal cartilage of the sound limb, so as to induce; such shortening as will correspond with that of the other. The use of-a high-soled shoe would seem to me less dangerous. 606 EXCISIONS. osteo-genetic power of which it may be hoped that the excised portion will be reproduced: another advantage of subperiosteal excision, is that, by preserv- ing the membrane in question, the attachments of the various muscles are not disturbed. If the periosteum cannot be preserved—and this can rarely be done in excisions of the short bones, as of the calcaneum—repair is effected by the Avound filling with granulations, Avhich are subsequently transformed into a dense, fibrous, cicatricial mass. In excisions of the joints (particularly among patients Avho have not attained their full height), it is important not to remove the entire epiphysis, nor even to encroach upon the epiphyseal line ; for, if this be done, the subsequent growth of the limb will be deficient. This is especially important in the case of the knee, the loAver epiphysis of the femur and the upper of the tibia being chiefly concerned in the growth of the lower extremity. "When this precaution is observed, the shortening is com- paratively slight, and, indeed, temporary elongation may occur, as in cases of osteitis and arthritis (see pp. 565, 586). An attempt should, as a rule, be made to preserve the periosteum, in articular resections, particularly Avhen, as in the case of the shoulder, elbow, or hip, a movable joint is desired—the effect of retaining the periosteum in these cases being, as sIioavii by Oilier, to improve the shape of the new articulating surfaces, which measurably ap- proach the form of those which Avere removed ; in the knee, Avhere the great object is to obtain firm bony union, the subperiosteal character of the opera- tion is not so essential, though still desirable, as tending to diminish the amount of consecutive shortening. Operation of Excision in General__The knives ordinarily re- quired for the operation of excision, are scalpels and straight bistouries, Fig. 296. Fergusson's lion-jawed forceps. which should be pretty thick at the back, and set in strong handles ; a strong probe-pointed knife, with a limited cutting edge, will also be found useful for Fig. 297. Butcher's saw. clearing the soft parts from the bones in the deeper portions of the wound. Bone forceps of various sizes and shapes will be required, the most important OPERATION OF EXCISION IN GENERAL. 607 Fig. 298. being strong cutting pliers, and the lion-jawed forceps designed by Fergusson (Fig. 296). Gouges and gouge-forceps Avill also be found useful for dealing with carious bone. The saw Avhich I prefer, in most cases, is that designed by Butcher, of Dublin (Fig. 297), which has the great merit of allowing the blade to be fixed at any angle, or even completely reversed, so as to cut from beloAV upAvards, and thus preserve the soft parts from injury. In certain cases (as in excisions of the hip), the chain saw is more convenient than any other instrument. The chain may be slipped over the part to be removed, or may be applied by the aid of a strong curved needle, or an ingenious conductor devised for the purpose by Dr. Buck, of Ncav York. If an ordinary saw be employed, a spatula or retractor must be slipped beneath the bone, in order to guard the soft parts ; a good instrument for the purpose is the " resection sound" of Bkndin, or the probe- pointed grooved retractor described by Dr. D. Prince, of Jacksonville, Illinois; or, Avhich in some cases will prove as satisfac- tory, an ordinary broad lithotomy staff grooved on the back, which may be readily slipped around the bone and then turned Avith its convexity upAvards. Another in- strument Avhich I have found of value, is the knife-bladed forceps of Mr. Butcher (Fig. 299). This cuts like a pair of scis- sors, and is very efficient in removing the thickened and degenerated synovial tissues, which, if alloAved to remain, are apt to slough and impede the pro- gress of cure. Chain saw. Pie. 299. Butoher's knife-bladed forceps for excisions The particular operative procedures required for excision in various re- gions of the body, differ of course according to the parts to be removed; it may be stated, however, in general terms, that the external incisions should be sufficiently free, and as much as possible in the direction of the muscular interspaces, so as to avoid unnecessary destruction of tissue. The incisions should, if practicable, include any sinuses that may be present, and should be made so as to avoid injury to the'principal vessels and nerves. The perios- teum should be preserved, if possible, and the amount of bone removed should he as small as may be consistent with the thorough extirpation of the dis- eased structure. It is a good plan in excising joints, to remove but a thin layer Avith the saAV, and then to attack any necrosed or carious spots Avith the gouge or trephine. The epiphyseal line should never be encroached upon in children, and, even in adults, it is important not to lay open the medullary canal. Care must be taken not to mistake bone Avhich is merely inflamed and softened (medullized), for that which is carious, nor bone thickened and roughened by inflammation, for that which is necrosed. The skin and other soft tissues, no matter how much altered in appearance, should be as a rule 608 EXCISIONS. preserved entire—the flaps, though at first redundant, ultimately shrinking and resuming their natural condition. The degenerated synovial lining of the joint may, however, be advantageously cut aAvay with the knife-bladed forceps; and, indeed, Volkmann goes so far as to advise complete " extirpa- tion" of the joint capsule. All bleeding should be checked, by ligature or otherwise, before the Avound is closed, as it is very important that Avhen the limb is once adjusted, it should not be disturbed for several days. The dressings should be light and simple, and precautions must be adopted to secure free drainage, by the arrangement of the incisions, or by the use of Chassaignac's tubes, etc. Concentrated food, with tonics and stimulants, will usually be required in pretty large quantities during convalescence. Finally, although the case should not progress as favorably as may be wished, the surgeon must not hastily conclude that the operation has failed, and that amputation is necessary ; even if caries or necrosis should recur in the sawn bony extremities, a re-excision may often be attended with a satis- factory result. Special Excisions. Scapula___Excision of the scapula, complete or partial, may be required for various causes, as caries, necrosis, tumors, and some forms of injury, though in traumatic cases it is often necessary to remove the whole upper extremity as Avell (see page 118). The operation may be done "with a crucial incision, or, which is probably better in most cases, a T-shaped incision, as recommended by Syme, the transverse branch of the cut running from the acromion to the posterior edge of the bone, and the other passing downwards, at a right angle from the centre of the former. If the operation be for tumor, the incisions should be merely skin-deep, the flaps being dissected off Avithout cutting into the growth, Avhich may, probably, be very vascular. It is advised by Fergusson and Pollock to liberate the posterior border of the scapula first, and then the inferior, turning up the bone from below upAvards as the operation proceeds. By this plan the subscapular artery can be con- trolled by the finger before division, and the risk of hemorrhage is thus con- siderably lessened. The subclavian artery should be compressed by an assistant throughout the Avhole procedure. In cases of malignant disease, the Avhole scapula should be excised, but under other circumstances a partial operation may suffice, there being certainly an advantage in retaining the head of the bone, acromion, and coracoid, Avhen there is no reason for their remoA al. The clavicle should not be interfered with unless it be itself dis- eased. After the operation, the arm should be supported in a sling, and an axillary pad may be sometimes advantageously employed for a few days. The history and statistics of this operation have been particularly investi- gated by Dr. Stephen Rogers, of NeAv York, \Arho published excellent papers on the subject in 1868 and 1869. Removal of the scapula with the arm has been considered under the head of amputation above the shoulder (page 118). The first case in which the entire scapula Avas removed, the arm being pre- served, was that of Langenbeck, who, in 1855, excised the whole scapula Avith three inches of the clavicle. Since then, complete excision of the sca- pula, with or without interference with the clavicle and head of the humerus (the arm being preserved), has been done by Syme (twice), Heyfelder, Jones, Hammer, Schuh, Michaux, Hamilton, Rogers, Pollock, Steele, Esmarch, Schuppert, Michel, Spence (two cases), King, Logan, O'Grady, Schneider, Wood, Omboni, MacCormac, Pirrie, Bird, Crawford, Mazzoni, Billroth, Peters, Brigham, and an anonymous surgeon, referred to by Dr. Otis. Of these 32 cases, 25 terminated successfully, and five in death, the result of tAvo EXCISION OF THE SHOULDER-JOIN T. 609 not having been ascertained. Extirpation of the scapula, subsequent to am- putation at the shoulder, has been practised by Mussey, Rigaud, Fergusson, Buck, Langenbeck, Busch, KrakoAvizer, Stimson, Jeaffreson, Soupart, and Deroubaix; the eleven cases giving six recoveries and four deaths (tAvo from recurrent disease), and the termination of one being unknoAvn. Total is thus more successful than partial excision, 96 Cases of which have given as many as 29 deaths, or nearly one in three. Clavicle and Ribs___The clavicle may require partial or, in rare in- stances, complete excision, on account of caries, necrosis, tumor, or com- pound fracture. The inner extremity of the bone may also require resection, if it be so displaced as to produce dangerous compression of the oesophagus or trachea. In cases of necrosis, the operation may be made subperiosteal, and presents no particular difficulties, a simple incision folloAving the course of the bone being sufficient for the purpose. In cases of tumor, the opera- tion is both difficult and dangerous, the principal risks being from hemor- rhage and the entrance of air into the Aeins. The entire clavicle has been extirpated more than a dozen times (the first operation of the kind having been performed by McCreary, of Kentucky, in 1811), and in only about one- third of the cases on record has the operation proved fatal. Portions of the ribs have been frequently excised, in cases of caries, ne- crosis, compound fracture, Avound of an intercostal artery, etc. The operation is not particularly difficult, but, except in case of necrosis, when the perios- teum can be detached, is attended Avith considerable risk of injury to the pleura or even the peritoneum. Thirty-seven cases mentioned by Heyfelder gave eight deaths. Fig. 300. Shoulder-joint___Excision of the scapulo-humeral articulation, or of the head of the humerus, may be required in cases of arthritis, caries or ne- crosis, compound fracture or dislocation, or non- malignant tumor. For malignant disease the operation would, I think, be improper, as un- necessarily exposing the patient to a recurrence of the affection. The operation may be conveniently performed by making a single longitudinal in- cision, beginning someAvhat to the outside of the coracoid process, and carried downwards and slightly outAvards—passing between the fibres of the deltoid muscle, in the line of the bicipital groove for about five inches. The long head of the biceps being held to one side, the capsule is divided, and the tuberosities of the humerus freed by the use of the probe-pointed knife, Avhen the head of the bone may be thrust through the Avound and removed Avith a chain saAv, or, in young children, with strong cutting forceps. If the glenoid cavity be diseased, it may then be attacked Avith the gouge-forceps, or may, if neces- sary, be exposed for the application of the saAv by a transverse cut, as directed for excision of the scapula. Hemorrhage having been arrested, the wound may be closed Avith a feAV points of suture, a space being left for drainage (and perhaps a tube introduced), and the arm then supported Avith a sling and axillary pad. In some cases, as of tumor, the longitudinal incision may not suffice to gi\re access to the part, and the surgeon may then raise a flap by means of a 39 Excision of shoulder-joint; lon- gitudinal incision. (Erichsen.) 610 EXCISIONS. V-shaped cut, or one in the form of a ~|, T, or U, as may be thought most convenient. These all have the common disadvantage of involving a trans- verse division of the fibres of the deltoid, and of therefore protracting the healing process, as well as of entailing subsequent weakness of the limb. The first excision of the head of the humerus for disease, appears to have been performed by Bent, of NeAv Castle,(England), in 1771, Avhile the first complete excision of the shoulder-joint Avas performed by the elder Moreau, in 1786. The operation is quite a successful one, considering its magnitude, 169 cases of excision for all causes having given, according to Heyfelder, but 30 deaths, a mortality of less than 18 per cent. If excisions for disease alone be considered, the statistics sIioav an almost equally favorable result, 115 cases tabulated by Culbertson giving 94 recoveries and but 21 deaths. The preserved arm is knoAvn to have been useful in more than three-fourths of the successful cases. The risk Avhich attends this procedure, therefore, is so moderate as to render shoulder-joint excision one of the most satisfactory of surgical operations. Humerus__Excision of the shaft of the humerus may be occasionally required in cases of compound fracture, especially as the result of gunshot injury (see page 167), or may sometimes be necessary in cases of caries or necrosis. Resection is also not unfrequently called for in the treatment of Fig. 301. Fig. 302. Excised extremities of humerus and ulna. (From a specimen in the museum of the Episcopal Hospital.) ununited fracture, and when performed with the precautions recommended by Oilier, of Lyons, and by BigeloAv, of Boston, is quite a successful pro- cedure (see page 237). The operation consists in making a single longi- EXCISION OF THE ELBOW-JOINT. 611 tudinal incision on the outer side of the arm, betAAeen the muscular inter- spaces, and, after carefully dividing and stripping off the periosteum (wliich should ahvays be preserved), removing as great an extent of bone as may be thought necessary Avith a chain suav ; the resected bony extremities should then be approximated and held together by means of a strong metallic suture, and the limb placed at rest, on a suitable splint. Elbow -joint—Excision of this articulation may be required for chronic disease of the joint, for bony anchylosis, or for compound fracture or luxa- tion. The lower end of the humerus was resected by Wainman (in 1758 or 1759), and by Tyre, Avhile the olecranon and upper part of the ulna were remoAed by Justamond, in 1775, but the first complete excision of the elboAv-joint Avas per- formed by the elder Moreau, in 1791, in a case of chronic disease of the articulation. The ope- ration may he conveniently done (as originally suggested by Park) by means of a single longi- ^ tudinal incision, beginning two inches above the olecranon and carried about three inches beloAV it, the line of the incision being parallel to the course of the ulnar nerve, and a few lines to its ,. , . , „. , . . . . fcxcision of elbow-joint by longi- radial side. The only point requiring special tudinal incision. (Bryant.) attention in this procedure is to aA-oid injuring the ulnar nerve, Avhich must be carefully dissected from its position behind the inner condyle (the edge of the knife being kept close to the bone), and then held out of the Avay Avith a blunt hook or spatula. The back of the articulation being thus exposed, the olecranon should be cleared, and may then be cut off Avith strong cutting pliers, this, though not essential, serving greatly to facilitate the subsequent steps of the operation. In order to pre- sence the function of the triceps muscle, Spence divides its tendon by an inverted /^-shaped incision, Avhile Hodges and Maunder take care not to cut the tendinous fibres Avhich are inserted into the fascia of the forearm. "With the same object, Prof. Sayre leaves that portion of the olecranon to Avhich the tendon is attached. The joint being forcibly flexed, and the forearm thrust backAvards, the lateral ligaments may now be carefully divided with the probe-pointed knife. The operation is completed by removing the condyles and the articulating surfaces of the radius and ulna, with Butcher's saAv. The tubercle of the radius should, if healthy, be left undisturbed, so as to preserve the attachment of the biceps tendon. BigeloAV also preserves the external and internal condyles of the humerus. Some surgeons employ a transverse incision in addition to that which has been described, making a Avound of this form |—, while others (as Mr. Butcher, and the late Mr. Syme, add also a second longitudinal incision on the outside of the joint—H, thus forming two rectangular flaps. The simple longitudinal incision is, hoAve\'er, perfectly satisfactory in the majority of cases, and is better adapted for rapid healing than either of the others, having no tendency to gape. As soon as the bleeding has been checked, the wound should be lightly dressed, and the limb laid upon a pillow, or well-padded splint, in a nearly straight position ; after a Aveek or two, when consolidation has begun, the splint may be dis- carded, and the limb simply supported in a sling. The results of elboAv-joint excision, Avhen performed for chronic joint-dis- ease, are commonly very satisfactory, 377 cases tabulated by Culbertson having given but 41 deaths, a mortality of only 10.8 per cent. Oilier reports 36 cases performed by the subperiosteal method, of Avhich only 5 proved fatal. With regard to the condition of the limb after excision, the statistical re- 612 EXCISIONS. Result of excision of elbow-joint. (From a patient in the Children's Hos- pital.) suits are equally satisfactory: thus, according to Hodges, 77 out of 8). Re-excisionhas, been occasionally prac- tised with adAantage, Avhile amputation, subsequent to excision, has resulted faAorably in 12 out of 18 cases in which it has been done. Elaborate statistics of hip-joint excision have been published by several authors, myself included, but the largest number of cases yet tabulated is embraced in Dr. Culbertson's Prize Essay, published in 1876. I haAe myself performed the operation in eleven cases with three deaths. The folloAving tables, compiled from Culbertson's, exhibit, in a form easy for reference, the statistics of the operation, as performed at different periods of life, and the comparative results, according as the aceta- bulum was or was not interfered Avith, or, in other words, of complete as compared with partial exci- sion. Sayre's cuirass for treatment of hip-joint sion. (Sayre.) after- exci- Results of Hip-joint Excision at Different Ages. t'nder 5 years....... 51 Between 5 and 10 ATcars . . . ; 102 " 10 " 15" •' . . . ' 85 " 15 " 20 " . . . i 52 " 20 " 30 ': . . . 39 Over 30 years.......I 26 Age not stated....... 55 Aggregate......470 Eecovered. 29 102 40 22 11 9 21 2:54 Result Died. undeter- mined. 18 4 4s 12 35 10 26 4 22 6 14 3 29 5 44 192 Mortality per cent, of termi- nated cases. 38.3 32.0 46.7 54.2 66.7 60.9 58.0 45.1 16 616 EXCISIONS. Comparative Results of Complete and Partial Excision. Form of Excision, Total. Recovered. Died. Result undeter-mined. Mortality per cent, of termi-nated cases. Complete excision...... 177 ?41 52 90 124 20 77 97 18 10 20 14 44 46.1 4:5.9 47.4 470 234 192 45.1 With regard to the utility of the limb after excision of the hip-joint, it may be said in general terms that a favorable result will be secured in two-thirds of the instances of recovery, the limb being reported as useful in 166 out of the above 234 successful cases. From the first of the preceding tables, it is seen that the most favorable age for the operation is from five to ten years, the mortality increasing after puberty, and in adult life being so large as to Fig. 310. Result of hip-joint excision. the Episcopal Hospital.) (From a patient in Excision of both hip-joints. (From a patient in the Children's Hospital.) be almost prohibitory. Even at the most favorable period, the death-rate is almost one in three, the operation being thus nearly as often followed by death as ligation of the third part of the subclavian or of the external iliac, and more often than amputation at the shoulder, for all ages. The second table sIioavs that complete is, upon the whole, /cry nearly as successful as EXCISION OF THE HIP-JOINT. 617 partial excision, and that hence the acetabulum should be freely gouged, in any case in which it is found to be diseased. The results of hip-joint excision, it Avill therefore be seen, are not very brilliant—one out of three dying under the most favorable circumstances, and but two out of seven recovering Avith useful limbs. Ought Ave, then, to abandon the operation? I ansAver, certainly not. The question is not so much,Avhat does excision promise? as, does any other mode of treatment promise as Avell? What, in fact, can the opponents of hip-joint excision offer instead? The operation is indeed such a grave one, that I have seldom felt that it Avas jus- tifiable to resort to it, in any case in Avhich it Avas not evident that life would be endangered by persistence in expectant measures. But in cases of hip disease in which suppuration has occurred, there usually, sooner or later, comes a time Avhen the only alternatives are excision, amputation, or a pro- longed and painful illness, terminated by death. These patients very rarely (at least in the class of cases Avhich we see in hospital practice) recover under expectant treatment; they are carried from one hospital to another, and at last die Avorn out by suppuration or visceral disease, or are carried off from a life of pain and Aveariness by some intercurrent affection. No one, probably, at the present day, would think of amputating, in any case of hip disease to Avhich excision was at all applicable; and, indeed, apart from the mutilation necessarily entailed, the chances of life are not a great deal better after removal of the limb than after excision—five out of tAvelve cases amputated for hip disease having terminated fatally ; so that excision is, in a good many in- stances, the surgeon's only available resource, and, as such, should be employed Avithout hesitation. In this respect, excision of the hip-joint differs from that of any other articulation of the body, and, as justly remarked by Mr. Holmes, "in cases Avhich sIioav a decided tendency to get Avorse, we may pretty confi- dently reckon all the recoveries after the operation as a clear gain." I once had occasion to resort to excision of both hip-joints in the same patient. The result (Fig. 310) as regards life Avas satisfactory, but the patient Avas not able to walk Avithout crutches as long as he remained under my observation. Cases of Primary Amputation at the Hip-joint for Hip Disease. 1 2 3 4 5 6 7 8 9 in 11 12 Result. Died. Died, 18 days Died, 3 mos. Recovered. Died, 2 mos. Recovered. Died, 6 days. Surgeon. Henry Thompson William Kerr. Baffos. W. J. Duffee. Sccourgeon. Allen. II. Lee. Curling. Waren Tay. A. J. dimming. Rivington. Date. 1778 1811 1840 1861 1862 1865 1866 1873 1873 1876 1877 Dr. John Thomson, Report on Belgian Hospitals, Edinburgh, 1816, p. 264. Med. and Philosoph. Commentaries, vol. vri., p. 337. Richerand, Nosograpbie Chirurgicale, t. iv., p. 518. Am. Journ. of Med. Sci., July, 1857, p. 283, and July, 1866, p. 22. Jamain et Wahu, Annuaire, 1862, p. 221. Trans. Penna. State Med. Society, 3d s., Part II. (1862), p. 209. St. George's Hospital Reports, vol. i.', p. 147. London Hospital Reports, vol. iii., p. 214, and vol. iv., p. 518. British Med. Journal, Oct. 18, 1873. Lancet, Nov. 29, 1873. Ibid., March 24, 1877 Ibid., July 28, 1877. 618 EXCISIONS. Knee-Joint___Excision of the knee-joint may be required in cases of chronic disease of that articulation, and may be occasionally justifiable in cases of compound fracture or dislocation, or of angular anchylosis. This operation appears to have been first performed by Filkin, of Norwich, in 1762 (the case terminating in recovery), and Avas again successfully done by Park, in 1781. So little favor, hoAvever, did the procedure meet with in the eyes of surgeons generally, that forty years ago it had been performed less than twenty times. Revdved by Textor, in Germany, and by Fergusson, in England (the last-named surgeon operating for the first time in 18.30), it has since been resorted to so frequently, that its statistics are now more exten- sive than those of any other Figs. 311, 312. excision. The operation maybe per- formed in several Avays,1 the methods most deserving at- tention being by the H, the U, and the simple transverse incision. The H incision was first employed by Moreau, and consists of tAvo longitudi- nal incisions, one on either side of the joint, Avith a trans- verse cut passing immedi- ately beloAV the patella. The lateral incisions should be placed far back, so as to give ready access to the femoral condyles, and to insure free drainage subsequently. This method, Avhich is preferred by Butcher, greatly facili- tates the subsequent steps of the operation, but has the dis- advantage of making an un- necessarily large wound. The U, horseshoe, or semi- lunar, incision Avas first prac- tised by Mackenzie, and is still preferred by many surgeons. This method consists in raising an anterior flap containing the patella, the base of the flap reaching to above the con- dyles. The ligamentum patellae is dhdded in the first incision, when, the crucial and lateral ligaments being cut, the articulating extremity of the femur can be readily excised with a Butcher's saw. The limb being then flexed and forcibly thrust upwards, the extremity of the tibia can be made to pro- trude, and may be removed Avith the same instrument. The best, in my judgment, is the simple transverse incision across the front of the joint, Avhich Avas suggested by Park, but which appears to have been first employed by Textor, Kempe, of Exeter, and Fergusson. It makes a smaller wound than either of the other methods, and has proved perfectly satisfactory in thirteen cases in Avhich I have employed it. It is to be ob- served, hoAvever, that an incision Avhich is transverse to the axis of the tibia, Avhen the limb is flexed to a right angle (as it frequently is in these cases), 1 Treves, of Margate, reviving the plan of Jeffray and Sedillot, recommends lateral incisions without any transverse wound. Extremities of femur and tihia removed by excision of knee-joint. (From a specimen in the museum of the Episcopal Hospital.) EXCISION OF THE KNEE-JOINT. 619 will, when the excision is completed and the limb extended, form an obliquely curved wound, with its convexity downwards, so that this is in many cases really a flap-operation. The incision should reach on either side to the pos- terior edge of the base of the condyles (so as to secure drainage), and should at its centre come far enough forAvard to pass beloAV the patella. The joint having been laid open, the skin and fascia are dissected up as far as may be necessary, and an incision then made directly down to the bone in the line of proposed section ; the lateral and crucial ligaments (if these remain) having been next divided, the blade of Butcher's saAv is slipped beneath the bone, Avhich is cut through from beloAV upAvards. In sawing through the articulating extremity of the femur, the natural obliquity of this bone should be borne in mind, and the section made in a line parallel to that of the free surface of the condyles; if this be neglected, and the section made transverse to the axis of the femur, the limb after adjustment Avill be found to be markedly boAved outAvards. It should also be remembered that the situation of the epiphyseal line is somewhat higher on the anterior, than on the posterior surface of the thigh-bone—so that it may be given as a safe rule, that the section of the condyles should be in a plane which, as re- gards the axis of the femur, is oblique from behind forwards, from below ■upwards, and from within outwards. The section of the tibia should be in a plane transverse to the long axis of the bone, Avith a slight antero-posterior obliquity so as to correspond with that of the section of the condyles. The epiphyseal cartilage of the tibia is less important for growth than that of the femur, and need not therefore be so scrupulously respected. The patella should be removed, Avhether it be or be not diseased ; it is shoAvn by Penieres's researches that, while its excision diminishes the risk of death by nearly one- third, its retention more than doubles the probability of subsequent amputa- tion becoming necessary. The bone sections being made, and the patella removed, the operation is completed by clipping away Avith scissors curved on the flat, or with Butcher's knife-bladed forceps, ail the fungous and de- generated synovial lining of the joint, taking care, hoAvever, not to sacrifice the posterior ligament, which serves a useful purpose in preventing displace- ment, and in protecting the important structures in the popliteal space. The limb should be dressed Avhile the patient is yet in a state of anaesthesia: for this purpose, the leg is brought into the extended position, the bone sec- tions accurately adjusted, and the whole limb securely fixed upon the splint on Avhich it is to be kept. It may occasionally happen that the limb cannot be brought into the straight position by the application of any justifiable amount of force : under such circumstances the hamstring tendons may be carefully divided, this procedure, though in itself undesirable, being prefer- Fig. 313. Price's apparatus for after-treatment in excision of the knee. able to the removal of an additional segment of bone. The chief difficulty to be contended Avith, during the after-treatment, is to prevent the anterior projection of the cut extremity of the femur, and hence, the surgeon may, if he think proper, fix the bones in apposition by means of a strong metallic 620 EXCISIONS. suture, as originally employed by Gurdon Buck, of Xcav York, and since resorted to by many other surgeons. In most instances, hoAvever, this will not, 1 think, be found necessary, particularly if the bone sections be made, as above recommended, in a plane slightly oblique from behind forwards and from below upwards—a suggestion which appears to have originated with Billroth, and which is readily carried out with the aid of Butcher's saAv. A good splint for the after-treatment of knee-joint excisions is that knoAvn as Price's (Fig. 313), and excellent cures have been obtained Avith Butcher's box splint, or, as recommended by Watson, of Edinburgh, Avith a posterior Fig. 314. w Wire splint for excision of knee. moulded splint and an anterior wire rod to enable the limb to be suspended. The essential points to be secured are absolute immobility of the limb, and ready access to the wound; and I have myself been abundantly satisfied with a simple bracketed wire splint (Fig. 314), with a movable foot-piece, the Fig. 315. Fig. 316. Excision of knee-joint for recurrent arthritis with partial anchylosis in bad position. (From a patient in the Episcopal Hospital.) splint being, of course, Avell padded, and the thigh, leg, and foot firmly fixed with bandages and broad strips of adhesive plaster. When the splint has EXCISION OF THE KNEE-JOINT. 621 been adjusted, the limb should be laid on a pillow, or, still better, in a large and loose fracture box. Any tendency to anterior projection of the femur may be counteracted, as advised by Butcher, by using in addition a short anterior splint, Avhile the risk of outward bowing may be prevented by using an external splint, a metal spring and truss-pad, as ingeniously suggested by Swain, or, which I have found sufficient, a simple strip of adhesive plaster carried around the outside of the limb and secured to the inner side of the splint. The object being to obtain firm bony union, the splint should be removed as seldom as possible, and the first application should suffice, if pos- sible, for at least a fortnight; and, indeed, I have occasionally extended this time Avith advantage to five or six Aveeks. The statistics of excision of the knee-joint have been investigated by a number of writers, and elaborate tables have been published by Butcher, Heyfelder, Hodges, Penieres, Picard, and many others. The most recent researches upon this subject are those of Cklbcrtson, avIio has analyzed nearly 700 operations, of Avhich no less than 603 were for chronic disease of .the articulation. These 603 cases gave 419 recoveries and 178 deaths, the result in six not having been ascertained ; the total mortality of terminated cases Avas therefore 20.8 per cent. The folloAving table will exhibit the results more in detail:— RecoA-ered without further operation ..... 354 or 58.7 per cent. " Avith useful limbs ....... 246 or 40.8 " Result undetermined (one amputated) . . . . . 6 or 1.0 " Amputated subsequently (65 recovered, 12 died, and 1 unde- termined).......... 78 or 12.9 " Died after excision ......... 166 or 27.5 " Death-rate of terminated cases in which no further operation was performed ......... 31.9 " It is thus seen that, even Avhen excision fails, consecutive amputation is attended Avith comparatively little risk, less indeed than thigh amputation for disease in general. The folloAving table, compiled from Culbertson's, sliows in a very satisfac- tory manner the mortality of knee-joint excision at different ages :— Result of Knee-joint Excision at Different Ages. Result Mortality per Age. Total. Recovered. Died. not deter-mined. cent, of termi-nated cases. 1 to 5 years . ..... 19 11 7 1 38.9 5 to 10 "....... 106 88 17 1 16.2 81 18 17.2 15 to 20 "....... 84 58 25 i 30.1 20 to 25 "....... 67 40 26 l 39.4 25 to 30 "....... 55 34 20 l 37.0 30 to 40 "....... 65 38 27 41.5 Over 40 "....... 19 9 10 52.6 89 603 60 28 i 31.8 Aggregate ...... 419 178 6 29.8 It thus appears that the operation of knee-joint excision, Avhich is quite fatal in very early childhood, is not attended with much risk from the age of five up to the period of puberty; while from that time the danger steadily increases, till in adult life the operation is again one of a very serious nature. 622 EXCISIONS We may, therefore, probably say, Avith Holmes, that fourteen is, all things being considered, about the most favorable age—there being then compara- tively little danger of consecutive shortening, while the operation is at tin1 same time not attended Avith any particular risk to life. Excision of the knee-joint should not as a rule be performed during the first five years of life, while it must be deemed an extremely grave procedure in persons past the age of thirty. Bones of the Leg.—Excision of the tibia is rarely justifiable, but may occasionally be proper in cases of acute necrosis from subperiosteal abscess (see p. 574). The operation requires a single longitudinal incision, the bone being then divided with a chain saw, and wrenched from its epiphyseal attachments with the lion-jawed forceps. Excision of the fibula, Avbich may be required for compound fracture or for necrosis, may be effected by a simi- lar operation, care being taken to pre\*ent subsequent eversion of the foot, by the use of a suitable splint. Ankle___Excision of the ankle-joint may be required for compound frac- ture or dislocation, or for disease of the articulation. The operation may be performed by means of tAA7o lateral incisions, one behind either malleolus, or, Avhich is probably better, by means of a semilunar incision passing around the lower border of the external malleolus and continued in a longitudinal direction along the line of the fibula. The anterior portion of the incision should not extend so far as to endanger either the extensor tendons or the dorsal artery of the foot. Having divided the peroneal tendons, the surgeon may remove the lower end of the fibula, when the astragalus "will come into vieAV. If this bone be but slightly affected, it will be sufficient to remove its upper articulating surface with saw or cutting forceps, and to gouge away such portions as may seem diseased, but under other circumstances the astra- galus should be removed entire. The foot being then inverted, the loAver end of the tibia is to be cautiously cleared Avith the probe-pointed knife, the inner malleolus being cut away Avith strong forceps, and as much of the articulating extremity of the tibia as may be thought necessary removed Avith the chain saAv ; or a second incision may be made on the inner side of the limb, and the extremity of the tibia removed with a narrow saAv passed across from one side to the other. The limb may be kept during the after- treatment in a fracture-box, or on a posterior wire splint provided with a foot-piece. The foot must be Avell supported, lest anchylosis Avith a " pointed toe" ensue. The statistics of excision of the ankle-joint for disease have been investi- gated by Spillman1 and Culbertson, the latter of Avhom has collected 124 cases. The disease, in most instances, Avas caries or arthritis, but occasionally necrosis, bony tumor, etc. The results maybe seen in the following table:— Naturk of Operation. Partial excision Complete " Undetermined . Aggregate 51 5 124 Recovered. Died. Result not deter-mined. Mortality per cent, of termi-nated cases. 57 45 5 4 6 7 6.6 11.8 107 10 7 8.5 ! Archives Gene"rales de Me'decine, Fev. 1869. EXCISION OF THE BONES OF THE FOOT. 623 The condition of the preserved limb in most of the cases of recovery is said to have been quite satisfactory, Culbertson giving the proportion of useful limbs as 66 per cent., and Stauff, as quoted by Rose, as 75 per cent. Foot.—The only excisions of tarsal bones which require special notice are those of the astragalus and of the calcaneum. Excision of the Astragalus may be required in eases of compound fracture or dislocation (or even simple dislocation, if irreducible), caries, necrosis, etc. The operation requires a semilunar incision on the anterior and outer aspect of the joint. The removal of the bone may often be facilitated by cutting across its neck with strong pliers, when the fragments may be successfully dislodged with elevator and forceps, the probe-pointed knife being cautiously used in the deep portions of the wound—but in other cases it may be neces- sary to remove the hone piecemeal, by means of the gouge. The statistics of this operation (Avhich Avas first performed in 1582 by a surgeon of Duisburg, in a case recorded by Hildanus), have been investigated by Hancock and Poinsot, the former of Avhom finds that of 112 patients sub- mitted to total excision, 70 recovered with useful limbs, 2 were cured by am- putation, and 19 died, while in 12 cases, the result was not ascertained. The mortality of terminated cases Avas thus exactly 10 per cent. The same Avriter has collected 28 cases of partial excision of the astragalus, with 18 satisfactory recoveries, one cured by amputation, and one death. Poinsot has collected, in all, 144 cases, of Avhich 26, or 18 per cent, terminated fatally. Excision of the Os Calcis is occasionally required in cases of caries or necrosis of that bone, though in the majority of instances, free gouging, or the extraction of sequestra, "will suffice. The operation of excision of the calcaneum, may be done by raising a heel flap, as in Syme's amputation, or (as recommended by Erichsen) by turning down an elliptic flap constituted of the tissues of the sole, and then making two lateral triangular flaps, by carrying a longitudinal cut through the tendo Achillis to meet the former incision. A still better method, probably, is that of Holmes, in Avhich an incision is made on the level of the upper part of the bone, beginning at the inner border of the tendo Achillis (Avhich it divides), and passing around the back and outer surface of the foot as far forAvard as the mid-point betAveen the heel and the base of the fifth metatarsal bone, a second incision passing at a right angle from near the anterior end of the former, downwards to the commencement of the grooved internal surface of the os calcis. The flap thus formed, AA'hich includes the cut peronei tendons, is then reflected from the bone, Avhen the ligaments of the calcaneo-cuboid joint being divided, the cal- caneum itself can be slightly displaced imvards, so as to facilitate the division of the various ligaments between that bone and the astragalus. This being done, the calcaneum is tAvisted outwards, and carefully separated from the soft parts on its inner side. The operation is completed by stuffing the cavity with a strip of oiled lint, and by fixing the foot at a right angle Avith the leg, by means of an anterior moulded splint. Southam, and Lund, of Manchester, employ a single external incision, beginning as in Holmes's operation, but carried fonvards to a point midAvay betAveen the projection of the fifth meta- tarsal and the tip of the malleolus. From a recent discussion in the Clinical Society of London, it Avould appear that the result of the operation is most satisfactory Avhen no attempt is made to preserve the periosteum. The statistics of excision of the os calcis, which appears to have been first performed by Monteggia, in 1814, have been studied by Burrall,1 of NeAv 1 Bellevue and Charity Hosp. Reports, 1870, p. 91. 624 ORTHOPAEDIC SURGERY. York, and by Polaillon1 and Vincent,2 of Paris. The last-named writer has collected 79 cases, Avhich resulted as follows : 49 patients recovered with useful limbs, 5 recovered, but without much use of the preserved member, 10 submitted to subsequent amputation, and 5 died, while the result in 10 cases Avas not ascertained. If Ave add 3 successful cases reported by McGuire, of Richmond, Va., Ave shall have a total of 72 terminated cases, giving o'l reco- veries Avith useful limbs, and but 5 deaths, a mortality of less than 7 per cent. Aincent's statistics sIioav that subperiosteal excision is more dangerous than the ordinary operation, having given 3 deaths out of 23 cases. The other tarsal bones, or those of the metatarsus or toes, comparatively seldom admit of excision, the disease, Avhen too extensive for successful goug- ing, usually requiring amputation ; I have, hoAvever, myself had occasion to resort to excision of one or more bones of the anterior tarsus and metatarsus, and P. S. Conner has collected 35 cases, including 2 of his own, in which tAvo or more bones were remoA'ed at one operation, 25 of the whole number having terminated in recovery, 5 in failure, and 5 in death. The same sur- geon has also reported a case in which he successfully removed the whole tarsus, the rest of the foot being preserved. AVhen excision is resorted to, the lines of incision should be regulated by the position of external sinuses; no rules can be given Avhich in such cases Avould admit of general application. The joint betAveen the astragalus and calcaneum has been successfully ex- cised by Annandale. CHAPTEE XXXIII. ORTHOPAEDIC SURGERY. Orthopaedic3 surgery is that branch of surgical science Avhich treats of the means of remedying deformities, congenital or acquired. Etymologically, the term should be used only Avith reference to the deformities of childhood, and might be taken to embrace a great variety of subjects, such as the removal of tumors, the reduction of dislocations, etc. In practice, however, the appli- cation of the term is limited to a few particular kinds of deformity, as wry- neck, lateral curvature of the spine, club-hand or club-foot, and contractions of joints not due to articular disease, while, on the other hand, no reference is intended to the age of the patient in Avhom these deformities occur. Among those who, in this country, have particularly illustrated this branch of sur- gery, may be mentioned J. M. Warren, BigeloAV, BroAvn, Detmold, Sayre, Bauer, Prince, Mutter, and J. Pancoast. Wry-neck. This affection, Avhich is also known as Torticollis, or Caput Obstipurn, is occasionally congenital, but more often originates in children from three to ten years old. It consists in a contraction of the cervical muscles, particularly the sterno-cleido-mastoid and trapezius, usually on one side only, but some- times on both. The head is drawn downAvards and inclined to the affected side, being at the same time rotated in the opposite direction. In the con- 1 Archives Ge"nerales de Medecine, Sept. et Oct. 1869. 2 De l'ablation du calcaneum, etc., Paris, 1876. 3 From ojflo; (straight), and wait (child). WRY-NECK. 625 genital form of the disease, and in that Avhich is acquired (if long continued), the deformity is increased by defective development of the corresponding side of the face and head. The cervical vertebra; undergo rotation on their axis, becoming twisted, and serving to maintain the deformity, and ultimately compensatory lateral curvature is developed in the rest of the spinal column. AVry-neck is more common in girls than in boys; it is apparently due to irritation of the spinal accessory nerve—the non-congenital Arariety coming on after the eruptive fevers, or as the result of glandular inflammation or ordinary muscular rheumatism. It sometimes occurs as a reflex phenomenon, depending on the irritation of teething, or of intestinal parasites. Many of the cases which are considered congenital are, according to Little, due to injuries received during birth. When both sterno-cleido-mastoid muscles are involved, the affection "will usually be found to have a rheumatic origin. Symptoms and Diagnosis.—The symptoms are easily recognized, the contracted muscles being tense and well defined ; frequently both portions of the sterno-cleido-mastoid seem equally rigid, but often the sternal portion is alone or principally involved. The diagnosis is usually easy ; the deformity may be closely simulated by the contraction of a cicatrix after a burn, or by disease of the cervical vertebra?; in the former event, the nature of the case will be evident upon careful examination, Avhile, if spinal disease be present, the fact can be ascertained by observing the localized tenderness on pressure, and the pain produced by moving the spine or by pressing the head doAvn- Avards, Avith perhaps the existence of inflammatory thickening and of partial motor paralysis. Treatment___In the milder form of the affection, especially Avhen of a rheumatic origin, a cure may be sometimes effected by the use of anodyne and stimulating embrocations, or, as successfully practised by Dr. J. M. Da Costa, of this city, by the hypodermic use of atropia ; in some cases, in Avhich the disease Avould appear to consist not so much in spasmodic contraction of the muscles on one side as of paralysis of those on the other, benefit may be derived from the employment of electricity, or from the endermic application of strychnia. In severer and more obstinate cases, it will usually be neces- sary to resort to an operation, though, if the degree of contraction be not very great, mechanical extension, by means of a suitable instrument, will occasion- ally suffice. The Operative Treatment of wry-neck consists in the subcutaneous division of one or both of the lower attachments of the affected sterno-cleido-mastoid muscle: the sternal portion may be divided by introducing an ordinary tenotome in front of the upper margin of the sternum, and about half an inch above the line of the clavicle, and, having passed the knife behind the tendon, Fig. 317. Tenotome. with its flat surface toAvards the latter, turning the edge forwards, and cutting the muscle, Avhich is previously rendered tense, Avith a slight sawing motion from behind forwards. The clavicular attachment may be divided by a similar operation, through a puncture made at its posterior edge ; or, which is perhaps safer, a small incision may be made down to the clavicle, between 40 626 ORTHOPAEDIC SURGERY. the two portions of the muscle, and the clavicular attachment then cut from behind forwards, with a delicate probe-pointed tenotome which is cautiously insinuated between the muscle and the bone. As soon as the tendons have been divided, the punctures should be closed Avith a little dry lint and an adhesive strip, the patient being then placed in bed Avith the head Avell sup- ported ; after a few days an apparatus may be applied to effect mechanical extension, Avhile the cure is further promoted by the systematic employment of friction and passive motion. The operation for wry-neck is one of much delicacy, and not free from risk, the principal danger being from the possi- bility of Avounding the external or internal jugular vein, or the carotid artery; that this risk is not merely imaginary is shown by the fact that, in more than one case, the operation has been folloAved by fatal hemorrhao-e. Various forms of mechanical apparatus are employed in the after-treatment of wry-neck ; in young subjects, it may sometimes be sufficient to apply a broad adhesive strip around the forehead and occiput, and another around the waist, fastening the tAvo together by means of a bandage carried from above the ear of the unaffected side across the chest to the opposite side of the trunk, thus reinforcing the healthy sterno-cleido-mastoid muscle, and so causing the disappearance of the wry-neck. A more elegant appliance is that of Jbrg, which consists of a leather corset and firm head-band, connected by a steel rod Avorked by a ratchet-wheel and key. Other efficient forms of apparatus act by means of two levers, one pressing on the side of* the chin, and the other on the opposite temple. Wry-neck accompanied with Painful Convulsive Spasm of the Affected Muscles is a very intractable form of the disease, and occurs chiefly in female adults. Here division of the sterno-mastoid muscle affords, usually, only temporary relief. Dr. Little has several times obtained a cure by the admin- istration of the bromide of potassium, or of the corrosive chloride of mercury, with attention to the digestive functions; and in one case a portion of the spinal accessory nerve was excised Avith benefit by Mr. Campbell De Morgan. The actual cautery has proved effective in the hands of Dr. C. K. Mills. Lateral Curvature of the Spine. This affection, which appears, in the majority of cases, to depend simply upon relaxation and debility of the spinal ligaments and muscles, is most com- mon in young girls of from tAvelve to eighteen years of age. There are usually two curves, one occupying the dorsal region, and in most instances presenting its convexity to the right side, and the other or compensatory curve in the lumbar region, and convex to the left. More rarely there are four curves, an upper and a lower dorsal, and an upper and lower lumbar. Together Avith the lateral curvature, there is always a rotation of the bodies of the vertebrae on their axis, this rotation or tAvisting taking place in the direction of the convexity at each portion of the curve. The bodies of the vertebra? are thus more displaced than the spinous processes, which, as pointed out by Judson, of New York, are held in place by their lateral attachments, and which sometimes appear, even in advanced cases, to occupy almost their natural line. The disease affects at first only the ligaments and muscles of the spine, but, in long-continued cases, may give rise to compression or par- tial absorption of the intervertebral cartilages, or even of the bones themselves. As the result of the tAvisting of the vertebra; Avhich accompanies the lateral displacement, a certain degree of antero-posterior curvature is sometimes superadded—a rounded or hump-like projection occurring in the dorsal re- LATERAL CURVATURE OF THE SPINE. 627 gion, with a corresponding incurvation of the lumbar spine, the former con- stituting the condition known as cyphosis, and the latter that called lordosis. These are indeed but exaggerations of the natural curves met with in every adult spine. In some cases, especially among rachitic persons, they may exist Avithout lateral displacement. Dr. Tuckey, an Irish physician, has described, under the name of acute lateral curvature, a condition Avhich seems analogous to the so-called " hysterical" joint-affections described in Chapter XXXI. Causes___The common cause of lateral curvature is, as already men- tioned, simply debility of the ligamentous and museular structures Avhich normally support the vertebral column, thus allowing, as it were, the head and upper part of the body to settle dowmvards, and necessarily forcing the relaxed and weakened spine to yield at its least-resisting point. The physio- logical changes Avhich occur in the female at the age of puberty, and the cus- tomary relinquishment, at that period of life, of the out-door sports of child- hood, appear to act as pOAverful predisposing causes of the spinal relaxation referred to. The very constant character of the displacement—to the right in the dorsal, and to the left in the lumbar region—is doubtless due to certain vicious habits and postures, such as supporting the whole weight on the riglit leg (" standing at ease," in the language of the drill-master), Avhereby the pelvis is rendered oblique, and the lumbar spine necessarily distorted to the left side; to sitting habitually at a desk with the left shoulder depressed and the right elevated ; to OA-er-exertion of the right arm in seAving, etc. Though the dorsal curve is usually most apparent, it is really, according to ShaAv, preceded in time of formation by the lumbar. The latter, hoAvever, does not become so quickly permanent, on account of the greater flexibility and elas- ticity of the part, which enable it to resist longer the occurrence of absorption of the articular processes and other secondary changes than can be done by the dorsal spine, fixed as that is by its connections with the thoracic walls. According to AVillett, both curves are deAeloped simultaneously. Among the rarer causes of lateral spinal curvature may be mentioned obliquity of the pelvis from any circumstance, as from anchylosis of the hip- joint after hip disease (here the deformity is principally of the variety called lordosis), and distortion resulting from contraction of one side of the chest after empyema or chronic pleurisy. Inequality in the length of the lower limbs is, according to BarAvell, a frequent cause of lateral curvature. Symptoms.—The symptom of lateral curvature which first attracts attention, is commonly a projection or ''groAving out" of the right scapula, often attended with pain in the shoulder and back ; this is usually worse while sitting, or upon first lying doAvn, so that a patient, Avho has made no complaint during the day, may lie aAvake in pain for several hours upon going to bed at night. Upon making an examination, the surgeon will readily per- ceive the Aving-like projection of the scapula, and may, even at this early stage, recognize a slight deviation in the line of the vertebrae, by tracing doAvn the spinous processes and marking each Avith pen and ink. It must be, moreoArer, remembered that the deviation of these processes by no means represents the degree of distortion of the bodies of the bones, the displace- ment of the latter being, I believe, invariably greater than that of the former. In the early stages of the affection, the deformity can be made to disappear by laying the patient on a bed in the prone position and making slight exten- sion on the spine; but in advanced cases, the deformity Avill persist in all positions, Avhile the AA'hole chest and the pelvis may be likeAvise markedly distorted, and serious functional disturbance, or even organic disease, may 628 ORTHOPAEDIC SURGERY. result from the consequent compression of the thoracic, abdominal, or pelvic viscera. Diagnosis___Lateral curvature may be distinguished from the graver condition known as antero-posterior curvature, or Pott's disease of the spine (Avhich Avill be described hereafter), by the fact that in the latter affection the displacement is com- monly angular, rarely lateral, and unat- tended with axial rotation of the vertebra;. There are besides, usually, marked immo- bility, thickening, and tenderness of the affected portion of the spine. From the spinal distortion of rickets, lateral curva- ture may be distinguished by observing the different ages at Avhich the diseases respectively occur, and by noting that in rachitis the primary displacement is antero- posterior, the lateral deformity, if there be any, being a mere coincidence ; while in the true lateral curvature the fact is exactly the reverse, cyphosis and lordosis being in these Lateral curvature of spine. (Erichsen.) Cases secondary phenomena. Treatment.—No matter how slight the deformity in any case may appear to be, it should not be neglected: in the early stages, before any structural alteration has occurred, it may be possible to effect a complete cure ; but at a later period, the most that can be done is to prevent further increase of the deformity. The treatment consists in the adoption of measures to improve the general health, the administration of tonics, especially iron and quinia, and the abandonment of any injurious hqbit or occupation. The patient should take exercise in the open air, and may often derive great advantage from gymnastics, sAvinging by the hands from bars placed above the head, the use of light dumb-bells, etc. The object is to put in motion and thus to strengthen the various muscles attached to the spinal column, and much ingenuity may be exerted in devising various modes of accomplishing this purpose. None of these exercises should, hoAvever, be persevered in to the extent of producing fatigue. During the intervals of exercise, the patient should be encouraged to keep the recumbent posture, lying upon a firm mat- tress or sofa Avith a single pillow, so as to relieve the vertebral column from pressure. If the curvature persist Avhile lying down, a cushion may be placed under the projecting portion of the spine, so as gradually to press the bones into their normal position. Friction of the muscles on either side of the spine, either Avith the hand alone or with stimulating liniments, will often be of service, as will also the daily use of the cold salt douche. In severer cases it Avill probably be necessary to afford mechanical support by means of some form of apparatus. A great many instruments have been devised for this purpose, the general principle of action being to elevate the shoulders by means of crutch-heads under the axilla: (connected with a well-padded pelvic collar), with side-pieces to support and gradually replace the projecting ver- tebras by applying pressure to the corresponding portions of the chest-Avails. Such an apparatus should be, as a rule, Avorn during the day only. Prof. Sayre has recently recommended the use of a plaster of Paris bandage, applied while the spine is made as straight as possible by suspending the Fig. 318. DEFORMITIES OF THE UPPER EXTREMITY. 629 patient by his head and arms. The suspension itself may also prove of ser- vice, as Avas pointed out by Glisson in the seventeenth century. If a case of lateral curvature be recognized at an early period, and promptly and judiciously treated, it may be, if not cured, at least kept in check until the critical period of adolescence has passed by, Avhen there "will be compara- tively little tendency to increase of the deformity. It thus happens that while a very large number of young girls suffer from incipient lateral curva- ture, its adA-anced stages are comparatively seldom seen—the disease being, as it Avere, "outgroAvn" in a great many instances. Myotomy, or subcutaneous division of the spinal muscles and aponeuroses, for a long time almost entirely abandoned in the treatment of lateral curva- ture, has been recently revived by Prof. Sayre, of NeAv A ork, who has in several cases divided the latissimus dorsi Avith alleged immediate benefit. I confess that the operation seems to me unnecessarily heroic, and, indeed, as the disease is mainly dependent upon ligamentous and muscular relaxation, not contraction, I do not understand why such a procedure should be expected to prove ultimately successful. Deformities of the Upper Extremity. Contraction of the Shoulder__Duplay has described, under the name of scapula-humeral periarthritis (see page 596), an affection Avhich consists in inflammatory thickening of the sub-acromial bursa and sub-deltoid areolar tissue, Avith the formation of adhesions which interfere with the motions of the humerus. The extra-articular character of the affection can be recog- nized by observing the localization of the pain and swelling in the sub-acro- mial region. The treatment consists in forcibly rupturing the adhesions Avhile the patient is under the influence of an anaesthetic, and in the subsequent employment of passive motion, friction, galvanism, and the cold douche. Gosselin has described a similar condition as occurring in the knee. Contraction of the Elbow, apart from disease of that joint, may be OAving to the retraction of the cicatrix of a burn, or to a contracted state of the biceps muscle—which latter condition may itself be variously due to hysteria, to rheumatism, or to constitutional syphilis (see pp. 451, 507). In hysterical cases, the proper constitutional treatment for that condition should be employed, the arm being, if necessary, extended Avhile the patient is in a state of anaesthesia, and then kept in a straight position for a Icav days. In the rheumatic form, when the contraction is permanent and accompanied with organic change, tenotomy may be required. The operation is performed by slipping a tenotome flatAvise beneath the tendon of the biceps from within outAvards, so as to avoid the artery, and then, turning the edge of the knife forwards and upAvards, effecting the section by cutting Avith a slight sawing motion Avhile the arm is forcibly extended. The wound should then be closed and the arm placed in a sling, extension being applied after a few days by means of a screAV-splint or Aveight. Contraction of the Forearm and Hand is occasionally met with, as the result of excessive use of certain muscles, Avith disuse of others : the treatment consists in a change of occupation, Avith the employment of a straight splint, friction, galvanism, etc. Club-Hand is a rare affection, analogous to club-foot. It is usually com- plicated with a deformed condition of the loAver end of the radius, and some- times of the carpal bones. Tavo forms of club-hand are met with, in one of 630 ORTHOPAEDIC SURGERY. which the part is in a state of extreme flexion, and in the other of extension. The affection is sometimes congenital, but usually results from infantile paralysis, and is, according to Holmes, ahvays accompanied by other defor- mities. The treatment consists in supplementing the action of the paralyzed muscles by means of India-rubber bands, attached to a light metal frame, and passing beneath a ring at the Avrist. In inveterate cases, tenotomy may be required, folloAved, after the healing of the Avound, by passive motion, aided by the use of friction and galvanism. Contraction of the Fingers into the palm of the hand is not unfre- quently met with, usually in old persons, as the result of an indurated state of the palmar and digital fascia, due apparently to a constitutional condition analogous to that of rheumatoid arthritis. The exciting cause of the affection (Avhich was first well described by Dupuytren) is often the habitual pressure of the head of a cane, or of the handles of various kinds of tools. A similar contraction may be due to burns or other traumatic causes (in Avhich case a scar would be perceptible), or to certain forms of eczema—an important point to be remembered, as the operation about to be described would not of course be applicable to that affection. The treatment of the deformity noAv under consideration consists in the cautious subcutaneous division of the contracted tendons or fascia, which may be effected by slipping a small tenotome beneath them in the palm, and cutting forwards, the cure being completed by passive motion (after a few days), with frictions, bandaging, or the use of a screw- splint. Under this treatment, the fascial induration gradually yields, the ridges and furrows disappearing, and the part slowly returning to its normal state. Relapse is, however, not infrequent (owing to the constitutional nature of the affection), and a repetition of the operation may therefore become necessary. Busch and Aladelung advise that a triangular flap of skin should be dissected up, and the palmar fascia notched at every joint at Avhich it seems tense ; the flap is then to be replaced, and, Avhen the wound has united, mechanical extension resorted to. Post divides the contracted fascia by direct incision, and Adams by subcutaneous section from above dowmvards; both lay stress upon the importance of making immediate extension. Webbed Fingers___This annoying deformity may be remedied by per- forating the base of the Aveb and allowing the parts to cicatrize around a metal ring, Avhen the rest of the web can be divided Avithout risk of readherence ; by a plastic operation as employed by Barwell, who transplanted flaps for the purpose from the patient's buttock, and by Harris, of Xew Jersey, avIio utilized for the purpose a strip of skin taken from the Aveb itself; or by the use of the elastic ligature, as recommended and successfully employed by Vogel, of Eisleben. Deformities of the Loaver Extremity. Contraction of the Hip. — Contraction of the muscles surrounding the hip may occasionally require tenotomy or myotomy, in cases of spasmodic rigidity of the lower extremities, of congenital luxation, or of chronic hip disease. The tendon Avhich most often requires division is that of the adductor longus, though the operation is also sometimes performed upon the adductor bre\ris, pectineus, tensor vagina? femoris, and rectus. Division of these mus- cles is performed in accordance Avith the principles of tenotomy in general, the knife being introduced behind the part to be divided, and the section then cautiously effected by cutting from behind forwards. DEFORMITIES OF THE LOWER EXTREMITY. 631 Knock-knee or Genu-valgum is a not uncommon deformity, consist- ing of a relaxation of the ligamentous and muscular structures of the knee- joint, allowing the articulation to yield in a direction iiiAvards and backwards. The internal lateral ligament is elongated, Avhile the external lateral ligament is rendered tense, together Avith the vastus externus and outer hamstring tendon. The inner condyle of the femur is, as compared with the outer, dis- proportionately large and prominent, Avhile the popliteal space is somewhat obliterated. The affection is probably never congenital, but comes on during childhood, and is apparently connected in many instances Avith a rachitic tendency. Both knees are usually simultaneously affected, though the disease may be more marked in one than in the other. The treatment consists in the adaptation of an apparatus such as is shown in Fig. 319. \n iron rod, hinged at the hip, knee, Fig. 319. and ankle, extends from a pelvic band to the sole of the shoe, and is provided with pads, straps, and buckles, by Avhich the knee may be draAvn outwards : in severe cases, motion should be permitted at the hip and ankle only, the knee being fixed, and its displacement gradually rectified by means of the adjusting straps or a ratchet-screw. Division of the external hamstring tendon is occasionally re- sorted to as a preliminary measure, but, ac- cording to Little, does not appreciably hasten recovery, and is therefore not to be recom- mended. Little, Schede, Annandale, and Chiene have, in aggravated cases, straight- ened the limbs by excising wedge-shaped pieces of bone, the two former from the tibia, and the tAvo latter from the condyles of the femur. Schede also divided the fibula Avith a chisel. Excision of the knee-joint has in a similar case been successfully resorted to by Air. HOWSC. OgSton simply saws through the Apparatus for knock-knee. projecting condyle and forcibly straightens the limb, while a similar operation Avith the chisel and Avith antiseptic precautions is practised by BarAvell. Reeves employs an operation of like character, but aAroids opening the joint, and thus makes the section extra-articular. Outward Bowing of the Knee or Genu-Extrorsum is a condi- tion Avhich is the reverse of Genu- Valgum; the external lateral ligaments are relaxed, and the tibia? themselves are commonly curved, giving the appearance known as " bow-legs." This deformity is sometimes traceable to premature attempts at Avalking, and is usually connected with a rachitic vice of constitution. The treatment consists in the application of padded splints, so as to overcome the outAvard bending of the limbs, and, at a later period, in the adaptation of suitable supports, so as to prevent a recurrence of the deformity. Air. Alarsh recommends forcible straightening of the curved tibia?, or ca en partial division of these bones with a narrow saAv, and fracture of the remaining fibres and of the fibula?, and reports several cases in Avhich this apparently severe operation was resorted to with good results. A similar mode of treatment has been successfully resorted to by Billroth, Avho, how- ever, employed a chisel instead of a saAv. Contraction of the Knee, dependent upon shortening of the ham- strings, may occur in connection with anchylosis of the joint, or independ- 632 ORTHOPAEDIC SURGERY. ently : the treatment consists in division of the hamstring tendons, folloAved by gradual extension, with passive motion, friction, etc. Division of the Hamstring Tendons is thus performed: the patient being in the prone position, an assistant renders the parts tense, by fully extending the limb, and the surgeon then introduces the tenotome flatwise on the inner side of the outer hamstring, or biceps tendon (Avhich is to be first divided), through a puncture which in the adult should be an inch above the point at which the tendon joins the fibula. By keeping the knife close to the tendon, the resk of wounding the peroneal nerve is avoided, and the section is then effected by cautiously cutting towards the skin. The semi-tendinosus, being superficial and prominent, is readily divided, but the semi-membranosus re- quires a freer use of the knife: it, however, comparatively seldom needs to be cut. In operating on the inner hamstrings, the tenotome should be intro- duced close to the outer (popliteal) side of the semi-tendinosus, as there is thus less risk of Avounding the important structures in the popliteal space. After the operation, the Avounds should be instantly closed with a firm com- press (to prevent extravasation, or the entrance of air), and no attempt at extension should be made until the parts are entirely healed, which usually requires a delay of four or five days. Neglect of this precaution may give rise to Avide-spread suppuration in the tissues of the ham. When cicatrization has occurred, gradual extension may be made by means of a Aveight, elastic bands, or screw apparatus, or in some few cases forcible extension may be preferably employed, the patient being of course in a state of ana?sthesia. Recovery may be further promoted by the assiduous practice of passive motion, aided by friction, douches, etc. Club-Foot.— Talipes or Club-foot is a common deformity, Avhich may affect one or both extremities, and may occur in either sex, though more frequently in boys than in girls. It may be congenital or acquired. There are four primary and as many secondary varieties of the deformity. The primary forms of club-foot are Talipes Equinus, Talipes Calcaneus, Talipes Varus, and Talipes Valgus, while the secondary forms are combinations of these, receiving the names of Equino- Varus, Equino- Valgus, Galcaneo- Varus, and Calcaneo- Valgus. All forms of club-foot depend upon contrac- tion of various muscles and tendons, which may result from spasm of the contracted parts themselves, or from paralysis of the antagonistic muscles; in most cases, the bones of the foot are not altered in structure, but in invete- rate cases of varus (Avhich is the most common form of congenital talipes), the astragalus, scaphoid, and cuboid will all be found more or less atrophied and tAvisted, the ligaments correspondingly altered in length, the tendons dis- torted, and the muscles of the Avhole limb Avasted. Adams indeed maintains that, in cases of varus, the astragalus is malformed from the moment of birth, the malformation probably being due to the pressure of the adjacent bones during intra-uterine life. In non-congenital club-foot, the muscles commonly undergo fatty degeneration, rendering prognosis in these cases less favorable than in those wliich are congenital. The first application of tenotomy to the cure of club-foot Avas an operation performed by Lorenz, in 1784, on the recommendation of Thilenius, of Frankfort. The operation consisted in a simple incision, involving the skin and subjacent tissues as Avell as the contracted tendon, and a perfect cure is said to have been obtained. Delpech, in 1 HI6,' transfixed the limb beneath the tendo Achillis, and cut towards the skin, which Avas, however, carefully protected from injury. To Stromeyer, of Hanover, in 1831, is due the credit of first resorting to subcutaneous tenotomy as it is now practised, Avhile to Guerin and Bonnet, in France, to Little, Tamplin, and Adams, in England, CLUB-FOOT. 633 Fig. 320. and to Detmold and Aliitter, in this country, are in a great measure OAving the general introduction and perfection of the procedure. The process of repair after division of tendons consists, as shown by Adams, in the development, between the retracted ends, of a new material, Avhich does not, as Avas formerly supposed, subsequently contract and bring doAvn the shortened muscle, but remains permanently, though gradually as- similating itself in structure and appearance to the original tendon. 1. Talipes Equinus—This is very seldom, if ever, a congenital affection, but is, on the other hand, the most common non-congenital form of club-foot, occurring, according to Tamplin, in forty per cent, of cases originating after birth, and in twenty-tAvo and a half per cent, (or, according to Lonsdale and Adams, thirty-four per cent.) of all cases taken indiscriminately. The de- formity in talipes equinus consists simply in an elevation of the heel, Avhich may be so slight as merely to prevent the foot from being flexed beyond a right angle, or may be so marked as to force the patient to walk upon the toes and extremities of the metatarsal bones, as seen in Fig. 320. The cause of this deformity (in children) is very often disturbance of the nervous system during dentition, or from the irritation of in- testinal Avorms, though some cases depend upon general infantile paralysis; in adults, this form of club-foot may result from paraly- sis, from abscess or injury of the calf of the leg, or from habitually keeping the foot in a bad position (during the treatment of fractures, etc.), by which the patient acquires a " pointed toe." The treatment consists in the subcutaneous division of the tendo Achillis, about an inch above its point of insertion. The patient being prone, and the tendon rendered tense by depressing the foot, the tenotome is introduced flat- wise (on either side, as most convenient), and carried across in close contact with the tendon, so as to avoid Avounding the posterior tibial artery; the edge of the knife being then turned backAvards, the tendon is forcibly brought against it by still further depressing the foot, Avhile the blade is given a slight saAving motion. An audible snap usually marks the completion of the opera- tion, Avhen the heel can be immediately brought down an inch or two further than before. Prof. J. Pancoast has in some cases advantageously substituted division of the lower portion of the soleus muscle for that of the tendo Achillis. In very severe cases of talipes equinus, it may be necessary to divide the plantar fascia, or even some of the tendons of the toes, as avcII : when the plantar fascia is to be divided, this should be done as a preliminary operation, the tendo Achillis being for the time untouched, so that its tense condition may fix the heel and facilitate the " unfolding" of the arch of the foot. After the operation, the punctures made by the tenotome should be immediately closed with a piece of lint and adhesive strip. Mechanical extension may be begun from the third to the fifth day (not before the former), and may be conveniently effected by Adams's modification of Scarpa's shoe, which differs from those in ordinary use, chiefly in having a transverse division of the sole- plate, corresponding to the transAcrse tarsal joint. In using this, as Avith all other forms of orthopa?dic apparatus, care must be taken to guard against Talipes equinus. (Pirrie.) 634 ORTHOPAEDIC SUROERY. Fig. 321. excoriation, by frequently removing the instrument and bathing the skin Avith some stimulating lotion. The extension must he effected very gradually, the maxim "festina lente" being in no cases more important than in these. 2. Talipes Varus is the most frequent variety of coiigenital club-foot, being met with, according to Tamplin, in ninety per cent, of such cases. The deformity of varus is t.AVofold, con- sisting in an inversion of the anterior tAvo-thirds of the foot, Avhich rotates upon a centre of motion constituted by the astragalo-scaphoid and calcaneo-cuboid joints, with an elevation of the posterior third by the contraction of the muscles of the calf. When the latter displace- ment is particularly marked, the affection receives the name of equino-varus. The inversion of the front part of the foot is due to contraction of the tibialis anticus, tibialis posticus, flexor longus digitorum, and occasionally the flexor and extensor longus pollicis, the plantar fascia and flexor brevis digitorum being also some- times more tense than in the normal state. The treatment of this form of club-foot, is best divided into tAvo stages, the inversion of the front of the foot being remedied during the first, and the eleA-ation of the heel during the second stage ; in other Avords, the case is first to be converted into one of simple talipes equinus, and then treated as was directed in speaking of that form of the affection. In some very slight cases of congenital varus, the deformity can be remedied by simple manipulation and friction repeated several times a day, but in cases of ordinary severity, tenotomy should be resorted to, the best age for the operation being probably betAveen the second and third months of life. The tendons to be divided in Talipes varus. (Fergusson.) Fiff. 322. Varus shoe, with jointed sole-plate. Acquired Talijies Calcaneus (Bryant.) the first stage of treatment, are those of the tibialis anticus and posticus, with sometimes that of the flexor longus digitorum, and the plantar fascia. Buchanan, of Glasgow, advo- cates division of the muscular substance of the abductor pollicis. The tibialis anticus tendon deviates from its normal direction, curving dowmvards and backwards across the inner malleolus, while the posterior tibial tendon passes from behind the inner ankle directly doAvnwards, or even with a slight backAvard obliquity. In dividing the latter tendon, CLUB-FOOT. 635 there is some risk of wounding the posterior tibial artery ; hence it is Avell to adopt Tamplin's suggestion of making a preliminary puncture, and then using a blunt-pointed tenotome. Should the vessel be Avounded, it should be cut completely across, and a firm compress and bandage then instantly applied. If a traumatic aneurism form, it may be treated by compression, by injection of the perchloride of iron, or by the "old operation." Similar treatment AA'ould be required if the internal plantar artery should be wounded in divid- ing the plantar fascia. After tenotomy, the inversion of varus may be sIoavIv overcome by bandaging the limb to a straight external splint, or by the use of a " varus shoe," provided with a joint in the sole-plate for effecting ever- sion (Fig. 322). The second stage of treatment consists in dividing the tendo Achillis, and in subsequently bringing down the heel, as in a case of simple talipes equinus. The time required for the cure of talipes Aarus varies from Iavo montbs to a year, according to the age of the patient and the severity of the affection. Excision of the cuboid bone, suggested by Dr. Little and first practised by Air. Solly in a case of talipes ATarus in an adult, has been lately revived Avith good result in several cases by Air. R. Davy, and the same surgeon and J. F. West, of Birmingham, have further extended the operation to removal of a wedge-shaped portion of the tarsus. Davies-Colley has, in a case of varus, excised the cuboid, Avith portions of tlm astragalus, calcis, scaphoid, cunei- forms, and outer metatarsals ; Avhile Lund, of Manchester, has in a similar case successfully excised the astragalus on both sides. Alason, of NeAv York, has excised the astragalus and external malleolus for equino-varus, but sloughing and hemorrhage folloAved, and amputation Avas performed Avith a fatal result. The astragalus has also been excised for club-foot (successfully) by A'erebelyi. 3. Talipes Calcaneus (Fig. 323) is very rare as a congenital affection, though as a non-congenital disease, resulting from infantile paralysis (particularly in combination with talipes valgus), it is, according to Adams, comparatively common. This form of club-foot depends upon contraction of the muscles of the front and outer part of the leg, the deformity, which is the reverse of talipes equinus, causing the patient to Avalk on the heel. In slight cases of the congenital A'ariety, a spontaneous cure may be effected by the simple process of walking, but in most instances, tenotomy will be required, the ten- dons to be divided being those of the tibialis anticus, extensor communis digitorum, extensor proprius pollicis, and peroneus tertius. The after- treatment consists in the application of an apparatus provided Avith an elastic spiral spring at the heel, to supplement the action of the tendo Achillis. This form of talipes is occasionally combined with varus, constituting calaneo-varus. 4. Talipus Valgus, orflat or splay- foot, is rare as a congenital, but suffi- ciently common as an acquired affec- tion. The deformity is here the re- ATerse of that seen in varus, the sole being flattened, the arch of the instep obliterated, and the foot everted. In severe cases, the heel is commonly depressed as Avell, constituting .calca- Talipes valgus; (Pirrie.) Fig. 324. 636 ORTHOPAEDIC SURGERY. neo-valgus; or, on the other hand, the heel may be elevated, constituting equino-valgus. Congenital cases of talipes valgus may often be cured by simple manipulation, or by bandaging the foot to an inside splint Avith a Avedge- shaped pad, as in Dupuytren's mode of treating fractured fibula. In other instances, tenotomy Avill be required, the parts to be divided being the tendons of the peroneus longus and brevis, and extensor communis digitorum, Avith sometimes the tendo Achillis, or even the tendons of the tibialis anticus and extensor pollicis. The after-treatment consists in applying an apparatus to produce gradual inversion, Avith a pad to restore the arch of the foot. Weak Ankles, Avhich often precede the deAelopment of acquired talipes valgus, should be treated by attention to the hygienic surroundings of the patient, and by the use of friction and the salt douche, Avith, if necessary, an elastic bandage, or light metallic lateral supports. On the Treatment of Club-foot without Dividing Tendons—Air. Barwell opposes the practice of tenotomy, in the treatment of talipes, on the ground that the affection is always the result of paralysis, and that divided tendons seldom reunite. He recommends instead, the employment of an apparatus, in which elastic cords supplement the paralyzed muscles, and counteract the action of-those wliich are contracted. Without entering into any discussion of Air. Barwell's theoretic vieAVS (Avhich are opposed to those of the leading authorities on the subject of club-foot), it will be sufficient to say that, while the ingenious mode of treatment which he advocates may undoubtedly effect a cure in mild cases, it "will, as undoubtedly, fail in many of those Avhich are more severe; and even in the slight cases, tenotomy (which has not been proved to do any harm) certainly abbreviates the time required for treatment. Indeed, we may safely say, in the words of Air. Adams, that the successful treatment of club-foot demands, in most cases, "a judicious combination of operative, mechanical, and physiological means." The chief advocate of Air. Banvell's views, in this country, is Prof. Sayre, of New York, who is how- ever too judicious a surgeon to recommend BarAvell's plan as an exclusive mode of treatment. ^Prof. Sayre's rule for determining whether or not a ten- don should be divided, is to anaesthetize the patient and then haAdng put the parts on the stretch to press with the finger or thumb on the stretched tendon; if this pressure produce reflex contractions, tenotomy is required.' Contraction of a Toe, usually the second, is commonly due to a tense state of the digital prolongation of the plantar fascia, and requires division of the offending structure ; the operation should be done subcutaneously, oppo- site the base of the second phalanx, the toe being then straightened, and secured to a small pasteboard or wooden splint. Contraction of the great toe, sometimes called Hallux valgus, has already been referred to in speaking of bunion (p. 512). DISEASES OF THE HEAD. 637 CHAPTEE XXXIV. DISEASES OF THE HEAD AND SPINE. Diseases of the Head. Tumors of the Scalp—The most common forms of tumor met with in the scalp, are the cutaneous proliferous cyst and the vascular or erectile tumor, though fatty and fibrous growths have also been occasionally seen in this situation. The treatment of these affections has been sufficiently dis- cussed in other parts of the volume. Tumors of the Skull.—Bony, cartilaginous, myeloid, and cancerous groAvths are met Avith in the cranial walls, the latter form of disease constitu- ting the affection sometimes described as Fungus of the Skull. Surgical interference is rarely admissible in this serious condition, though a case is referred to by Erichsen, in which such a groAvth was successfully removed by B. Phillips. Fungus of the Dura Mater__Under this name is commonly de- scribed a tumor which, beginning without any obvious cause, makes its appear- ance on the top or side of the head, or in the temporal region, forming a semi- fluctuating mass, sometimes crackling on pressure, pulsating, attended with much pain, and accompanied with various cerebral symptoms, such as double- vision, deafness, convulsions, and, in the latter stages, coma and paralysis. The tumor, as it increases, becomes softer and more prominent, a distinct margin of bone being often felt surrounding the morbid groAvth, indicating the occurrence of erosion of the skull. The pathology of this serious affec- tion, which Avas first clearly described by Louis, has been recently investi- gated by Air. Lawson Tait, Avho concludes, from the disseetion of a case which came under his own observation, as well as from the recorded histories of other instances of the disease, that the so-called fungus of the dura mater is really an affection of the skull, originatiag in the layers of osteal cells, and, clinically speaking, of a malignant character. The disease may originate either beneath the pericranium (outside the skull), or between the cranial wall and the dura mater, or, as happened in Air. Tait's own case, in both situations simultaneously, the skull thus undergoing erosion on both sides, until the masses meet and amalgamate, Avhen pulsation is developed. The Diagnosis from vascular tumor of the scalp, which is the only disease with Avhich the affection is likely to be confounded, may be made by observ- ing that the growth cannot be moved laterally upon the skull, and (in cases in Avhich the bone is perforated) can be often partially reduced Avithin the cranial cavity. A fungus of the dura mater has been punctured under the impression that it was an abscess, but such a mistake could scarcely arise except through carelessness. The Treatment of this affection is extremely unsatisfactory: Louis recom- mends that the growth should be excised, or othenvise extirpated, after removing as much of the skull as may be necessary with the trephine ; but the case which he gives of recovery after this severe treatment, seems, as justly remarked by Holmes, to have been really one of simple caries with 638 DISEASES OF THE HEAD AND SPINE. underlying exuberant granulations. Any partial operation, in view of the malignant character of the affection, Avould be Avorse than useless, Avhile com- plete extirpation would, in all probability, but hasten the fatal issue. Fungus of the Brain, or Hernia Cerebri, has been sufficiently alluded to in a preA'ious portion of the Avork. (See page 318.) Encephalocele, Meningocele, etc__These are the names given to congenital tumors, consisting of a protrusion through a suture, or part of the skull Avhich in foetal life is membranous, of portions of the cranial contents. The meningocele contains merely a bag of cerebral membranes with sub- arachnoid fluid, while the encephalocele contains a portion of brain-substance as Avell. Hydrencephalocele, as the term is used by Prescott Hewett, is an encephalocele complicated by the protrusion of one of the ventricles filled with fluid. These malformations usually, but not imrariably, occupy the occipital region, protruding a little behind the situation of the foramen mag- num ; they are usually solitary, but occasionally multiple, varying in size from that of a pea to that of the head itself, and complicated Avith internal hydrocephalus. The sac of a meningocele may be single or multilocular, and the contained fluid may be clear like that of a hydrocele, or may be dark from the admixture of blood. If the tumor be sessile, it may be wholly or partially reducible by pressure, such reduction being folloAved by symptoms of cerebral compression ; the tumor sAvells up and becomes tense when the child cries, and sometimes partakes of the motions of the brain. The affec- tion is occasionally complicated with na?vus, and not unfrequently with other congenital malformations. The Diagnosis from congenital cystic tumor, when the meningocele is sessile, is sometimes very difficult; but in most cases may be made by ob- serving the situation of the malformation, its variations of tension, and the fact that it is not movable upon the skull; if, hoAvever, the communication with the cranial cavity be very small, the diagnosis may be quite impossible. The affection is also liable to be confounded with erectile tumors of the scalp, and indeed, as already mentioned, the two diseases may coexist. The Prognosis is unfavorable, the large majority of these cases terminat- ing fatally during infancy, though occasionally patients thus affected have survived to adult life. Death is usually preceded by convulsions, due to cerebral pressure, but in some cases ulceration or rupture occurs, when inflam- mation of the sac and general spinal meningitis are the immediate precursors of the fatal issue. The Treatment in most cases should (according to Holmes, avIio has de- voted special attention to the subject) be limited to affording support and making gentle pressure, by means of a gutta-percha cap lined with cotton Avadding; and in cases evidently complicated with general hydrocephalus, nothing further is admissible ; compression Avith a plate of sheet-lead proved successful in a case recorded by Dr. AV. S. Hill, of Maine. If the tumor be rapidly increasing, Avithout general symptoms, repeated tappings may be re- sorted to, with precautions against the entrance of air ; the aspirator has been thus successfully employed by J. F. AVest. In cases of meningocele, if pe- dunculated, iodine injections may be tried Avith some hope of benefit. Finally, if there be reason to believe that, as sometimes happens, the communication with the cranial cavity has become obliterated, the tumor may be excised; or even if a communication persist, the operation might be occasionally justi- fiable, the pedicle of the tumor in such a case being first compressed by means of a clamp, Avhich should be alloAved to remain for twenty-four hours. A very remarkable case Avas reported a feAV years ago by Dr. Daniel Leasure, of DISEASES OF THE SPINE. 639 Alleghany City, Pa., in which a meningocele (or, as the author termed it, hydrencephalocele) was said to have been radically and permanently cured by evacuating the contents of the sac, and invaginating its integuments so as to plug the cranial aperture—very much as is done with the scrotal tissues, in Wutzer's operation for the radical cure of hernia. Paracentesis Capitis—The operation of tapping the head is occasion- ally required in cases of acute, or even of chronic, hydrocephalus, when death seems imminent from the intra-cranial pressure exercised by the accumulated fluid. The relief afforded by paracentesis, under these circumstances, can scarcely be expected to be permanent, particularly in congenital cases, in which there is usually malformation of the brain. Still the operation is not, even in these instances, likely to add much to the gravity of the situation, while in the non-congenital cases it has unquestionably been occasionally productive of much benefit. An aspirating tube or very delicate trocar is to be employed, being introduced through the anterior fontanelle, as far as possible from the niedian line (so as to av-oid wounding the longitudinal sinus), or, in cases of internal hydrocephalus, tlirough the coronal suture on either side, midway betAveen the anterior and sphenoid fontanelles, the point being then directed inwards and backwards so as to penetrate the lateral ventricle. A small quantity only (about two fluidounces) of fluid should be evacuated, the sides of the skull being compressed during the operation by the hands of an assistant. As soon as the instrument has been withdrawn, the puncture should be closed with an adhesive strip, and an elastic, perforated, India-rubber cap (as ad- vised by Holmes) tightly drawn over the head, so as to support the skull and prevent syncope. If no bad results follow the operation, it may be repeated at another point, after a few weeks' interval. Diseases of the Spine. Spina Bifida (Hydrorachis)—This is a congenital malformation, which consists in a deficiency of the spinous processes and lamina? of one or more vertebra?, allowing the protrusion of the spinal membranes, wliich form a tumor containing Fig. 325. cerebro-spinal fluid and usually some of the spinal nerves, or even it is said a part of the spinal cord itself. Spina bifida in the cervico- dorsal region, however, according to Giraldes, contains no nervous filaments, and I have been told by Dr. J. B. S. Jackson, of Boston, that in numerous dissections of spina? bifida?, he has invariably found the cord itself to terminate above the upper margin of the tumor. Hy- drorachis may occupy any portion of the ver- tebral column, though most frequent in the lumbar and sacral regions ; may be single or multiple; is usually of an oval shape ; and varies in size from that of a walnut to that of a child's head. It may be sessile or pedun- culated, sometimes lobukted, and is usually covered by skin of a more or less normal character, though in some instances there is no cutaneous investment, the sac-Avail beinc constituted of the spinal dura mater itself, in which case ulceration is apt to occur. The 0 .~~ZZA ZZZ^ZZ 1 Spina bifida. (Druitt.) 610 DISEASES OF THE HEAD AND SPINE. tumor is tense and elastic Avhen the child is in the upright position and during the action of expiration, becoming softer during inspiration and when the child is laid on its face. Fluctuation is sometimes observed, and partial reduc- tion may be often effected by pressure—the bony aperture through which the protrusion has taken place being then perceptible to the touch. Spina bifida often coexists with other deformities, and is frequently complicated with hydro- cephalus. Death usually occurs within a short time of birth, from convulsions or spinal meningitis, though occasionally life is prolonged to adult age (74 years in a case obseiwed by Callender), and in some rare instances it Avould appear that a spontaneous cure has been effected, by the channel of communi- cation Avith the cavity of the spinal membranes becoming obliterated. The treatment of this affection is usually not very satisfactory ; if the tumor be not rapidly increasing in size, the surgeon should content himself Avith applying equable support, with perhaps slight pressure, by means of a well- padded leather or gutta-percha cap, or an air-pad ; if the skin be not irritable, the tumor may be painted with collodion, thus taking advantage of the con- tractile properties of that substance. If the child be otherAvise healthy, and life seem to be endangered by the rapid growth of the tumor (threatening ulceration and rupture, or inducing convulsions or paralysis), paracentesis may be tried ; the sac is tapped with an aspirator or a small trocar at a distance from the median line (in Avhich position the nerve-structures are most likely to be placed), an ounce or iavo of fluid being evacuated, and the wound then in- stantly closed, and pressure reapplied. If these means fail, and the tumor be pedunculated, a small quantity of a solution of iodine may be cautiously in- jected, a plan wliich, Avith various modifications, has been successfully employed by Brainard, of Chicago, Aklpeau, J. Alorton, AVatt, Eate, EAvart, and other surgeons. According to Alorton, hoAvever, the iodine treatment is not applica- ble in cases accompanied by paralysis. The formula recommended by this surgeon is iodine, 10 grains; iodide of potassium, 30 grains; glycerine, 1 fluid- ounce. Of 18 cases treated in this Avay, 15 are said to have terminated successfully. Ligation and excision have been occasionally resorted to, and each has proved successful in at least one instance, but, in most cases, has but served to hasten death. The use of the elastic ligature, Avith or Avithout para- centesis, has been employed by Laroyenne, Ball, Colognese, Baldossare, and Alouchet, 6 cases collected by the last-named surgeon having given 3 recove- ries and 3 deaths. It is best adapted to cases in the cervical and dorsal regions, as in these, no nerve-elements are involved. False Spina Bifida—Under this name are included three distinct condi- tions, viz.: (1) a true spina bifida, the connection of which with the spinal membranes has become obliterated ; (2) a congenital tumor, cystic or fatty, which originates Avithin the spinal canal and protrudes through an aperture due to a deficiency in the vertebral lamina?; and (3) a tumor containing foetal remains, constituting the malformation properly described as included feta- tion. If the surgeon can satisfy himself, by careful and repeated examination, that, in a case of this kind, there is really no communication Avith either the cavity of the spinal meninges, or with the pelvic or other internal viscera, an operation for the relief of the deformity may be properly resorted to; if the tumor be evidently cystic, iodine injection would be the proper remedy, but under other circumstances excision Avould be preferable.1 Congenital Cystic Tumors, unconnected with the spine but occupying the median line of the back, may closely simulate cases of spina bifida, but as 1 See, upon this subject, Holmes's Surgical Treatment of Children's Diseases, pp. 90-93. ANTERO-POSTERIOR CURVATURE OF THE SPINE. 641 pointed out by T. Smith, can sometimes be distinguished by feeling the line of spinous processes beneath the cyst; the diagnosis might further be aided by an analysis of the contained fluid, which in some cases of spina bifida has been found to contain a substance resembling grape-sugar. Antero-posterior Curvature of the Spine (Disease of the Spine, Pott's Disease)—This affection usually originates in osteitis of the bodies of the vertebra?, though occasionally it Avould appear that the disease began in the intervertebral fibro-cartikges. In some instances, and in these the prog- nosis is least unfavorable, the case is one of ordinary osteitis ;^but in most ^f / ** " cases there is evidence of the existence of scrofula, or even of the deposit of tubercle. Spine disease occurs chiefly in children and in young adults, and is perhaps rather more frequent in boys than in girls. Occasionally a fall or a blow is referred to as the exciting cause of the affection, but in most in- stances no explanation of its origin can be given. Any part of the vertebral column may be the seat of the disease, Avhicli is, hoAvever, most common in the dorsal region. The bodies of several vertebra? are usually simultaneously affected, becoming softened and disintegrated, and leading to disorganization of the intervertebral fibro-cartikges—the superincumbent weight of the head Fig. 320. Fig. 327. Antero-posterior curvature of spine. (Liston.) Caries of the vertebra. (Liston.) and upper part of the body eventually giving rise to the posterior angular deformity Avhich is characteristic of the fully developed affection. In most cases, the osseous change runs on to caries (whence the disease is frequently spoken of as caries of the vertebre), abscess forming as a consequence, and the pus usually making its way to the surface, either in the loin, or by descending in the course of the psoas muscle ; in other cases, however, the pus, for a time at least, becomes concrete and obsolete, rendering the spine a favorite situation of the residual abscess (see p. 384). In a few instances, the disease runs its course Avithout any evidence of pus-formation whatever, the 41 642 DISEASES OF THE HEAD AND SPINE. pathological change in these cases, therefore, being more properly designated as interstitial absorption than as caries (see p. 570). Although, in the course of the disease, the spinal canal may be bent to a right angle, it is very seldom that the spinal cord is pressed upon or otherwise injured. This is evidently owing to the gradual nature of the change, Avhich alloAVS the cord to accommodate itself to its altered circumstances ; and to the occurrence of anchylosis, which prevents injurious motion. Anchylosis is indeed the process by Avhich nature effects a cure in these cases. It fre- quently goes on pari passu Avith the disintegrating changes, arches of iicav bone being thrown across from one vertebra to another, and the same speci- men exhibiting, at once, caries, medullization, and eburnation in different parts. In cases in which anchylosis is deficient (as may happen Avhen the angular projection is not marked, the diseased vertebral bodies being then separated and prevented from coalescing), spinal meningitis may occur, lead- ing to secondary changes in the cord, and to consequent paralysis ; while in the cervical region, where the vertebral column has a considerable range of motion, consecutive fracture or dislocation may take place, and, by compress- ing or bruising the cord, lead to a rapidly fatal issue. Symptoms___The early symptoms of spine disease, particularly in children, are somewhat equivocal, consisting chiefly in evidences of spinal irritation, such as Aveakness, numbness, and tingling of the loAver extremities, a difficulty in standing or Avalking, Avith a tottering gait, and a tendency to fall forwards. The spinal column is somewhat stiffened, the patient moving it as a Avhole, and thus being unable readily to raise or turn himself in bed without assist- ance. Examination may re\'eal an undue prominence of some of the dorsal spines, with perhaps thickening of the surrounding tissues, and tenderness on pressure. Pain may be elicited by pressing on the head, or by making the patient jump from a stool to the floor, thus approximating the extremities of the vertebral column. In adults, pain is a more constant symptom, being usually of a dull rheumatic character. Spasmodic pain in the abdomen is, according to Dr. B. Lee, an early and characteristic symptom of this affec- tion. As the disease advances, paralysis may be developed, involving the loAver or upper extremities, according to the part of the spine affected. In- continence of feces and retention of urine sometimes form further disagree- able complications. Abscess sometimes occurs quite early in the course of the disease, and not unfrequently before the development of angular deformity. According to Dr. C. S. Bull, Pott's disease is usually accompanied with dila- tation of the pupils, and with passive engorgement of the vessels of the retina and optic disc. Diagnosis—The diagnosis in the early stages is often very difficult; in- deed it is sometimes quite impossible to distinguish spine disease, particularly in children, from inflammation of the surrounding ligamentous structures, until the milder course of the latter affection reveals its true nature. From neuralgia of the spine, an affection analogous to the hysterical knee-joint, the diagnosis may be made by observing the absence, in the neuralgic affection, of rigidity or other physical evidence of disease, even in cases of long dura- tion. The Avincing of the patient, upon the application of a sponge wrung out of hot water to the suspected part of the spine, is looked upon by many surgeons as a sure proof of the existence of caries. According to my experience this test is not to be implicitly relied upon ; at least, I have known it to fail in cases in which the deformity and other symptoms left no doubt as to the nature of the case. The diagnosis from morbus coxarius, and from sacro- iliac disease, has already been referred to. (See pp. 591 and 594.) AVhen the characteristic deformity appears, there is little difficulty in recognizing the nature of the affection. This deformity consists, as already mentioned, in a ANTERO-POSTERIOR CURVATURE OF THE SPINE. 643 posterior angular projection of the diseased vertebra?, due to the absorption or disappearance of their bodies, and the consequent subsidence of the upper portion of the column. It is distinguished from the antero-posterior curva- ture of simple debility, by its persistence in the prone position—and from that of rickets, by its angular character. This angular^ deformity is accom- panied, after the occurrence of anchylosis, Avith compensatory forward curva- tures above and beloAV ; the gibbosity of the spine is thus throAvn into a plane behind that of the pelvis, while the head is directed upAvards and backwards, giving the peculiar but involuntary strut and air of pride, Avhich are so often seen in hunchbacks. Occasionally the displacement is at first someAvhat lateral, and a hasty examination might then give the impression that the case Avas one of lateral curvature: the diagnosis may be made by observing that in true spine-disease there is no axial rotation of the vertebra?, such as ahvays exists in the other affection (see p. 617). AATien the vertebra? involved are those of the cervical region, particularly the atlas and axis, the case may be mistaken for one of wry-neck. The sterno-mastoid muscles are, under these circumstances, tense and prominent, and the neck stiff; Avhile the patient often involuntarily supports the head with both hands, so as to guard against sudden movements. The diagnosis from wry-neck may be made by noting the localized tenderness and thickening of the spine, and the increase of pain by tapping or pressing on the head. The diagnosis of Abscess arising from Spine-disease requires some atten- tion. The situation of the abscess, in these cases, varies with the part of the vertebral column Avhich is involved. Thus, in disease of the cervical verte- bra?, the pus may present itself at the back of the pharynx, at the side of the neck (beneath the sterno-mastoid muscle), or more rarely in the axilla; it may even pass downwards into the thoracic cavity. Abscess from disease of the upper dorsal vertebra? commonly makes its way downwards, along the course of the aorta and iliac arteries, presenting itself in the iliac fossa above Poupart's ligament, but may gravitate to the back of the pelvis, passing out through the sacro-sciatic notch into the gluteal region, may pass forwards along the ribs, opening at the side of the trunk, or may go directly back- wards, forming a dorsal or lumbar abscess ; finally, it may, in some rare cases, burst into the air-passages or gullet. AYhen the lumbar and lower dorsal vertebra? are affected (the most common situation of the disease), the abscess usually descends in the sheath of the psoas muscle, on one or both sides, con- stituting the condition known as psoas abscess.1 This generally points in the front of the thigh beneath Poupart's ligament, but may burroAv downwards to the ham or even to the ankle. In other cases the pus may present itself in the lumbar region, in the perineum, on the outer side of the hip, in the iliac fossa, or in the inguinal canal; or it may even burst into the bowel or bladder. By care and attention it is usually possible to determine whether an abscess, occurring in any of these situations, be or be not dependent upon disease of the spine. It is, hoAvever, sometimes a matter of great difficulty to distinguish betAveen psoas and iliac abscess—the former commonly arising, as Ave have seen, from caries of the dorsal or lumbar vertebras, Avhile the latter originates in the areolar tissue of the iliac fossa, and may or may not be connected with disease of the bony pelvis. This difficulty is further in- creased by the circumstance that, while spinal abscess occasionally presents itself, as we have seen, in the iliac region, an iliac abscess may, on the other hand, make its way into the sheath of the psoas muscle. Psoas abscess is, hoAvever, commonly a disease of early life, points below Poupart's ligament, 1 Psoas abscess, hoAvever, according to Stanley, Bryant, and others, sometimes ori- ginates independently of spinal disease. 644 DISEASES OF THE HEAD AND SPINE. is usually attended with irritation and rigidity of the psoas muscle, and often makes its appearance suddenly ; while iliac abscess, on the other hand, occurs almost exclusively in adults, points above Poupart's ligament, and is gradually developed. Psoas and iliac abscesses must also be distinguished from inguinal aneu- rism which has become suddenly diffused, from femoral hernia, and from fatty, serous, or hydatid tumors. The diagnosis from aneurism, may be made by investigating the history of the case, and by observing the presence of fluctuation and the absence of any bruit or other stethoscopic signs. From hernia, the affection may be distinguished by noting the fluctuating character of the SAvelling, the absence of gurgling (in both diseases the swelling is re- ducible, and there may be an impulse transmitted by coughing), and the situ- tion of the femoral vessels, which in hernia are to the outside, and in abscess usually to the inside, of the tumor. Fatty and other tumors may be recog- nized by their not being reducible within the abdomen, and, if necessary, by the use of the exploring needle. Prognosis___The prognosis of antero-posterior curvature of the spine is never favorable ; the best that can be hoped for is the occurrence of anchylo- sis, Avith a permanent angular deformity. If the spine retain its straight position, fatal inflammation of the membranes is apt to occur, Avhile if abscess forms, the patient almost always perishes from exhaustion or from secondary visceral disease. In a case at the Episcopal Hospital, some years ago, a psoas abscess caused ulceration of a branch of the internal iliac artery, leading to rapid death from hemorrhage. Treatment___In the treatment of disease of the spine, rest of the part is of the utmost importance : if the cervical vertebra? be affected, the head must be carefully supported with sand-bags or other mechanical contrivance, so as to prevent any sudden movement which might cause death by producing dislo- cation. In ordinary cases, the patient may be confined to the horizontal po- sition on a suitable couch, the prone being more desirable than the supine posture. No attempt should be made either to extend the spine or to remove any existing backAvard projection, for such attempts could only do harm by interfering with the occurrence of anchylosis. The horizontal position must be rigidly maintained for many months, until the surgeon can satisfy himself indeed that bony union of the diseased vertebra? is Avell advanced. Tonics, especially cod-liver oil, may be exhibited with advantage, and the patient, if a child, should be daily carried into the open air on a couch or in a suitable coach. Counter-irritation (by means of setons, issues, or the actual cautery) Avas highly commended by Pott, aa ho first accurately investigated the nature of this disease—and is still in much repute Avith many surgeons. I am not myself very enthusiastic with regard to these severe applications, believing with Shaw and Holmes that, in most cases, the milder remedy of painting the tincture of iodine on either side of the affected a ertebra?, will be quite sufficient. If there be much pain, tenderness, and other evidence of inflam- mation, there can be no better local remedy than dry cold applied in the form of an ice-bag. In most cases, it Avill be desirable to combine mechanical support with rest in the prone position, and this may be conveniently done by the use of a moulded gutta-percha, felt, or pasteboard splint, or a corset-like bandage stiff- ened with whalebones, or a plaster-of-Paris bandage, applied while the patient is suspended by the head and shoulders, as recommended by Prof. Sayre. Air. Adams, and J. C. Hutchison, of Brooklyn, apply a " poro-plastic felt" jacket, while the patient is suspended, and consider this material, upon the ARTHRITIS AND NECROSIS OF THE SPINE. 645 328. whole, better than the plaster-of-Paris. AVhen anchylosis is Avell advanced, the patient may be allowed to get up, wearing the felt or plaster jacket, or a Avell-fitting apparatus, consisting of a firm pelvic band with crutch-pieces to take off the Aveight of the upper portion of the trunk, and suitable pads and straps to immovably fix the portions of the spine above and below the seat of deformity. If the cervical vertebra? be involved, a firm but Avell-fitting leather collar, so arranged as to fix the neck and support the head and chin, will probably ansAver a better purpose than any more com- plicated contrivance. The treatment of spinal abscess is that of cold or chronic abscess in general (see page 383). E\ery effort should be made, in the first place, to induce absorption of the fluid, it being remembered that, even if a residual ab- scess follows at a later period, the prognosis will then, probably, be more favorable than if the collection had been evacuated in the first instance. Even if the opening of a psoas ab- scess appear inevitable, it is better in most in- stances to leave the case to nature, rapid sink- ing not unfrequently folloAving the use of the knife under these circumstances. If, hoAvever, it be determined to interfere, the aspirator may be used, or an incision may be made un- der a veil of lint dipped in carbolic oil, Avith the precautions recommended by Prof. Lister. Dr. S. AV. Gross advises that after the abscess has been evacuated, its walls should be sup- ported with adhesive strips and a flat sponge, and that opium should be freely administered. Arthritis occasionally attacks the articu- lations of the vertebra1, and, in the case of the occipito-atloidand atlo-axoid joints, is attended with risk of sudden death from the occurrence of dislocation. The most important points in the treatment are to fix the head and neck by suitable mechanical appliances, so as to pre- vent injurious movements, and to give free vent to any pus that may be formed, lest suffo- cation should result from pressure of the ab- scess upon, or from its bursting into, the air- passages. suspension apparatus for the applieation of the plaster-of-Paris bandage. Necrosis of the bodies of the cervical vertebra? is occasionally seen in cases of syphilitic ulceration, or as the result of gunshot or other injuries; and cases in Avhich recovery has folloAved the discharge of huge sequestra, under these circumstances, have been recorded by AVade, Koate, Syme, Alercogliano, Alorehouse, Bayard, Alackenzie, Ogle, and Beck. 646 DISEASES OF THE EYE. CHAPTER XXXY. DISEASES OF THE EYE. It would be utterly impossible to give, within the narrow limits of this chapter, even a sketch of the present state of ophthalmic surgery, nor indeed Avould the attempt to do so be worth making, since the diseases of the eye have become, of late years, to a great degree an object of especial study, and since numerous excellent manuals and treatises on the subject are accessible to any one who may desire to make himself familiar therewith. I shall, therefore, chiefly confine my attention, in the folloAving pages, to a brief reference to those more common affections of the eye Avhich every surgeon may be called upon to treat, and to a short description of the more important operations which are performed upon this organ. Diseases of the Conjunctiva. Acute Conjunctivitis (Catarrhal Ophthalmia)—An inflammation of the conjunctiva, usually caused by cold or other local irritation, but some- times prevailing epidemically in certain localities, and apparently transmissi- ble by contagion. Symptoms___A sensation as of dust in the eye, with heat, smarting, and stiffness of the lids. The conjunctiva is brilliantly injected, the redness being quite superficial, and, at first, greatest at the circumference of the globe. Slight photophobia, with increased lachrymation, followed by muco-purulent discharge, which, becoming dry, causes the lids to adhere. Treatment___Astringent lotions of alum, sulphate of zinc, or corrosive sub- limate (gr. £ to f^j), with frequent ablutions with &old water, and, in severe cases, the application once or twice daily of a few drops of a solution of nitrate of silver (gr. j—ij to f §j). The lids maybe smeared at night Avith simple ointment, to prevent their adhering together. The constitutional treatment consists in regulating the digestive functions, and in improving the general health by the use of tonics, especially iron and quinia. A shade may be worn if there is much photophobia. Chronic Conjunctivitis, or Chronic Ophthalmia, may occur as a sequel of the affection just described, or may originate from the irritation of inverted lashes, or from reading or sewing with an insufficient light. Treatment—The cause must, if possible, be removed, by taking aAvay any sources of local irritation, forbidding overuse of the eyes, etc. In addition to the measures above directed for the acute form of the affection, counter-irri- tation by means of a small blister or the vapor of bromine may be advanta- geously applied to the temples, or behind the ears. If complicated with granular lids, this condition must, of course, be remedied before the conjunc- tival inflammation can be cured. Phlyctenular Conjunctivitis (Pustular or Papular Ophthalmia). —This is a form of conjunctivitis characterized by the formation of little ele- vated vesicles, with increased vascularity of. the conjunctiva in their imme- PURULENT OPHTHALMIA OF ADULTS. 647 diate vicinity. The treatment, after any acute irritation has been subdued, consists in dusting into the eye Avith a camel's-hair brush a little finely-poAv- dered calomel, in the application to the inside of the lids of a Aveak red precipitate ointment (gr. iv-viij to ^j), or in dropping into the eye, thrice daily, a weak solution of the bichloride of mercury.1 Purulent Conjunctivitis, or Purulent Ophthalmia, is a very high grade of conjunctival inflammation, attended Avith a profuse muco-purulent discharge which is fully developed Avithin twenty-four to forty-eight hours after the first onset of the disease. There are three varieties, the purulent ophthalmia of new-born infants, the contagious or Egyptian ophthalmia of adults, and the gonorrhoeal ophthalmia, which has already been considered. (See page 429.) Ophthalmia Neonatorum.—This form of the disease usually begins a feAV days after birth, involving both eyes simultaneously or consecutively, and sometimes ending in total loss of vision. The affection often appears to originate during birth, from direct contact Avith a purulent \raginal discharge in the mother. Symptoms___A whitish or yelloAV, muco-purulent or purulent discharge, rapidly increasing in quantity, Avith SAvelling of the lids and chemosis of the ocular conjunctiva. If the disease be not checked, opacity, ulceration, or even sloughing of the cornea will probably occur, Avith, of course, total loss of sight. Treatment.—The discharge should be removed as fast as it accumulates, by syringing the eye with a solution of alum (gr. v to f§j), to Avhich Power advises that permanganate of potassium should be added, e\Tery half hour, day and night, the lids being gently separated with the thumb and finger of the left hand, while the syringe is Avorked Avith the right; or, the lids being everted, a five-grain solution of nitrate of silver may be applied, with a camel's-hair brush, once a day, any excess of the caustic being immediately neutralized Avith a solution of common salt; the lids should be greased with simple ointment, to prevent their sticking together. If ulceration of the cornea occur, quinia should be given, in doses of about half a grain, three times a day. Purulent Ophthalmia of Adults, Contagious or Egyptian Oph- thalmia (so called from its prevalence as an endemic in Egypt), in its mildest form resembles catarrhal ophthalmia, but often runs a course quite as severe as the affection Avhich results from the contagion of gonorrhoea. Purulent ophthalmia is eminently contagious, and often prevails as an epidemic. It may originate sporadically from A'arious forms of local irritation. Symptoms —A muco-purulent and afterAvards purulent discharge, Avith great chemosis, and inflammation and SAvelling of the lids, with burning pain, and a good deal of constitutional disturbance. One or both eyes may be attacked. Opacity, ulceration, or sloughing of the cornea may ensue ; or the inflammation may spread to the deeper tissues of the eye; or a persistent granular condition of the lids may be deAeloped. Treatment___If only one eye be affected, the other should be effectually closed by means of Buller's bandage (page 430), or a compress of charpie covered Avith a disc of adhesive plaster, and the whole coated with collodion. 1 The following formula, which corresponds to the preparation known as Aqua Con- radi, will be found satisfactory : R. Hydrara:. chlorid. corrosiv. gr. \; Mucilag. cydonii f 3ss ; Vin. opii. gtt. v; Aqua? destillat. f§ij. M. 648 DISEASES OF THE EYE. Fig. 329. This may be remoA'ed twice a day, to Avash and inspect the organ. In mild cases, astringent and detergent applications, as recommended for catarrhal ophthalmia, Avill probably prove sufficient; but, if the disease assume a severe type, no time should be lost in adopting those measures which were fully de- tailed in speaking of Ophthalmic Gonorrhoea. (See page 4*29.) The appli- cation of copaiba to the lower eyelids, cheeks, and temples is recommended by A. R. Hall. Diphtheritic Conjunctivitis is an affection rarely met with in this country, but which has been recently Avell described by Dr. Robert Sattler, of New York. The treatment in the early stages consists in the application of iced compresses, with frequent syringing with luke-warm salt and Avater, and at a later period in the cautious use of nitrate of silver. Bergmeister recommends the insufflation of the flowers of sulphur. Tuberculous Ulceration of the conjunctiva, the cornea being un- affected, is a rare affection described by Sattler as occurring in the latter stages of general tuberculosis. Granular Lids ( Trachoma) is a condition Avhich has been referred to in the preceding pages, and wliich consists of a rough, villous, granular state of the palpebral conjunctiva, keeping up a chronic muco-purulent discharge, causing much pain, and inducing, by friction, a vascular and hazy condition of the cornea. There are two conditions to which the name of granular lids is commonly applied, one consisting merely in a hypertrophied state of the papilla?, and the other Tn the development of true or vesicular granula- tions, Avhich are by some authors regarded as neAv formations, the. result of inflamma- tory action, and by others as enlargements of the closed lymphatic follicles. These vesicular granulations appear as little round bodies, like the grains of boiled sago, often occur epidemically, and are transmissible by contagion. Symptoms___Heat and a sensation as of sand in the eye, with slight photophobia, and enough discharge of muco-pus to glue together the eyelids during the night. The caruncle and tarsal margins of the lids are reddened, and the upper lid is thickened and droops over the eye. The cornea becomes nebu- lous, uneven, and extremely vascular (Trachomatous Pannus), and ulceration sometimes occurs. The palpebral conjunctiva may eventually undergo con- traction, causing Entropion and Distichiasis. Treatment___In some cases, counter-irritation to the outside of the lids, as by the application of the tincture of iodine, with the use of tonics, will be sufficient. In other cases, it may be necessary to apply astringents or caus- tics, to the granulations themselves. Akrious articles are employed for this purpose, such as a solution of nitrate of silver, gr. v-xx to f^j (LaAvson), the " lapis mitigatus," or nitrate of silver in substance, diluted by fusing with it nitrate of potassium (Wells), the undiluted Liguor Potasse (Dixon), or, which is a favorite in this country, the blue-stone or crystallized sulphate of copper. These applications may be repeated at intervals of tAvo or three days, the pre- Granular lids. (Jones.) PTERYGIUM. 649 caution being taken, if nitrate of silver be used, to neutralize it at once by the injection of salt and water. The powdered acetate of lead is another remedy which is occasionally useful, as is the sulphate of quinia, dusted into the eye in the Avay recommended by Bader. Wolfe, of GlasgOAv, recommends scarifi- cation of the conjunctival cul-de-sac, and the application of the syrup of tannin (3ij-foj)- Carbolic acid is favorably spoken of by Chisholm, as are chlorine water and the glycerate of tannin, by the younger Sichel. If the cornea be ulcerated, instillations of atropia should be practised, and, in any case, advan- tage may be derived from the use of a compressing bandage. Stokes, of Dublin, has suggested the use of delicate ivory plates, applied within and Avithout the lid, and held together by a spring or screAv, so as to maintain constant pressure upon the granulations. Inoculation, with the matter from a case of purulent ophthalmia, has been successfully employed in inveterate cases by Bader, Dixon, LaAvson, and others. Syndectomy or Peritomy, Avhich is an operation consisting in the excision of a very narroAv band of conjunctiva and subconjunctival tissue from around the cornea, mav be practised in cases of pannus Avhich persist after the relief of granular lids. This operation, which was introduced by Furnari, in 186"2, is also recommended by Lawson, as a preliminary to purulent inoculation. Canthoplasty, or slitting up the outer canthus, and stitching together the skin and mucous membrane above and beloAV so as to prevent re-adhesion, is recommended in these cases by Althof, ]Soyes, C. R. AgneAv, and others. Pterygium.-—This is a peculiar, fleshy groAvth, consisting of a hypertro- phy of the conjunctiva and subconjunctival tissue, Avhich is most common in warm climates. One or both eyes may be affected, the groAvth almost inva- riably occupying the inner or nasal part of the eye, arising by a fan-shaped Fig. 330. expansion from the semilunar fold and lachrymal caruncle, and converg- ing as it approaches the cornea, the centre of which it rarely passes. The treatment consists in excision, which is performed by seizing the pterygium with toothed forceps, raising it from the surface of the eye, and shaving it off from its corneal attachment, then turning it backAvards and carefully dissecting it from its base; the groAvth is apt to recur, to prevent which the seat of attachment may be touched every tAvo or three days Avith a crystal of blue-stone. Another operation, called transplantation, consists in di- viding the corneal attachment, turn- ing the pterygium back, and fixing its free extremity in an incision in ptevyium. (Stellwag von Carion.) the lower part of the conjunctiva, by means of a fine suture ; or the growth may be removed by means of a liga- ture threaded upon two needles, and introduced as seen in Fig. 330. AVhen the needles are cut off, the pterygium is transfixed by three ligatures, by the tightening of which it is effectually strangulated. Lupus of the Conjunctiva is usually secondary to a similar condition o the neighboring skin, but, according to Sattler, may occur as a primary affec" 650 DISEASES OF THE EYE. tion. The treatment consists in repeated cauterization Avith the, solid nitrate of silver, and the application of the ointment of the yelloAV oxide of mercury, suitable constitutional remedies being at the same time administered, as in cases of lupus occurring in other parts. Psoriasis and Pityriasis of the conjunctiva are described by Terrier and Blazy respectively. Tumors of various kinds grow from the conjunctiva, and may be readily excised with toothed forceps and delicate scissors, curved upon the flat. For serous cysts occurring in this region, it is sufficient to cut away the anterior Avail of the cyst, and then touch the part with a pointed stick of nitrate of silver. Diseases of Cornea, Sclerotic, and Ciliary Body. Keratitis (Come/'tis, Inflammation of the Cornea)___Essentially a dis- ease of malnutrition, most common in children, sometimes arising from in- jury, but often from no obvious cause. Both eyes are usually consecutively affected, the course of the disease extending from six months to two years. The symptoms are pinkness (not the redness of conjunctivitis) in the ciliary region (see page 657), with hazi- Fig. 331. ness of the cornea, dimness of vision, photophobia, lachrymation, pain, and a sensation of dust in the eye, Avith (in the stage of re- pair) a red appearance of the cor- nea due to its increased vascularity, the resulting condition of Pannus sometimes involving almost the Avhole cornea. In favorable cases this increased vascularity gradu- ally fades away, and the part re- sumes its normal appearance, but in other cases corneal ulcers are developed and retard recovery. Permanent though slight dimness of vision generally remains, due to a general haziness of the cornea, or to the formation of a Nebula in the pupillary region. Treatment___Internally, atten- tion to the digestiATe functions, with the administration of tonics, such as iron and quinia, and of opium or belladonna, if there be much pain and photophobia. Locally, the use of sedatives, particularly belladonna or atropia, with counter-irritation by means of iodine or the solid stick of nitrate of silver to the broAv and upper lid, the eyes being protected from light by a shade or dark-colored glasses. Dr. Bull, of Ncav A'ork, recommends the use of iodoform, both internally and as a topical application. Chronic Interstitial Keratitis is a frequent manifestation of heredi- tary syphilis (see page 452). Hutchinson recommends the cautious use of mercury, applied by inunction behind the ear. Attention to the digestiA-e functions, and the administration of tonics, are also necessary. Bader recom- mends the use of croton chloral hydrate in doses of gr. v-x, three times a day. Pannus. (Jones.) PARACENTESIS CORNER. 651 Strumous Keratitis, in its course and symptoms, resembles the simple form of the affection already described; the photophobia and kchrymation are more marked, and corneal ulceration is apt to occur. The treatment con- sists in the administration of cod-liver oil and the syrup of the iodide of iron, and in improving the hygienic surroundings of the patient. Phlyctenular Keratitis___Closely allied with the preceding, is this affection, Avhich is also knoAvn as Phlyctenular or Scrofulous Ophthalmia, and as Herpes Corneal; it frequently accompanies phlyctenular conjunctivitis (p. 646). This disease, which occurs in quite young children, is attended Avith intense photophobia and spasm of the orbicularis palpebrarum (blepha- rospasm), which often renders the induction of anaesthesia necessary before a satisfactory examination can be made. The affection receives its name from the existence, usually near the corneal margin, of phlyctenular or herpetic vesicles, which burst, leaving superficial but slowly healing ulcers. The treat- ment is essentially that of keratitis in general ; if, as often happens, there is eczema of the lids, advantage may be derived from the use of borax lotions. The administration of arsenic is recommended by AVells, in some cases, as is calomel insufflation, when the disease has become chronic. Power speaks favorably of the internal administration of belladonna. A solution of sulphate of eserine (gr. ij to f ^j) is recommended by H. AV. AVilliams as a local appli- cation. The affection is apt to recur, and frequently produces permanent opacity or even perforation of the cornea. Suppurative Keratitis.—This affection may be excited by traumatic causes, or may be secondary to other inflammatory diseases of the eye. Sup- purative keratitis is, as its name implies, attended Avith the formation of pus between the layers of the cornea, in one part only, or throughout its structure. The resulting Abscess of the Cornea usually bursts exteriorly, leaving an unhealthy-looking ulcer; but occasionally opens into the anterior chamber of the eye, giving rise to the condition known as Hypopyon. A small abscess at the lower part of the cornea, from its fancied resemblance to the lunula of the thumb-nail, is called Onyx. The treatment consists in the use of tonics and anodynes, with good food and stimulants if necessary. Locally, atropia should be freely used, with a compressing bandage, or, in cases unattended with pain or intolerance of light (the non-inflammatory form of AVells), warm chamomile fomentations. Paracentesis of the cornea may be performed once or oftener, serving to relieve intra-ocular tension, and to e\racuate the pus if hypopyon be present. If the abscess be central, an iridec- tomy should be performed op- posite a clear portion of the cornea. Paracentesis Corneae is performed by puncturing the cornea near its lower margin with a broad needle held flatwise, the point being kept well for- ward, so as to aAoid wounding the lens; by rotating the needle slightly on its long axis, the opening is ren- dering patulous, alloAving the slow escape of the aqueous humor and of any Paracentesis corneae. (Erichsen.) 652 DISEASES OF THE EYE. pus that may be present. The operation is completed by restoring the needle to its original position, and quickly Avithdrawing it. This little operation is usually facilitated by separating the lids Avith a stop speculum, and steadying the eye Avith suitable fixation forceps. Anaesthesia may be employed if de- sirable. Ulcers of the Cornea__These may result from various forms of con- junctivitis and keratitis, or may apparently originate primarily, as the result of depraved health and malnutrition. Several varieties of corneal ulcer are described by systematic writers, as the superficial and deep, the transparent and nebulous, the sloughing, and the crescentic or chiselled ulcer. These names sufficiently explain themselves. The deep and sloughing ulcers are apt to lead to perforation, previous to the occurrence of Avhich, the membrane of Descemet, with, according to Stelhvag, the posterior layer of the cornea, may bulge foi'Avards through the site of the ulcer, forming a transparent vesi- cle which is called Keratocele or Hernia of the Cornea. During the stage of repair, in any case of corneal ulcer, enlarged vessels may be seen running from the margin to the ulcerated surface; should these vessels remain perma- nently after cicatrization, the condition usually known as chronic vascular ulcer results. Treatment.—The treatment of ulcers of the cornea usually requires the administration of tonics and good food, Avith attention to the digestive func- tions. Locally, soothing applications are commonly indicated, such as lotions of belladonna or poppy-heads, the instillation of atropia or eserine, hypoder- mic injections of morphia, etc. It is only in chronic cases that stimulating applications are ever proper, and even in these they should be used with caution. Syndectomy (see page 649) has been occasionally employed Avith advantage in the treatment of the crescentic ulcer, which is a very intract- able form of the affection. Paracentesis cornee is often of use in cases of sloughing ulcer. This operation should be performed (through the floor of the ulcer) whenever perforation is threatened, a compressing bandage being subsequently applied. If the intra-ocular tension be very great, iridectomy may be preferable. During the stage of repair, the patient should be encour- aged to take exercise in the open air, and if the part fall into the condition of the chronic vascular ulcer, a compressing bandage and a seton in the tem- poral region will often prove of service. Fistula of the Cornea may result from a wound, or from the imperfect healing of a perforating ulcer. The treatment consists in the application of a compressing bandage, in touching the edges of the fistulous orifice with nitrate of silver, or, if these fail, in the performance of an iridectomy. Sometimes the fistulous condition is maintained by the irritation caused by a wounded lens, Avhich should then be removed. As a last resort, Lawson recom- mends paring the edges of the fistula, and bringing them together Avith a fine silk suture. The intentional formation of a corneal fistula is recom- mended (under the name of Keratectomy) in some cases of ophthalmitis, by Spencer AVatson. Opacities of the Cornea__Nebula is the slightest form of opacity, consisting of a mere filmy cloudiness Avhich may be superficial or interstitial, and wliich commonly results from keratitis or superficial ulceration. Albugo or Leucoma is a dense opacity, due to the cicatrization of a deep ulcer, as of a smallpox pustule. Treatment—Akrious remedies are. employed for nebula, such as the insuf- flation of calomel, or the use of lotions containing corrosive sublimate, oil of STAPHYLOMA. 653 turpentine, sulphate or chloride of zinc, iodide of potassium, sulphate of sodium, or common salt. A Aveak ointment of the red or yellow oxide of mercury, is highly spoken of by AVells. Leucoma, which is usually incurable, may re- quire the formation of an artificial pupil opposite a clear portion of the cornea. Opacity resulting from the injudicious application of preparations of lead to an ulcerated cornea, may be remedied by shaving off the deposit Avith a deli- cate knife, convex on its cutting edge : after the operation, the abraded sur- face should be protected by applying a drop of olive or castor oil, and by the use of cold water dressing. The same treatment may be required if calcare- ous degeneration occur in an ordinary leucoma. In order to obviate the de- formity caused by opacities of the cornea, AVecker, C. B. Taylor, Levis, of this city, and others, recommend that the opaque spots should be tinted with vari- ous coloring matters, as in the familiar operation of tattooing. PoAver, Gra- denigo, Schoeler, and others, go further, and having removed the opaque portion, transplant a segment of a rabbit's or dog's cornea to supply the defi- ciency. These operations have occasionally been folloAved by irido-cyclitis, and should not be resorted to, therefore, Avithout due caution. Conical Cornea—The cornea retains its transparency, but assumes a conical form, the apex of the projection being commonly central. A'ision is interfered Avith by the development of myopia (short-sightedness) and astig- matism, the latter being a general term for want of symmetry in the state of refraction of different meridians of the eye. In slight cases, vision may be aided by the use of concave glasses, with a diaphragm containing a circular or slit-shaped perforation, but in most instances an iridodesis should be per- formed, or, if there be much intraocular tension, a small upAvard iridectomy. Another plan, suggested by A on Graefe, is the formation of an ulcer on the apex of the protrusion, by cutting off a small superficial flap and subsequently cauterizing the surface. The contraction which accompanies the cicatrization of the ulcer diminishes the conicity of the cornea. Bader and Nunneley have modified Akn Graefe's operation by cutting off the flap and bringing the edges of the Avound together with delicate sutures. Kerato-globus, Hydrophthalmia, or Buphthalmos, is an affec- tion analogous to the preceding, consisting in a uniform, spherical bulging of the Avhole cornea. If the disease be rapidly increasing, a large iridectomy may be performed, Avhile if vision be lost, and the protrusion prevent the closure of the eyelids, excision may be indicated. Staphyloma___When perforation folloAvs an ulceration of the cornea, the iris commonly falls fonvards. If the corneal aperture be very small, no protrusion may occur, the iris merely adhering to the inner corneal surface (anterior synechia) ; under other circumstances prolapse of the iris takes place, the protrusion increases by the distension produced by the pressure of the accumulating aqueous humor, adhesion to the margin of the ulcer fol- Ioavs, and the surface assumes a cicatricial character. The portion of cornea immediately surrounding the protrusion also yields, and a disfiguring projec- tion of the front of the eye results, which is called staphyloma. Various forms of staphyloma are described by systematic writers, as staphyloma of the iris, partial or complete staphyloma of the cornea, and staphyloma race- mosum (in which perforation occurs at several points); again, surgeons speak of ciliary staphyloma, or anterior1 staphyloma of the sclerotic—this condition 1 Posterior staphyloma is a projection of the posterior half of the eye, met with in severe cases of myopia. 654 DISEASES OF THE EYE. consisting of a series of bulgings of the weakened sclerotic (through which the dark hue of the ciliary body is perceptible), and resulting from injury of the part, or from chronic irido-choroiditis. When the staphyloma entirely surrounds the cornea, it is said to be annular. 1. Staphyloma of the Iris.—Prolapse of the iris may sometimes be prevented. If the threatened perforation be central, the pupil should be dilated with atropia so as to keep the iris out of the Avay, while, on the other hand, if the ulcer be marginal, the Calabar bean should be used to contract the pupil. The alternate use of these substances may also prove useful in breaking up an anterior synechia. If prolapse of Fig. 333. the iris have actually occurred, an attempt may be made to replace the protrusion Avith a delicate probe, aided by the instillation of atropia. If this fail, the prolapsed iris should be punctured, so as to let it collapse, a compressing bandage being then applied; or the prolapsed or staphylomatous iris may be punc- tured, and then excised close to the cornea with curAred scissors, a compressing bandage being used as before. Finally, if the prolapse or staphyloma be Prolapse of the iris- (Mil- extensive, a krge iridectomy may be performed in ler.) an opposite direction, this operation diminishing the intraocular tension, and thus lessening or at least pre- venting the increase of the projection, Avhile it also affords an artificial pupil if that should be required. Another plan of treating prolapsed iris, consists in touching the protruding portion with a pointed stick of nitrate of silver, as recommended by Dixon. tous condition of the entire corneal surface. 2. Partial Staphyloma of the Cornea__This may be considered as an aggravated degree of Staphyloma of the Iris. The treatment consists in the formation of an artificial pupil, opposite a healthy part of the cornea, by iridectomy. 3. Complete Staphyloma of the Cornea signifies a staphyloma- Its occurrence may be sometimes prevented by an early removal of the lens, either immediately after the sloughing of the cornea, or at a later period—when the opera- tion may be performed as directed by BoAvman, by the use of a broad needle to break up the lens, and a curette to favor the evacuation of any part that is dif- fluent. Fully formed, complete staphyloma may be treated by abscission, the seton, strangula- tion, or excision of the eye. (1) Abscission may be per- formed by either Beer's, Scar- pa's, Critchett's, or Carter's me- thod. The first consists in trans- fixing the staphyloma with a Abscission of staphyloma (Stellwag von Carion.) Beer's knife (Fig. 334), at the SCLEROTITIS AND CYCLITIS. 655 junction of the upper and middle thirds, and cutting downwards. The remain- ing bridge of tissue is then divided with scissors, and the broad wound left to heal by granulation. Scarpa's plan differs from the above, in that a flap is formed from the upper part of the staphyloma and laid doAvn over the wound." Critchett's method consists in passing four or fh-e curved needles, armed with silk, across the base of the staphyloma, and then removing an elliptical segment with probe-pointed scissors introduced through a puncture made Avith a Beer's knife. The operation is completed by carefully tying the sutures, Avhen a linear wound results (Fig. 335). Carter's plan is to unite the recti muscles by catgut sutures, and then close the Avound superficially by stitches passed through the conjunctiva only. Fig. 335. Critchett's operation for staphyloma. (Lawson.) (2.) A seton may be formed through the base of the staphyloma, as recom- mended by Akn Graefe, the thread being removed in the course of twenty- four or forty-eight hours. Suppurative choroiditis ensues, Avhich induces shrinking and atrophy of the globe, alloAving the application of an artificial eye. AVecker employs a thread of carbolized catgut. (3.) The staphyloma may be strangulated, in part or wholly, by Borelli's method, Avhich consists in transfixing the prominence Avith tAvo needles, in- troduced at right angles to each other, and throwing around them a fine liga- ture, as in operating for na?vus. (4.) Excision of the eye (the mode of performing Avhich will be described hereafter) is particularly indicated in any case of staphyloma in which the deep portions of the eye are believed to be diseased. 4. Ciliary Staphyloma, when resulting from irido-choroiditis, may be occasionally arrested in its early stages by iridectomy, but Avhen caused by a rupture of the sclerotic, is probably incurable. If, in such a case, vision be entirely lost, and the staphylomatous globe a source of irritation, excision may be properly resorted to. Sclerotitis and Cyclitis (Inflammation of the Sclerotic and Ciliary Body)___These affections constantly coexist, and are usually secondary to inflammation of the iris or choroid, though they may occur primarily, as the result of traumatic causes. Systematic writers recognize two A7arieties of cyclitis, the serous and suppurative—the latter being the graver form of the affection. 656 DISEASES OF THE EYE. Symptoms___There are pain and tenderness in the ciliary region, with photophobia and kchrymation, impairment of vision, increased intra-ocukr tension, sub-conjunctival injection (constituting a distinct pink zone around the cornea), cloudiness of the vitreous, dilatation of the veins of the iris, inactivity or distortion of the pupil (from coincident iritis), with, perhaps, turbidity of the aqueous humor, and, in the Avorst cases, hypopyon. Sclero- titis and cyclitis, in their milder forms, are often seen in rheumatic sub- jects, constituting what was formerly called Rheumatic Ophthalmia, and under this head belongs anatomically the eye affection obseiwed in cases of gonorrhoeal rheumatism (see page 431). Treatment___If the pain be very great, a feAV leeches may be applied to the temple, followed by warm fomentations and the administration of opium. The state of the prime vie should be attended to, and the strength of the patient maintained by means of nutritious food, and stimulants if necessary. Quinia may usually be given with advantage, together with the iodide of potas- sium, and the oil of turpentine (in drachm doses) if the iris be much involved. Copaiba is recommended by A. P. Hall. In a very urgent case it may be proper to administer mercury, either by inunction, or internally in combina- tion Avith opium. Frequent instillations of atropia should be practised through- out the course of the disease. Iridectomy may occasionally prove beneficial at an early stage of the affection, Avhile, in cases resulting from injury, excision of the globe should be resorted to Avithout hesitation, if the other eye be threatened with sympathetic implication. Episcleritis is the mane given to a small, dusky-red, sub-conjunctival SAvelling, wliich usually appears on the temporal side of' the cornea, and some- times causes a good deal of irritation and pain, running a very chronic course, and being prone to recur. The treatment consists in subduing irritation by the use of atropia, and then employing weak collyria of the chloride or sul- phate of zinc. PoAver recommends the internal administration of a combina- tion of aconite, colchicum, and camphor. Tumors of the Sclerotic__Knapp has recorded a remarkable case of intra-ocukr enchondroma, originating from the inner layers of the sclerotic. The groAvth was removed by Chisolm, of Alaryland, and ten days afterwards the common carotid artery Avas tied for secondary hemorrhage, the patient dying from tetanus three days subsequently. Diseases of the Iris. Iritis, or Inflammation of the Iris, may be a primary or a secondary affection. Primary iritis may be due to some systemic disease, such as syphilis or rheumatism, or may result from exposure to cold, from injuries, etc. AVhen secondarily involving the ciliary body or choroid, it receives the name of Prido-cyclitis or Irido-choroiditis. Secondary iritis is caused by the extension of inflammation from neighboring structures, as the cornea, choroid,1 etc. Different classifications of iritis are adopted by authors, the best perhaps being that of Wells, who speaks of the Simple, Serous, Paren- chymatous, and Syphilitic varieties. Symptoms—The following symptoms are common to all forms of iritis: (1.) Marked sub-conjunctival injection, giving rise to the characteristic ciliary Hence, some systematic Avriters describe choroido-iritis separately from irido-cho- roiditis. DISEASES OF THE IRIS. 657 zone, which is easily recognized by its pink color, its deep, subconjunctival character, and the radiating course of the enlarged vessels. It is often accompanied by general suffusion of the conjunctiva, and sometimes by chemosis. (2.) A contracted and sluggish state of the pupil, which, OAving to the formation of ad- hesions betAAreen the iris and capsule of the lens (synechia posterior), assumes, when acted upon by atropia, an irregular and distorted IrttiR. showing subconjunctival Outline. If the synechia be complete, the injection forming the ciliary zone. pupil is not at all dilatable, and soon becomes (Pirrie.) occluded by inflammatory lymph. In serous iritis, however, the pupil is often abnormally dilated. (3.) The iris loses its natural lustre, and becomes discolored ; its striated appearance is obscured, owing to inflammatory SAvelling; its vessels may become enlarged and vari- cose ; Avhile beads of lymph may perhaps be detected upon its surface. The change of color is even greater apparently, than in reality, OAving to the state of the aqueous humor, which is often turbid from the admixture of flocculent lymph or pus. This may accumulate in such quantities as to form a hypo- pyon. (4.) Vision is impaired, partly by the diminished transparency of the aqueous humor, but also in many cases by the coexistence of cyclitis, which alters the accommodation of the eye, and often causes turbidity of the vitreous (p. 643). (5.) Pain is usually a prominent symptom of iritis, though in some cases, particularly of the syphilitic form of the affection, it is almost or altogether absent. The pain is deeply seated in the eyeball, and often extends to the forehead, temple, and nose, assuming a neuralgic character, and being Avorst at night. Tenderness in the ciliary region indicates the presence of cyclitis. (6.) Photophobia and lachrymation are not usually very intense— much less so, indeed, than in many cases of keratitis. Simple or Idiopathic iritis presents the symptoms above described in a mild, and Parenchymatous iritis in a severe, form, the latter variety being that in Avhich suppuration chiefly occurs, leading sometimes to perforation of the cornea and permanent loss of sight. Serous iritis is especially charac- terized by the absence of lymphy deposits, and by an increase in the amount of aqueous humor, leading to augmented intra-ocukr tension and consequent dilatation of the pupil. Serous iritis often accompanies choroiditis and reti- nitis, and is the form sometimes assumed by Sympathetic Ophthalmia; it is also seen in connection with hereditary syphilis. The so-called Rheumatic iritis belongs to one or other of the above varieties, and is often associated with sclerotitis in cases of gonorrhoeal rheumatism (pp. 430, 644). The true Syphilitic iritis belongs to the parenchymatous variety of the affection, being an accompaniment of tertiary syphilis, and characterized by a deposit of yel- Ioav tubercles Avhich are strictly analogous to gummatous tumors (p. 447); the iritis of secondary syphilis, on the other hand, is an ordinary iritis, simple, serous, or parenchymatous, which is not essentially dependent on syphilitic infection (see page 444). Any form of iritis may be met with as a recurrent affection, particularly in rheumatic and syphilitic persons. Treatment—The use of atropia is unquestionably the most important point in the treatment of iritis. A strong solution should be employed (at least gr. iv to fo.j)> and this may be applied in very urgent cases, as advised by AVells, at intervals of five-minutes, for half an hour, three times a day. The advan- tages gained by the use of atropia are the dilatation of the pupil, thus pre- venting the occurrence of synechia posterior, the physiological rest secured to 42 658 DISEASES OF THE EYE. the iris by paralyzing its circular fibres, and the diminution of intra-ocular tension. Even if adhesions to the capsule of the lens are already formed, these can often be stretched and even ruptured by the unsparing use of atropia. Hypodermic injections of morphia may be administered to relieve pain, and the same remedy may be employed as an antidote, in the rare event of a poisonous effect being produced by the passage of atropia through the lachry- mal puncta into the throat. Leeches to the temple are often serviceable in relieving the intense ciliary neuralgia, and are also of use in lessening intra- ocular tension, and thus preparing the way for the action of atropia. Para- centesis of the cornea may also be employed for the latter purpose, and is particularly indicated if the aqueous humor be cloudy, or if hypopyon be pre- sent. Mercury is certainly a valuable remedy in those cases of iritis in which there is an abundant formation of inflammatory lymph, but is by no means so essential as was formerly supposed. It may be given internally, in combina- tion Avith opium, or may be employed by inunction. Iodide of potassium and oil of turpentine are particularly useful in cases of syphilitic and rheumatic iritis. Copaiba is recommended by Alacnamara, Hall, and other Indian sur- geons. Finally, iridectomy may be required, if there be extensive and firm adhesions betAveen the iris and capsule of the lens, or if, as in some cases of serous iritis, there be a marked increase of intra-ocular tension. Tumors of the Iris.—If of a cystic nature, the proper remedy is iridectomy, the cyst being removed with its seat of attachment. Excision of the entire iris was suggested by Air. R. B. Carter in a case in which both hides were the seats of round-celled sarcoma, and excision of the growth alone by an operation analogous to that of iridectomy, has been successfully practised by Kipp, of XeAvark, and other surgeons. Melanotic cancer of the iris demands excision of the globe, Avhich is the only mode of treatment offer- ing even a hope of benefit. [Mydriasis (Dilatation of the Pupil) may result from rheumatism affect- ing the nerve sheaths, from syphilis, from contusions or other injuries, from irritation of the sympathetic, from cerebral disease, or from any disease of the eye which produces increased tension of the globe. Paralysis of the ciliary muscle often coexists, producing disturbance of the accommodation. The accompanying impairment of vision, if due to mydriasis alone, may be relieved by the use of a diaphragm with a pin-hole perforation ; while the paralysis of accommodation will often yield to the application of a blister behind the ear, and the administration of iodide of potassium. In chronic cases, a weak solu- tion of Calabar bean may be dropped into the eye. Myosis ( Contraction of the Pupil) may result from excessive use of the eyes, as in watchmaking or engraving, or may depend upon disease of the cervical portion of the spinal cord, the pressure of an aneurism or tumor on the cervical sympathetic, etc. Little can usually be done in the Avay of treat- ment, though temporary relief may sometimes be afforded by the instillation of atropia. Operations ox the Iris. Iridectomy.—This operation consists in the excision of a portion of the iris. AVhen done for the relief of intra-ocular tension (as in glaucoma), or as a preliminary to extraction of cataract, the section should, as a rule, be made upwards ; though as the outward section is an easier procedure, this may be sometimes preferred by an inexperienced operator. The advantage of an up- OPERATIONS ON THE IRIS. 659 Avard iridectomy is that the lid subsequently covers the seat of operation, thus cutting off the irregularly refracted peripheral rays of light, and at the same time partially hiding the resulting deformity. If, on the other hand, an iridectomy is to be performed as a means of making an artificial pupil, a small iiiAvard section is preferable—the visual line cutting the cornea on the inner side of its central point—though, in cases of corneal opacity, the surgeon may be forced to make his section at any point opposite to Avhich the cornea may happen to be clear. Iridectomy is thus performed: The patient being in the recumbent posi- tion, and under the influence of chloroform (which in eye surgery is usually 1 (referable to ether), the surgeon separates the lids by means of a Liebreich's, Xoyes's, or ordinary spring-stop speculum (Fig. 335), and, standing behind the patient's head, fixes the eye by seizing Avith firm catch-forceps the conjunc- tiva and subjacent fascia, at a point directly opposite to that of the pro- Fig. 337. posed section. A lance-shaped kera- ^ lar for the upAvard or inward section —is then to be thrust through the ^«^»s- sclerotic at about half a line to a line ^f* ~^t£~\.....iai from its junction with the cornea, the ^^ handle being well depressed. SO as not Lance-shaped iridectomy knife. to Avound the iris or lens, Avhile the blade is slowly thrust omvards, until the section is of the desired extent. The knife is then cautiously AvithdraAvn, so as to allow the slow escape of the aque- ous humor, Avhen the first stage of the operation is completed. The fixation forceps are now handed to an assistant, avIio may rotate the globe a little downwards, and steady it Avhile the surgeon excises a portion of the iris ; this second stage of the operation is accomplished by introducing curved iris for- ceps (Fig. 338), expanding the blades so as to grasp the pupillary margin, Fig. 338. Curved iris forceps. cautiously AvithdraAving the forceps Avith the included portion of iris, and snipping off the latter close to the wound by one or tAvo cuts Avith delicate curved scissors. AVhen the object of the operation is to reduce intra-ocular tension, the iris should be excised close up to its ciliary margin. Sometimes, immediately after the withdrawal of the knife, the iris prolapses, when it may be instantly seized with forceps and excised. If the anterior chamber be very shallow, it may be safer to substitute, for the lance-shaped instrument, the knife used by Von Graefe for the modified linear extraction of cataract, making a puncture and counter-puncture, and then cutting outwards as in the opera- tion referred to. If the section of the iris cause hemorrhage into the anterior chamber, the escape of blood may be facilitated by carefully introducing a curette (Fig. 345, b), and making cautious pressure with the fixation forceps. The speculum being removed, the lids are gently closed, and a compressing bandage applied. This is done by covering the closed lids with an oval disc of soft linen, spread AArith simple ointment or glycerin to prevent its adhering, filling up the inequalities of the orbit by carefully packing the part Avith fine charpie, and finally securing the Avliole with a Liebreich's (Fig. 339) or other 660 DISEASES OF THE EYE. Fig. 339. /I Liebreich's bandage. (Lawson.) light bandage. For the first few days, both eyes should be excluded from the light. Iridectomy for Artificial Pupil re- quires a smaller section, which should be made through the cornea—as in this case it is desirable to leave the ciliary attachment of the iris, so as to cut off some of the peripheral rays ; the por- Fig. 340. Tyrrell's hook. tion of iris which is to be excised may be drawn out with forceps, or with a blunt silver or platinum Tyrrell's hook. R. B. Carter has modified this operation by cutting off a portion of the iris with delicate scissors (AVecker's) introduced into the anterior chamber of the eye, and subsequently withdraw- ing the severed fragment with forceps. 341. Iridodesis___This operation was introduced by Critchett, and is adapted to the formation of an artificial pupil in cases of opaque or conical conea, lamellar cataract, etc. It is performed by making an incision, with a broad needle, at the junction of the cornea and sclerotic, a loop of fine black silk (Fig. 341, A) being laid around the Avound as soon as the needle is withdrawn. An iris hook is then passed through the loop, and into the anterior cham- ber, seizing a portion of iris by its pupillary margin, and bringing it out, when the loop is tightened by an assistant drawing with forceps upon its free extremities. The ends of the ligature being cut off, the eye is bandaged, the loop com- Fig. 342. Iridodesis. (Lawson.) Canula forceps. ing aAvay in two or three days, and leaving the iris adherent to the point of in- cision. If it be only desired to displace or enlarge the original pupil, the pen- CATARACT. 661 pheral^portionof the iris maybe seized with canula forceps (Fig. 342), introduced through the loop (instead of the hook), the remainder of the operation being conducted as already described. A double iridodesis (one downwards, and, after several days, another made upwards) has been recommended by Boav- man in cases of conical cornea. Artificial Pupil by Incision (Iridotomy)__This operation may be practised in cases in which the lens is absent (as after cataract extraction), and in wliich the pupil is entirely occluded. It is performed by simply split- ting the fibres of the iris with a broad needle, the retraction usually affording a sufficient pupil. Under other circumstances, a Tyrrell's hook may be in- troduced, and the operation converted into a small iridectomy. BoAvman has modified this operation by excising a triangular-shaped piece of iris, with delicate scissors introduced through a corneal wound. Iridotomy is also em- ployed by Bowman and Wecker in cases of zonular cataract, opacity of the cornea, etc., the former surgeon employing a knife blunt at the point and back, which is introduced behind the iris and made to cut forAvards, and the latter employing a triangular keratome and delicate forceps scissors. AVecker's operation has also been successfully employed in a number of cases by Dr. H. D. Xoyes, of Xcav York. Corelysis is an operation practised by Streatfeild and AVeber, for the detachment of adhesions passing betAveen the pupillary margin of the iris and the capsule of the lens. It consists in making, Avith a broad needle, a corneal wound at a convenient point, and then with a spatula-hook (Fig. 343) passed behind Fig. 343. the adhesion, drawing forAAards and slowly rup- rgg Passavant's Operation, for the accomplish- Spatula-hook. ment of the same object, consists in making a small opening at tbe edge of the cornea, introducing suitable forceps and seizing a fold of the iris in close proximity to the synechia; the latter is then torn loose from its attachment to the lens, and the forceps disengaged and cautiously withdrawn, care being taken to guard against the occurrence of prolapse of the iris. Iridodialysis is an operation employed in cases of extensive central opacity of the cornea; it consists in tearing loose the ciliary attachment ot the iris, thus forming a. peripheral artificial pupil. Cataract. An opaque condition of the crystalline lens, of its capsule, or of both, is called cataract, the several conditions being distinguished by the names len- ticular, capsular, and capsulo-lenticular. A collection of lymph or blood in front of the lens is sometimes called spurious cataract. Cataracts are classi- fied according to their mode of origin, as idiopathic, traumatic, or con- genital ; according to their color, as black, amber, etc.; and according to the consistence of the cataractous lens, as hard or soft. Symptoms__The first symptom of cataract which attracts the attention of a patient, is dimness of vision, as if from a cloud or mist, Avhich, in idio- pathic cases, comes on gradually; the sight is usually best in a somewhat dim light, for the pupil dilates under such circumstances, and allows light to 662 DISEASES OF THE EYE. penetrate the periphery of the lens, Avhich is usually less opaque than its centre. The appearance of a cataractous patient differs from that of one Avho is amaurotic: the former has not the vacant stare of the latter; instead of helplessly rolling up his eyes to the sky, he is able to direct them tOAvards any object with some certainty; and, to a moderate extent, he can find his way about by himself; there is no involuntary oscillation of the eyeball, nor divergent squint, and the pupil reacts normally to the stimulus of light. In a case of uncomplicated cataract, the poAver of distinguishing day from night is never lost. In a case of advanced cataract, the opacity can be readily recognized by the unaided eye of the surgeon, but in an earlier stage more careful examination may be necessary. The Catoptric Test, AA'hich was proposed by Sanson, is now, since the intro- duction of the ophthalmoscope, seldom employed, but is still worthy of men- tion : if a lighted candle be moved before a healthy eye, three images of the flame Avill be seen ; two erect, formed by reflection from the convex cornea and anterior surface of the lens, and one inverted, from the concave posterior surface of the latter. If now the lens be opaque, the inverted image will be wanting, the deeper erect image similarly disappearing Avhen the opacity involves the capsule, and the corneal image being then alone perceptible. The diagnosis of cataract may be most satisfactorily made by means of Oblique Illumination and the Ophthalmoscope. Oblique illumination (Fig. 169) is practised by placing the patient in a darkened room, and, Avith a con- vex lens, concentrating the light from a suitably-placed Argand lamp upon the pupil, previously dilated with atropia—Avhen any opacities may be readily recognized by their whitish-gray color. AVhen now the light is reflected by means of the ophthalmoscopic mirror into the eye, the opacities appear as streaks or spots, which are black from the interference with the return of light from the fundus oculi; or if the opacity be of a diffused character, the ordinary red hue of the fundus may be partially or completely obscured. The most important practical points in the examination of a cataract are to determine—-first, whether it be or be not complicated by the presence of some more deeply seated lesion, and secondly, whether it be hard or soft. In a case of uncomplicated cataract, the patient should be able to distinguish the light of an ordinary Argand burner at a distance of fifteen or tAventy feet. Hard cataracts usually occur in persons over fifty years of age, and are probably never met with in those under thirty-five. They are commonly of a smoky-ash color, and frequently present a regularly striated appearance ; after extraction, they have an amber tint. Soft cataracts are most frequent in the young, present a bluish-Avhite appearance, and are irregularly, if at all, striated. Congenital cataracts are always soft. Treatment___Akrious operations are practised for the relief of cataract —all having for their object the immediate or gradual removal of the opaque lens. In cases of lamellar or zonular cataract, however (a variety of soft cata- ract met with in children, and, according to Arlt, in connection with a history of convulsions, and in which an opaque lamella or zone intervenes between the nucleus and cortical portion, which are both clear), if the disease be not pro- gressive, an iridodesis may be preferable to any operation upon the lens itself (see p. 648). Before resorting to any operation for cataract, the surgeon should test the sensibility of the retina to light, as unless the patient, Avhen placed in a dark room, is able to recognize the presence and general position of the flame of a lamp at a distance of fifteen to tAventy feet, the prospect of benefit from an operation will be comparatively slight. AYith regard to the time for operation, it may be said that congenital cataracts should be operated upon at an early period, as otherwise a disfiguring involuntary habit of oscillation OPERATIONS FOR CATARACT. 663 of the eyeballs (nystagmus) is apt to be developed ; in other cases it is better, as a rule, to Avait until the cataract is fully ripe or mature, or, in other words, until the whole lens has become opaque. In cases of double cataract, that which is furthest advanced should be first operated upon, so that the patient may continue to use the second eye Avhile the process of cure in the first is going on. Chloroform may be administered in any operation except that of flap extraction ; the patient should lie on a table of convenient height, Avith a good side light, and with the pupil Avell dilated by atropia. I shall not attempt to describe all the A^arieties of operation Avhich have been and are practised for the cure of cataract, but shall speak merely of the ordinary flap operation, the traction method, and that of Akn Graefe, the needle operation (or that of solution), and the suction method. The first three are adapted for hard, and the last tAvo for soft cataracts. The old operation of Reclina- tion, depression, or couching, by Avhich the lens was forcibly thrust doAvn into the vitreous (Avhere it constantly gave rise to destructive inflammation), is now happily almost totally abandoned, and is mentioned merely as a matter of historical interest. Operations for Cataract. Extraction "by Flap Operation__In this operation the use of chloro- form is not admissible. The surgeon, if able to use the knife Avith his left as well as Avith his right hand, may stand behind the patient's head, no matter which eye is to be operated upon; under other circumstances, he should take this position for the right eye only, standing on the patient's left side and in front, for an operation on the left eye. The peculiarity of this method consists in making a large semicircular flap, involving half the Fig. 344. cornea, and the operation may be done either by an upward or down- ward section, the former being usually preferred. The foliowing description refers to the operation by upward section on the right eye. It is usually best to dispense with specula in this procedure, the eye being fixed by the fingers of the surgeon and his assistant ;l the former with his left forefinger raises the upper lid, and holds its tarsal edge firmly beneath the upper border of the orbit, while his middle finger is fixed steadily on the inner canthus, the assistant in the same way depressing the lower lid, and fixing the outer canthus ; the eye is thus securely held Avithout in- jurious compression. If, however, the patient be very restless, the surgeon may himself fix the eye Avith forceps, intrusting the raising of the upper lid to his assistant (Fig. 344). The surgeon then, standing behind the patient, and holding the triangular extraction knife lightly in his right hand, enters its point half a line within 1 Chesshire, of Birmingham, recommends division of the external canthus as a preliminary to all cataract operations, so as to avoid the risk of injurious pressure from sudden contraction of the orbicularis palpebrarum muscle. Flap extraction of cataract. (Wells.) 664 DISEASES OF THE EYE. the sclero-corneal junction on the temporal side, at first in the direction of the radius of the corneal curve, so as not to split the lamellae of the cornea, but keeping the blade subsequently in a plane parallel to that of the iris. The flap is made by simply pushing the blade across the anterior chamber, the point of exit being diametrically opposite to that of en- Fig. 345. trance ; the peculiar shape of the blade causes it to constantly fill the wound, and thus prevents the premature escape of the aqueous humor. If fixation forceps are used, they should be disengaged as soon as the counter-puncture is effected. The flap being completed, the eyelids are alloAved to close for a few seconds, Avhen the surgeon proceeds to the second1 stage of the operation, the laceration of the lens capsule. This is effected by introducing the cystotome (Fig. 345, a), the patient look- ing downwards, and the upper lid being slightly elevated; when the cystotome has reached the inner side of the pupil, its point is turned doAvnwards, and the capsule freely divided as far as the outer pupillary margin; the instrument is then cautiously withdraAvn, when the eyelids may again be allowed to close. The third stage of the operation consists in the evacuation of the lens, which is effected by making gentle pressure with the back of the curette (Fig. 345, b) upon the lower lid, Avhile counter-pressure is made with the forefinger upon the upper portion of the eyeball. The curette should at first press backwards, and then backAvards and upwards, so as to cause the lens to present itself edgewise at the corneal wound. The pressure must be very cautiously made, lest rup- ture of the hyaloid membrane and loss of vitreous follow. The operation is now completed, but before applying the after- dressing the surgeon should again, in a few minutes, separate the lids, to make sure that the corneal flap is properly adjusted, and that no prolapse of the iris has occurred. The after- treatment consists in closing the eye with a single strip of isinglass plaster, and applying a compressing bandage (see p. 659) to both eyes. The patient should be confined to bed for three or four days. Dr. H. AV. AVilliams (Boston City Hos- pital Reports, 1870, p. 378) recommends the insertion of a delicate suture in the centre of the wound after the operation of flap extraction ; his statistics do not, hoAvever, show any particular gain by the proceeding—102 cases with suture having given 85 successes, 8 partial successes, and 9 failures, while 104 cases without suture gave 87 successes, 7 partial successes, and 10 failures. If all goes Avell, the eye should a Cystotome not as a ru^e De °Pene^ until the end of a week, though the 6. Curette. external dressing may be renewed once or even twice a day. Should, however, the occurrence of any unfavorable symptom, such as great pain, SAvelling, or muco-purulent discharge, lead the surgeon to fear that the case is not progressing satisfactorily, the lids should be gently separated and the eye inspected (by the light of a candle), that the exact condition of things may be recognized, and appropriate treatment resorted to. The chief complications which may arise during the operation, are as fol- Ioavs : (1) the iris may fall in front of the knife—to be remedied by gently 1 Correnti, of Florence, and Spencer Watson recommend that the laceration of the capsule should, in both this and Von Graefe's operation, be effected before making the flap, by means of a curved cataract needle introduced, through the cornea from the temporal side. VON GRAEFE'S METHOD OF EXTRACTION. 665 disentangling the point of the instrument, and by making cautious pressure through the cornea; if this fail, the section may be completed, the resulting iridectomy not being of any particular disadvantage ; (2) the corneal wound may be too small—to be remedied by cautiously enlarging it with blunt- pointed knife or scissors ; (3) the lens may drop down into a fluid vitreous— the lens must be instantly extracted with a suitable spoon or hook, and a compressing bandage applied; (4) prolapse of the iris may occur—to be remedied by gently repressing the protruding portion with a fine probe, or by softly rubbing the lids in a circular direction; if this fail, the prolapse should be seized with forceps and excised ; (5) portions of the cortical matter of the lens may be detached during its exit—these should, if possible, be removed by Arery gently rubbing the eyelids in a circular direction, so as to bring the fragments into the anterior chamber, Avhence they may be removed Avith a scoop or spoon. If, from its transparency, the cortical matter at first escape observation, subsequently swelling and producing irritation, atropia must be freely used ; it may even be necessary to make a small corneal incision, facilitating the escape of the remaining lens substance by means of the curette or suction apparatus (see p. 667). The escape of a considerable quantity (more than one-third) of the vitreous humor, is usually folloAved by loss of the eye, and an equally bad result at- tends deep intra-ocular hemorrhage, Avhich may occur during the operation, or some hours subsequently. Failure after flap extraction may occur from these causes, or from inflammation attacking the cornea or iris, or even the Avhole globe ; the treatment of these accidents must be conducted upon gene- ral principles—the application of a few leeches to the temples, and the free use of atropia, are to be recommended during the early stages, followed by warmth and moisture, and the compressing bandage, if suppuration occur. Traction Method.—In this operation (AA'hich originated with Akn Graefe and has been modified by AValdau, Critchett, and others), chloro- form may be employed, and the eyelids may be held apart with the stop- speculum. The surgeon, standing behind the patient, fixes the eye Avith forceps, and makes with an iridectomy knife, or a Graefe's linear extraction-knife, an incision in the Flo* ^4°- upper part of the sclero-corneal junction, involving one-third of the corneal circumference ; the fixation forceps are then intrusted to an assistant, and the surgeon, cautiously introducing delicate iris forceps, makes a broad iridectomy as directed at page 647. The capsule of the lens is then freely lacerated Avith the cystotome, and the lens itself draAvn out with a silver spoon (Fig. 346), provided with a barbed or Traction spoons. recurrent edge, which allows it to slip easily between the lens and the posterior capsule, and then catches the loAver edge of the lens and holds it firmly as it is AvithdraAvn. Care must be taken in the intro- duction of the spoon, not to push the lens before it, and not to rupture the hyaloid membrane, Avhich would alloAv loss of vitreous. Von Graefe's Method of Modified Linear Extraction, with its lamented author's latest modifications, may, probably, be considered the best operation yet devised for extraction of cataract. The peculiarities of this method are that the incision is through the sclerotic, and does not form a flap,1 and that no traction instrument is employed. The following descrip- 1 The incision is usually said to be linear (whence the name of the operation), but this distinction is not mathematically correct, the section in this method no more 666 DISEASES OF THE EYE. tion and accompanying wood-cuts are taken from Laurence; the eye operated upon is supposed to be the left. The surgeon opens the extreme periphery of the anterior chamber with a narroAv knife, represented at Fig. 347, in its Fig. 347. Fig. 348. Fig. 348a. Von Graefe's cataract knife. actual size, by an incision A B (4-^-4f lines long) through the sclerotic, at the point A (Fig. 348), half a line external to the margin of the cornea, and tAvo-thirds of a line below the level of its uppermost summit. The point of the knife is, in order to enlarge the internal corneal incision, in the first in- stance, directed, not to the point of counter-puncture, B, but to about the point C. After the knife has been entered fully three lines into the anterior chamber, its handle is depressed, counter-puncturation at B effected, the knife-edge directed abruptly forAvards, and the section completed. In Fig. 348a, the uppermost undotted line sIioavs the direction of the incision.1 The next steps of the operation are the same as in the traction method, consisting in an iridectomy and the laceration of the anterior capsule. To re- move the lens a spoon of vulcanite or tortoise-shell is employed, not being used as a traction instru- ment, but simply to exercise pressure from without. The convex back of the instrument is applied to the loAver border of the cornea, Avhen, by using a little pressure, the Avound at its upper part begins to gape. Then the spoon is given a slight turn (so that its upper border buries itself a little in the outer surface of the cornea), at the same time that it is moved a little upAvards, in consequence of Avhich the equator of the lens presents itself at the wound. By continuing this manoeuvre and making slight counter-pressure on the scleral border of the wound, the exit of the lens is effected. Any cortical matter which may have become detached, is to be coaxed out by gently stroking the cornea from below upwards Avith the back of the spoon, as long a time as may be necessary being devoted to the satisfactory accomplishment of this final part of the operation. Fig. 349. Diagram of Von Graefe's opera- tion for cataract. Von Graefe's hook. If in any case the evacuation of the lens in the manner described be found impracticable, it may be extracted with a silver spoon, or (which Graefe pre- fers) a blunt hook (Fig. 349). The after-treatment in this, and in the traction method, is the same as in corresponding to the geometrician's definition of a line, than does that of the ordinary flap operation. The curve in Graefe's incision is that of the eye itself. 1 Knapp and C. R. Agnew advise that the middle of the incision should come almost to the scelro-corneal junction. CAPSULAR AND SECONDARY CATARACT. 667 the flap extraction, except that in these the eye may be safely examined after tAAenty-four hours, and the patient alloAved to leave his bed on the second or third day. Akrious modifications of Graefe's method, or combinations of it with the old operation of extraction, have been proposed by AVarlomont, Liebreich, Bader, and other surgeons. Needle Operation, or the Operation for Solution__This is the method ordinarily to be preferred for the removal of soft cataracts. Chloro- form or ether may be indiscriminately employed, but neither is usually required. The pupil being Fig. 350. Avell dilated, and the lids separated by the stop"___________ speculum, the surgeon fixes the eye with forceps, ^ ' and enters a lance-headed, or, if preferred, a Hays's Bowman.8 stcp.needie. knite-needle, through the cornea at its outer side, and carries h across to the centre of the pupil, when the edge is turned to the lens, and a slight laceration made in the capsule. The operation usually has to be repeated at intervals. Care must be taken not to use so much force as to dislocate the lens, and not to lacerate the capsule too freely in the first operation, lest the lens substance, SAvelling up from the contact of the aqueous humor, should produce injurious pressure on the iris and ciliary body. When the bulging lens matter has disappeared by absorption, the operation may be Fig. 351. Hays's knife-needle. repeated, the needle this time being used more freely. The only after-treat- ment required is the closure of the eye for twenty-four hours, and the main- tenance of pupillary dilatation by means of atropia. If the lens be dislocated, it should, as a rule, be removed by means of a corneal incision and the intro- duction of a scoop, an iridectomy being at the same time performed; Avhile, if the swelling of the lens be so great as to threaten injurious consequences, a small incision, with a keratome or broad needle, may be made, and the escape of the offending substance aided by the introduction of a curette.1 Suction Method__This operation, which was introduced by Teale, is specially adapted to cases of fluid cataract, such as are frequently met with in diabetic patients. Air. Teale used a " suction curette," consisting of a curette roofed in to within a line of its extremity, Avith a handle and a piece of India- rubber tubing furnished Avith a mouth-piece. The anterior capsule of the lens being lacerated Avith tAvo needles, the curette is introduced through a small corneal Avound into the area of the pupil, and the fluid lens matter sucked out by the application of the operator's mouth. Air. BoAvman has devised a " suction syringe," Avhich is in some respects more convenient than the curette. Treatment of Capsular and Secondary Cataract__It some- times happens that, after the removal of a cataractous lens, the field of vision is still obscured by an opaque or Avrinkled condition of the remaining cap- sule, containing, perhaps, some portions of lenticular matter inclosed Avithin 1 The operation is thus essentially converted into the true " linear extraction," Avhich originated in 1811 Avith Gibson, of Manchester. 668 DISEASES OF THE EYE. its layers ; the obstruction may be aggravated by the presence of nodules of inflammatory lymph. No operation should be practised for the relief of this condition until all the irritation caused by the original operation has passed away, an interval of several months being usually required. The safest mode of treating secondary or capsular opacities, is to tear through the occluding membrane with a Hays's needle, introduced through the cornea. If the cap- sule be very dense and resisting, two needles, introduced at opposite sides of the cornea, may be used, as advised by BoAvman—one serving to fix the membrane Avhile laceration is effected Avith the other. Other plans are to divide the capsule Avitli delicate " canula scissors" (Fig. 352), to tear it Avith Fig. 352. Canula scissors. toothed forceps, as practised by Higgens, of Guy's Hospital, or, as recom- mended by C. R. AgneAv, of New York, to perforate and fix the membrane with a needle, and then with a sharp hook, introduced through a small cor- neal opening, to tear and roll up the membrane, Avhich, if not too closely attached, may be drawn out with the instrument. After these, as after other cataract operations, the pupil should be kept for some time well dilated with atropia. Diseases of Vitreous Humor, Choroid, Retixa, and Optic Papilla. (Amaurosis and Amblyopia.) Amblyopia and amaurosis are, strictly speaking, symptoms, the former Avord denoting obscurity, and the latter more or less complete loss of vision.1 These terms are ordinarily applied to all cases of partial or total blindness, which are dependent neither on external obstructions (such as cataract or opaque cornea) nor upon optical defects of the eye, but are limited by Akn Graefe and many other modern ophthalmologists, to cases of lost or impaired vision which are caused by primary atrophy of the optic nerve, or by such irregulgj-ities in the circulation of the nervous system as may eventually lead to such atrophy. Looking, then, upon these conditions (amblyopia and amaurosis) as symp- toms of disease, rather than as definite pathological states Avhich can be re- ferred to any particular cause, I shall first speak of the morbid changes in the deeper structures of the eye, to Avhich their manifestation may be due, and subsequently of those cases of nervous blindness to Avhich alone Akn Graefe and his followers would apply the term amaurotic. The Ophthalmoscope___These cases can only be investigated by the aid of the ophthalmoscope, a brief account of Avhich instrument may, there- fore, be appropriately given in this place. The ordinary form of opthalmo- scope consists essentially in a perforated mirror, by Avhich the light from a 1 Etymologically the words are synonymous, both signifying, literally, dimness of vision. THE OPHTHALMOSCOPE. 669 suitably placed lamp is reflected into the patient's eye, and thence back to that of the surgeon, avIio looks through the central perforation. Liebreich's portable ophthalmoscope, which is, perhaps, the most convenient for general use, consists of a polished, concave, metallic mirror, about \\ inch in diame- ter and of (3 to 8 inches focal length. It has a central perforation, about a line in diameter, and is mounted in a light frame with a handle of convenient length. A mov-able arm, attached to the side of the frame, supports a clip, in wliich may be placed, behind the sight-hole, an ocular lens, either concave or coiiATex, according to the needs of the observer. Accompanying the ophthal- moscope is a double-convex object lens, for use in the method of indirect examination. Alore perfect but more complicated forms of ophthalmoscope have been devised by surgeons, but are, perhaps, less Avell adapted to the purposes of the general practitioner than that which has been described. Among the most ingenious may be mentioned those of Loring and Knapp, of New York, and Shakespeare, of this city. Fixed Ophthalmoscopes and Binocular Ophthalmoscopes (in Avhich the surgeon uses both eyes at once) have each some particular advantages in special cases. Prof. Beale has devised a self-illuminating ophthalmoscope, which, Fig. 353. by an ingenious arrangement of lamp and mirror (the latter of wliich is inclosed with the object lens in a darkened tube), can be used Avithout the necessity of pre- viously darkening the room. The ordinary ophthalmoscope is used in a darkened room, the-patient being firmly seated, and the surgeon standing or sitting in front of him; an Argand lamp or gas- burner is placed to one (usually the left) side of, and. a little behind the patient's head, with the flame on a lewd with his eyes. The patient's pupil may, if deemed necessary, be dilated with atropia. For the indirect method of examination, Liebreich's portable ophthalmoscope. Avhich is that commonly employed, the surgeon holds the mirror close to his own eye, and about a foot and a half from that of the patient. Looking tlirough the central perforation, the sur- geon is soon able, by a little manoeiwring, to catch the rays from the lamp and reflect them directly into the patient's eye, the pupillary space of which noAv appears of a reddish-yellow color. Then taking in the other hand the object lens, the surgeon holds it from an inch and a half to two inches in front of the eye wliich he is observing, fixing it in that position by resting his fin- gers on the patient's forehead. By noAv moving his own head a little back- wards or forAvards, the operator obtains an inverted aerial image of the fundus of the observed eye. By directing the patient to turn his eye in various directions, the surgeon can explore the whole fundus of the eye, it being re- membered that, in the aerial image which is seen, the position of every part is inverted. In the direct method of examination, no object lens is used. The surgeon at first holds the mirror about a foot from the eye of the patient, and then, by gradually approximating it more closely, can illuminate and examine in suc- cession the cornea, crystalline lens, and vitreous; the fundus oculi is not fairly brought into view until the mirror is within about tAvo inches of the observed eye, Avhen a virtual erect image becomes apparent, seeming to be placed some distance behind the patient's eye. If either the surgeon or patient be 670 DISEASES OF THE EYE. short-sighted, a concave lens must be placed behind the sight-hole of the mirror. The entrance of the optic nerve, Avhich is usually the part first inspected, may be brought into view by causing the patient to look at that ear of the operator which corresponds to the eve under examination ; thus, the right ear for the right eye, and the left for the left. The optic papilla gives a Avhiter Fig. 354. Use of the ophthalmoscope. (Erichsen.) reflection than the rest of the fundus, and, Avhen brought into distinct view by the adjustment of the object-lens (in indirect examination), appears as a pinkish, white, or gray disc, marked by the convergence of the retinal vessels: of these, one artery and tAvo veins commonly pass upAvards, and as many doAvnwards, each soon dividing and ramifying over the fundus. The veins may be made to pulsate by pressing on the eye, and sometimes do so sponta- neously in a normal state. Spontaneous pulsation of the retinal arteries, on the other hand, is ahvays an eAridence of increased intra-ocular pressure, and is a symptom of glaucoma. The macula lutea, or yellow spot, may be brought into view by directing the patient to look at the central perforation of the mirror, and may be recognized by the absence of retinal vessels. The macula lutea is frequently the seat of hemorrhagic extravasations or other lesions. It is not my purpose to offer any detailed account of the various ophthal- moscopic appearances observed in different morbid states of the eye: the limits of this volume would not justify my doing so, and, indeed, as justly remarked by Dixon, it is not possible to convey, by mere verbal description, any information upon these topics which would be of much real value. The use of the ophthalmoscope can only be satisfactorily acquired by long and continued actual practice, and the assistance which the student can derive from any verbal description of what he is expected to see, will not prove of CHANGES IX THE CHOROID. 671 material advantage. Those, however, avIio cannot pursue their labors in this branch under the direction of an experienced and skilful ophthalmoscopist (Avhich is much the best manner of acquiring a practical knoAvledge of the instrument), may study Avith benefit the works of Zander and Hulke, and the colored illustrations of ophthalmoscopic appearances published by Ja-ger, Liebreich, Stelhvag, Power, AVells, and others. The morbid changes of the deep structures of the eye which induce amau- rosis and amblyopia, may now be briefly referred to. Changes in the Vitreous Humor__Opacities of the Vitreous__ These may consist of filaments of lymph, shreds of pigment, or the contracted remnants of blood clots. They result frequently from diseases of the iris, retina, or choroid, especially when of a syphilitic character—in which case they are to be treated by means of remedies addressed to that condition. Dense membranous opacities have been successfully treated by Von Graefe by means of a needle-operation, as in cases of capsular cataract. The use of the continuous galvanic current is recommended in these cases by Onimus and Car- nus, and by Lefort. Musce Volitantes are floating opacities of the vitreous, consisting of fila- ments, cells, or cell-debris derived from that structure, Avhich are not unfre- quently observed by those avIio are short-sighted, or who strain their eyes by fine Avork : they frequently persist for years, causing annoyance by their pres- ence, but being productive of no further evil consequences. The only treat- ment to be recommended is the administration of tonics to improve the general health, with rest for the eyes, and the use of dark glasses. Hemorrhage into the Vitreous is a much more serious affair than hemor- rhage into the aqueous humor. In the former situation, absorption takes place very sloAvly, and shreds of clot are apt to be left, which permanently interfere Avith vision. The treatment consists in local depletion, the applica- tion of cold, etc. Synchisis is a term used to denote a softened and fluid condition of the vitreous. In some cases, the vitreous holds in suspension numerous scales of cholestearine, with, according to Poncet, tyrosine and crystallized phosphates, giving a sparkling appearance when examined with the ophthalmoscope ; the condition is then called synchisis scintillans. Fluid vitreous may result from injuries, or from various non-traumatic inflammatory affections of the eye ; it usually causes diminished tension of the eyeball, though it may be met Avith in cases of glaucoma. The condition is, I believe, irremediable. Inflammation of the Vitreous (Hyalitis) is a condition the possibility of the existence of which is denied by Pagenstecher ; Spencer Watson has, Iioav- ever, recorded an instance of its occurrence, in which a cure was effected by the administration of mercury and the local use of atropia. Changes in the Choroid__Choroiditis frequently occurs in connec- tion Avith inflammation of the iris and retina. The changes revealed by the ophthalmoscope may consist merely of increased vascularity, of cloudiness due to serous effusion, or of yellowish-white patches of lymph, often surrounded by pigment, and perhaps traversed by the retinal vessels. Choroiditis is fre- quently an accident of constitutional syphilis, in Avhich case it is said that the lymphy patches are more circumscribed than in the simple variety of the affection. Bull, of New York, has observed that irido-choroiditis often fol- Ioavs neuralgia of the trigeminal nerve. The treatment consists in the cautious administration of mercury, or iodide of potassium, with tonics, especially iron and quinia. Atrophy of the Choroid, commonly of a local character, usually accom- 672 DISEASES OF THE EYE. panics posterior staphyloma, in severe eases of myopia. In an advanced stage of atrophy, the choroid is entirely deficient in parts, the exposed scle- rotic appearing in its place in the form of white patches. The treatment consists in the enforcement of rest to the eyes, with local depletion and counter-irritation. If the disease be rapidly progressive, Lawson advises the administration of the bichloride of mercury. Anemia of the Choroid is characterized by paleness of the fundus oculi, and is often accompanied by contraction of the retinal vessels. Bony Deposits are occasionally found in the choroid, apparently resulting from osseous change in previously formed inflammatory lymph ; calcareous deposits are in the same cases often found in the lens and cornea. Tubercles of the Choroid are met Avith in cases of acute tuberculosis ; the coexistence of the choroidal affection with tuberculosis of the lungs is, ac- cording to Steffen, more constant than with the same condition of the pia mater. Tumors of the Choroid___The morbid growths met Avith in this situation belong either to the group Avhich A'irchow designates as sarcomata (see page 481), or to the medullary form of cancer. In either case the tumor is apt to contain a certain amount of melanotic deposit. The only treatment to be re- commended is excision of the globe, Avhich should, if possible, be performed before the tumor has made its way through the external coats of the eye. AVilson, of Dublin, records a case in which a cyst containing crystals of cholestearine Avas developed between the choroid and retina, simulating glioma of the latter structure. Changes in the Retina___Hyperemia of the Retina may be due to over-exertion of the eyes, in which case its treatment consists in rest of the organ, and in the use of local depletion, counter-irritation, and the cold douche, with the administration of tonics, etc. In other cases there is a passive venous congestion, due to cerebral disease or the pressure of a tumor. The iodide and bromide of potassium are recommended under such circumstances, but the results of treatment are far from satisfactory. Retinitis is very often associated with choroiditis, and not unfrequently with iritis. It is marked in its early stages by increased vascularity, and subsequently by the occurrence of extravasation, serous effusion, or lymphy deposit. It is often due to syphilitic or nephritic disease, particularly the former (see p. 446). Alercury, Avhich is serviceable in the syphilitic variety, is totally contra-indicated in that Avhich depends on kidney disease, the most useful remedy in the latter form of the affection being probably the muriated tincture of iron. Retinitis Pigmentosa (which, from night-blindness being one of its promi- nent symptoms, is also called Retinitis Hemeralopica) is characterized by the deposit of pigment matter on the retina; the disease is incurable, going on to the production of total blindness, though, as the course of the affection is very slow, old age may be attained before this consummation is reached. Prof. Arlt, of ATenna, has given the name Retinitis Nyctalopica to certain cases of inflammation of the retina in which the opposite condition is present, the patients seeing better in the dusk than in a bright light; the treatment Avhich he recommends is functional rest, with the use of colored glasses and the ad- ministration of mercury. Apoplexy of the Retina may occur in any of the forms of retinitis (more particularly in the nephritic), or may result from other causes, such as heart disease, atheroma of the retinal vessels, embolism, or suppressed menstrua- tion. The treatment consists in obviating a recurrence of the hemorrhage by endeavoring to remove the cause, if this can be ascertained. Advantage may CHANGES IN THE OPTIC PAPILLA. 673 perhaps be derived from the use of iodide of potassium in hastening the ab- sorption of the effused clots. Anemia of the Retina may accompany anaemia of the choroid. Such a condition, when met with in cases of epileptiform convulsions, has been called by Hughliiigs Jackson Epilepsy of the Retina. Kavnaud has observed anosmia of the retina causing amblyopia, increased by external heat and diminished by cold. Detachment of the Retina may occur in cases of extreme posterior staphy- loma, or may be due to loss of vitreous, to hemorrhage or serous effusion, or to the growth of tumors of the choroid. AVhen the detachment is caused by sub-retinal effusion, an attempt may be made to evacuate the fluid by punc- turing the retina Avith one or two needles, passed through the sclerotic and vitreous, as advised by Akn Graefe and Bowman ; or with a delicate trocar, as recommended by Wecker ; or by puncturing the choroid from without, as suggested by Laurence. AVecker has recently suggested drainage of the sub- retinal space by the introduction of a gold or catgut thread, Avhile McKeoAvn, of Belfast, has successfully operated by excising sub-conjunctivally a portion of both sclerotic and choroid. Fatty Degeneration of the Retina sometimes occurs in cases of albu- minuria. Embolism of the Central Artery of the Retina produces contraction of both sets of retinal vessels, but particularly of the arteries, and is often accompanied Avith sub-retinal effusion in the neighborhood of the macula lutea. Embolism of the retinal artery often depends upon the existence of cardiac valvular dis- ease of the left side. It produces sudden and total blindness, and is rarely recovered from.1 Tumors of the Retina___Cystic degeneration of the retina is occasionally observed in an eye wliich has long been blind, and may require excision of the globe, if the disease should produce pain and threaten the integrity of the other eye. The most common retinal tumor, however, is the Glioma, Avhich runs an almost malignant course, and was indeed formerly considered to be of an encephaloid character. The only treatment to be recommended is early excision, Avhich may be required in the case of both eyes, if both be affected. The disease often recurs in the orbit. Changes in the Optic Papilla__Optic Neuritis__Tavo forms are recognized, one confined to the optic nerve, and the other likewise involving the retina (neuro-retinitis). The former is often an attendant upon cranial or cerebral disease (descending optic neuritis), Avhile the latter is frequently of a syphilitic, nature. In some cases the optic disk is first affected, the dis- ease subsequently extending upAvards (engorged papilla, choked disk, ische- mia, or ascending neuritis). The optic papilla is at first SAvollen and congested, afterwards assuming a peculiar " Avoolly" appearance. In ische- mia or choked disk vision may be retained until a late period of the affection, but in descending neuritis it is impaired from the beginning. According to Higgens, and some others, choked disk is at first merely a passive, non- inflammatory condition due to intracranial pressure. The prognosis is unfavorable, and the treatment usually unsatisfactory; mercury, cautiously administered, with the iodide and bromide of potassium, are the remedies commonly employed. Neurotomy, or slitting the sheath of the optic nerve, has been advantageously resorted to by AVecker and PoAver. 1 According to Loring, Magnus, and Zehender, many cases of sudden blindness which are ordinarily attributed to embolism are really due to other conditions, such as hemorrhage or serous effusion within the sheath or amid the fibres of the optic nerve. 43 674 DISEASES OF THE EYE. Excavation, or Cupping of the Optic Papilla.—A slight depression in the centre of the optic disk may exist in the normal state, constituting what is known as the physiological cup. In glaucoma, and in some cases of ad- vanced myopia, a much more marked and abrupt form of cupping is observed ; the most distinctive characteristic of this condition is the bending of the retinal vessels at the margin of the optic disk, the whole of which is occupied by the glaucomatous cup; if the excavation be very deep, the retinal and papillary portions of the vessels may be seemingly quite disconnected. A third form of cupping often accompanies atrophy of the optic nerve, a condi- tion Avhich may result from the pressure of intra-orbital tumors, from disease of the brain or spinal cord, or from the abuse of tobacco, etc. Tumors of the Optic Nerve___Various forms of morbid groAvth are met with in this situation, as the fibrous, fibro-cellular, cystic, and cancerous ; there are usually in these cases double vision and protrusion of the eyeball, Avith diminution of the field of vision, or amblyopia ; the treatment consists in removal of the tumor, Avhich Knapp has succeeded in effecting in one case without removal of the eyeball. Amaurosis and Amblyopia from Extra-Ocular Causes— Impairment or loss of vision, Avithout any recognizable primary lesion of the eye, may result from disease of the cerebrum, cerebellum, or spinal cord ; from sudden suppression of the menses, or other uterine disturbance (even from pregnancy) ; from profuse hemorrhage ; from reflex irritation, as from a carious tooth; from compression of the optic nerve ; from embolism ; from the toxic influence of tobacco, alcohol, lead, or quinia; from uramnic poison- ing, diabetes, etc. In all cases the immediate cause of the loss of sight is interference Avith the circulation of the nervous structures concerned in vision, or, in permanent cases, atrophy of the optic nerve. A symptom, Avhich by some authors is considered of value, in the diagnosis betAveen amaurosis from cerebral and that from spinal disease, is that, in the former, both eyes are usually affected, and the pupils dilated, Avhile in the latter, one eye only is commonly involved, and the pupil contracted. 'The field of vision is differently affected in different cases; thus the centre, or the periphery, of the field may be chiefly involved, or the loss of sight may involve just half of the field (hemiopia), vision being perfect on one side of a vertical line, and absent on the other. I have seen a well-marked case of hemiopia following a fracture of the base of the skull. The treatment of these forms of amaurosis consists in endeavoring to re- move the cause, Avhen that can be ascertained; when resulting from disease of the central nervous system, the prognosis is extremely unfavorable. Na- gel, of Tubingen, Chisolm, of Baltimore, Bull, of NeAv York, and Harlan, of this city, have derived advantage in some of these cases from the use of strychnia. The drug may be administered hypodermically, or, which Chisolm now prefers, may be given by the mouth in quantities varying from ro t0 2 grain daily, in divided doses. Quaglino and Bull speak favorably of the use of bromide of potassium in cases of alcoholic amblyopia. Inhalations of nitrite of amyl have been successfully used by Swanzy. Hemeralopia, Day-Sight, or Night-Blindness, is a functional condition consisting in a diminished sensibility of the retina, due apparently to excessive exposure of the eyes to light, together Avith a debilitated and especially a scorbutic condition of the system. It is most common among residents in tropical countries, soldiers and sailors, etc. This affection must not be confounded with Retinitis Pigmentosa, in which night-blindness is a frequent symptom ; in the true hemeralopia, no morbid changes whatever are ACCOMMODATION AND REFRACTION. 675 revealed by the ophthalmoscope. The treatment consists in the administra- tion of tonics, especially cod-liver oil, with the use of dark-colored glasses to protect the eyes. If the disease can be traced to scurvy, or to malarial fever, remedies suitable to those affections must be employed. Instillation of a solution of strychnia (gr. j-f^j) is recommended by AValker, of Liverpool. Snow-Blindness is a condition analogous to hemeralopia, resulting from exposure to the dazzling reflection from snoAV; the eyes should be shielded by colored glasses, and tonics administered if the patient's general condition demand their use. Nyctalopia___This rare affection is the reverse of hemeralopia, and consists in a hypera?sthetic state of the central portion of the retina, the peripheral part being anaesthetic. The treatment consists in protecting the eyes from light, and in improving the constitutional state of the patient, by the use of tonics, particularly the preparations of zinc and iron. Color-BlindneSS, or, as Dixon more accurately terms it, Acritochro- macy, is a defect of a ision in which the poAver of distinguishing one or more colors is lost. Usually red and green are the two colors Avhich are confused together, but in some cases vision is achromatic, all colors alike appearing as Avhite, black, or gray. Color-blindness is usually congenital, but may result from disease ; achromatic vision existed, as a temporary condition, in a case of optic neuritis observed by Chisolm. AVhen congenital, the affection is probably incurable. Accommodation and Refraction. T Accommodation is the poAver of self-adjustment Avhich an eye pos- sesses, by means of which, objects at various distances are equally Avell seen. This adjustment is accomplished by a muscular effort (on the part of the ciliary muscle), of which the individual is, however, usually unconscious. Refraction is the passive power by which, when the eye is at rest, rays of light are brought to a focus in the retina; it is a purely physical property, depending upon the shape of the eye and of its various refracting media, as the cornea, lens, etc. The various anomalies of refraction and defects of accommodation, to which the human eye is subject, have received of late years a great deal of attention from ophthalmologists, and the means by which these anomalies and defects may be recognized and corrected, have been thoroughly studied and systematized ; for information on these topics, I must, hoAvever, refer the student to special treatises on the subject, contenting myself with men- tioning and explaining the principal terms employed. Emmetropia___This is the normal condition ; an eye is emmetropic, when parallel rays are converged to a focus on the retina by the refractive poAver of the eye itself, Avithout any effort of accommodation. Myopia or Brachymetropia (Short Sight)__In this condition, dis- tant rays are brought to a focus in front of the retina, the image formed upon Avhich is therefore indistinct. Myopia is usually due to an elongation of the antero-posterior diameter of the eye, and commonly results from a prolonga- tion of the posterior half of the eye, often accompanied Avith thinning of the sclerotic and partial atrophy of the choroid, constituting posterior staphy- 676 DISEASES OF THE EYE. loma. This condition requires the use of concave glasses. As spasm of the ciliary muscle is present in many cases, the methodical use of atropia is recommended by Schiess, AVindsor, and Derby. Hypermetropia or Hyperopia is a condition exactly the reverse of the preceding; here, distinct' rays come to a focus behind the retina, the image on the latter being of course indistinct as in the previous case. A hypermetropic is usually smaller than an emmetropic eye, particularly in its antero-posterior diameter, whence it has a flattened appearance. According to Stevens, of Albany, hypermetropia is often associated with nervous dis- orders, particularly chorea and epilepsy. Hypermetropia requires the use of convex glasses. The local use of Calabar bean is recommended by Magnus. Ametropia1 is a general term embracing both the preceding conditions; it is therefore the opposite of emmetropia. Astigmatism is a condition in which the refracting power varies in different meridians of the eye. Thus one meridian may be emmetropic, and others ametropic ; or there may be myopia in one meridian, and hyperme- tropia in another. Many persons have slightly astigmatic vision without knowing it, and it is only when the want of symmetry is marked that the affection excites attention : the remedy is the use of cylindrical glasses. Aphakia is an anomalous state of refraction caused by the absence of the crystalline lens, as after cataract operations. Aphakia renders the normal eye markedly hypermetropic, wliile it diminishes myopia, and may even make a myopic eye emmetropic. The remedy for aphakia (which is accom- panied Avith loss of accommodation) is the use of powerful convex lenses. Presbyopia is a diminution of the range of accommodation, interfering with vision of near objects, while distant \ision remains unimpaired. Pres- byopia is an almost constant attendant upon old age, and can scarcely be looked upon as abnormal: the treatment consists in the use of convex glasses. Paralysis, and Spasm of the Ciliary Muscle may each be a cause of loss of accommodation. The Calabar bean may be used for the former, and atropia for the latter condition. Asthenopia, or Weak Sight, may depend upon exhaustion of the poAver of accommodation in cases of hypermetropia, or upon insufficiency of the in- ternal recti muscles, by which the necessary convergence of the eyes for near vision cannot be long maintained. The former (which is called accommoda- tive asthenopia) requires the use of convex glasses, while the latter (muscular asthenopia) may demand division of one or both external recti, or the use of appropriate prisms. As pointed out by S. AT. Mitchell, Higgens, Carter, Piorry, and other writers, asthenopia may give rise to cerebral symptoms, such as headache, giddiness, etc., and may thus be mistaken for intracranial disease. Glaucoma. Glaucoma is the term which was formerly applied to all cases of impaired vision accompanied by a greenish hue of the pupil, and not manifestly due to 1 For a convenient mode of determining the degree of ametropia, see an able paper by Dr. W. Thomson, in the American Journal of Medical Sciences for October, 1870. GLAUCOMA. 677 lesions situated in front of the iris. The affection was variously supposed to consist in an abnormal condition of the vitreous, retina, optic nerve, or choroid, but its pathology was not Avell understood until quite recently, and in a great degree through the labors of Akn Graefe, who has sIioavii that all the symptoms of this formidable disease are due to an increased intra-ocular tension, caused by the augmented volume of the vitreous and aqueous hu- mors, and probably originating in an irido-choroiditis.1 The distinctive Symptoms of glucoma are increased hardness or tension of the eyeball; diminished sensibility, and, at a later period, haziness of the cornea ; distension of the ciliary vessels ; diminution in the size of the an- terior chamber; sluggishness and dilatation of the pupil (which has a green hue) ; partial atrophy of the iris ; and lastly opacity of the crystalline lens. By the ophthalmoscope, the retinal arteries are seen to pulsate ; the optic papilla presents the characteristic glaucomatous cup (page G74) ; the vitreous appears cloudy ; and hemorrhages into the deep structures of the eye may be observed. A'ision is hypermetropic and presbyopic ; the field of vision be- comes contracted ; amblyopia, at first periodic, ends in complete amaurosis ; halos or prismatic spectra are seen on looking at the flame of a candle ; and pain, more or less intense, is felt in the eyeball, and along the course of the optic nerve. Glaucoma is usually met with in persons past the middle period of life, and may arise spontaneously, or as the result of some injury or antecedent in- flammation. It is said to be occasionally traceable to the shock of mental or moral emotions. A'arious forms of the disease are recognized by systematic writers, as the glaucoma fulminans, in which the symptoms may be fully developed in a feAV days or even hours, the acute, the subacute, the chronic or simple, and the consecutive or secondary, the latter being often of traumatic origin. The Treatment of glaucoma consists essentially in the adoption of means to lessen the intra-ocular tension. In very mild cases, advantage may no doubt be derived from the assiduous use of atropia, and of constitutional remedies, but in the majority of instances, no time should be lost in resorting to iridectomy, Avhich, under these circumstances, should be performed as di- rected at page 659. The benefits to be expected from this operation, for the introduction of Avhich we are indebted to Akn Graefe, are in inverse propor- tion to the duration of the disease ; thus, if performed during the forming stage of the affection, a perfect cure may be reasonably hoped for; an early operation, even in fully developed acute glaucoma, will probably at least arrest the course of the disease, and prevent further deterioration of sight; while in chronic glaucoma, the structural changes are usually so far advanced before the nature of the case is recognized, that comparatively little can be expected from any mode of treatment. Other operations for the relief of glaucoma have been practised, and with alleged good results. Thus repeated paracentesis of the cornea is highly recommended by Sperino, trephining of the cornea by Dr. Argyll Robertson, the use of a catgut or metallic seton by Wecker, cylicotomy, or division of the ciliary muscle, by Hancock, and puncture or incision of the sclerotic (sclerotomy) by Quaglino, AVecker, Lefort, Spencer AVatson, Bader, and Alauthner. The weight of testimony in favor of iridectomy is, however, so ovenvhelming, that it can scarcely be regarded as justifiable for the surgeon to delay the latter operation while experimenting with any other mode of treatment. 1 Jonathan Hutchinson, however, has advanced tbe vieAV that glaucoma is a neu- rosis, and that the tension of the eyeball is due to tonic contraction of the sclerotic. 678 DISEASES OF THE EYE. Affections of the Entire Eyeball. Ophthalmitis, or Inflammation of the Eyeball, may result from trau- matic causes, may be idiopathic, or may be an incident of pyaemia, etc. The symptoms are those of deep-seated inflammation generally, Avith such special phenomena as are traceable to the implication of the various ocular tissues. The disease usually terminates in suppuration and rupture of the globe, or in sloughing of the cornea. The treatment during the early stages consists in the use of cold applications, with local depletion, scarification of the conjunc- tiva, and the instillation of atropia. If there be much tension, the cornea may be tapped with advantage. Spencer AVatson recommends, under the name of keratectomy, the establishment of a corneal fistula. AVhen suppu- ration has occurred, Avarm should be substituted for cold applications, and a free incision should be made as soon as fluctuation reveals the presence of pus. If the eyeball be totally disorganized, excision may be required. Sympathetic Ophthalmia, or the secondary implication of one eye as the result of disease or injury of the other, is especially apt to occur in consequence of wounds inAolving the ciliary region, particularly if compli- cated by the presence of a foreign body. According to C. Higgens, it often follows the operation of sclerotomy. Sympathetic ophthalmia is usually de- veloped five or six weeks after the reception of an injury, though sometimes not until a much later period. In its common form it appears as a sca ere irido-cyclitis, though it also occurs as a serous iritis, or asaretino-choroiditis. In some cases the sympathetic irritation, though so great as to render the eye practically useless, does not reach the point of structural change, constituting then what Donders describes as Sympathetic Neurosis. The treatment of sympathetic ophthalmia, as regards the eye originally affected, depends upon the stage of the disease, and the amount of vision possessed by the injured organ. Foreign bodies should be extracted before the development of any sympathetic symptoms, and if the lesion of the eye be so great as to render it useless, excision should be unhesitatingly performed. The same operation would, of course, be indicated, should the case be first seen when the second eye is becoming involved. If the injured eye still retains some sight, at the time of occurrence of sympathetic symptoms, the course to be pursued is more doubtful; for it has sometimes happened, under these circumstances, that the eye first affected has in the end proved more useful than the other. If the case be seen at a very early period, an iridec- tomy on the sympathetically affected eye may occasionally prove serviceable, but in most instances it is better to wait until the subsidence of acute symp- toms, and then, if necessary, extract the lens and make an artificial pupil. The general treatment of sympathetic ophthalmia consists in the enforcement of functional rest, with the administration of tonics, especially quinia, the cautious use of mercurial inunction, and the free instillation of atropia. A'on Graefe has suggested, in some cases, the formation of a seton through the vitreous, as a substitute for enucleation of the injured globe; while, in the comparatively mild cases of sympathetic neurosis, division of the nerves of the ciliary region has been successfully practised by Meyer, Secondi, and Laurence. Excision or Enucleation of the Eyeball is thus performed: The patient being fully etherized, the lids are held apart Avith a stop-speculum, while the surgeon divides the conjunctiva and subjacent fascia Avith scissors, in a circle as close as possible to the margin of the cornea. The tendons of the ocular muscles are then successively raised upon a strabismus hook and STRABISMUS. 679 divided, when, the eye being draAvn forAvards and outAvards, the optic nerve can be cut Avith long and narroAv scissors, curved on the flat. The eye being removed, hemorrhage is to be checked by the application of cold, Avhen, if thought proper, the conjunctival Avound may be closed with a silk suture. This, hoAvever, should not be done Avhen the operation is performed upon an inflamed eye, as a free vent should then be provided for the discharges. The after-dressing consists in the introduction of a piece of sponge or strip of lint within the lids, and the application of a firm bandage. When cicatrization is complete, and all inflammatory symptoms have subsided, an artificial eye may be adapted. In some cases of malignant disease, it may be necessary to extirpate the whole contents of the orbit. This may be done by dividing the external commissure of the lids, incising the conjunctiva, severing the levator palpe- bral, attachments of the oblique muscles, and all other orbital connections of the eye, and then, draAving the globe iiwards, cutting the optic nerve Avith curved scissors, introduced on the outer side. The lachrymal gland should be also removed, if it be diseased. Strabismus. Strabismus, or Squint, is defined by Donders as a "deviation in the direc- tion of the eyes, in consequence of wliich the two yelloAV spots receive images from different objects." AVhen the squinting is constant in one eye, the stra- bismus is said to be monocular; Avhen the patient can use either eye at will, but not simultaneously, it is called concomitant, alternating, or binocular. Strabismus is usually convergent (cross-eyes), or divergent—the former being commonly associated Avith hypermetropia, and the latter Avith myopia. Squinting may be periodic, or persistent; it may be brought on by various forms of reflex irritation, or may depend on some anomaly of refraction, on defective vision in one eye, or on paralysis of some of the nerves which sup- ply the ocular muscles. Treatment___If the affection be periodic, an attempt may be made to effect a cure by suitable constitutional treatment, by the use of glasses to remedy the defect in refraction, etc. If the strabismus be persistent, and not depend- ent on mechanical causes, such as the contraction of a cicatrix, or the pres- sure of a tumor, an operation may be resorted to, one or both internal or external recti muscles being divided, according to the nature and extent of the squint. Before having recourse to an operation, the surgeon should (in a case of concomitant squint) determine which eye is primarily affected, and the degree of convergence or divergence, as the case may be ; the former point may con- veniently be ascertained by re- peatedly causing the patient to close both eyes and suddenly open them, that eye Avhich con- stantly or habitually deviates from the straight position being the one primarily affected. The degree of squinting can be best ascertained by using the stra- bismometer devised by Lau- rence, or that of GalezoAvski; but in the absence of these in- struments, may be simply de- Fisr. 355. G.ilezowski's strabismometer. 680 DISEASES OF THE EYE. termined by marking on the lower lid points corresponding to the centre of the pupil, when the eye is fixed, and when it is squinting. If the degree of strabismus be moderate, less than three lines for instance, the primarily af- fected eye alone need be submitted to operation; but in cases of great devia- tion, a better result Avill be obtained by dividing the operation between both eyes. The object to be accomplished in an operation for strabismus, is to alter the point of attachment of the divided tendon, and thus diminish the range of motion which it can impart to the eye ; hence the importance of ascertaining the degree of deviation, that the separation of the tendon from its attachment may be more or less complete, according to the exigences of the particular case. The operation for Division of the Internal Rectus Tendon is thus per- formed : The eyelids being separated Avith a stop-speculum, the surgeon catches with fine-toothed forceps a fold of the conjunctiva and subjacent fascia, on a level Avith the lower border of the tendon, and with delicate probe- pointed scissors makes an opening just large enough to admit the strabismus hook ; the latter is then insinuated be- hind the tendon, which it renders tense by draAving it forAvards and outwards ; the scissors are next introduced closed, and then opened, so as to place one blade behind, and the latter in front of the tendon, Avhich is subsequently divided sub-conjunctivally, close to its sclerotic attachment, by a number of slight cuts. To prevent the slipping of the tendon Avhich is apt to occur with the ordinary strabismus hook, an inge- nious instrument known as the " crotchet hook" has been recently introduced by Dr. Theobald, of Baltimore. A counter-opening in the conjuctiva, to allow the escape of blood, may be made, as is done by Bowman, by cutting with the scissors on the point of the hook before this is withdrawn. The above is knoAvn as the sub-conjunctival operation, and was introduced by Critchett. Other surgeons prefer to divide the conjunctiva more freely, afterwards bringing the edges of the wound together Avith a suture. The surgeon can regulate the effect of the operation by separating more or less freely the sub-conjunctival fascia from the tendon to be divided, thus allowing the greater or less retraction of the latter. The application of a suture also serves to lessen the effect of the operation. Snellen makes the conjunctival incision in a direction parallel to and immediately over the muscle, which he then seizes with forceps and divides with sharp-pointed scissors. Dr. Frank, of Baltimore, effects the division of the tendon with an instrument similar to the knife-hook used by Purves in cases of aural polypi. The External Rectus Tendon may be divided by an operation analogous to that above described. Considerable difference of opinion exists among surgeons as to Avhether both eyes should be operated on simultaneously (when both require operation), or Avhether the second operation should be postponed until after an interval of several days. Probably a safe rule is that given by Wells, to wait and observe the effect of the first operation, in cases of devia- tion of less than five lines ; by this precaution the surgeon can form an esti- mate as to hoAV much remains to be accomplished in the second operation. In cases in wliich by too free division of the internal recti muscles, a con- vergent has been converted into a divergent squint, it may be necessary to divide the new attachments of one or both tendons, and bring them fonvard to insert them nearer the cornea,1 holding them in place with fine sutures, 1 An ingenious method of doing this is described by C. R. Agnew, in Trans. N. Y. State Medical Society for 1871. Fig. 356. Strabismus hook. DISEASES OF THE EYELIDS. 681 and thus reversing the effect of the original operation. A similar procedure is sometimes employed in cases of paralytic strabismus, in the treatment of which R. B. Carter has also resorted to localized faradization. Anesthesia is, as a rule, undesirable in squint operations, though it may be employed in cases of children, or in those of nervous adults. The after-treatment in cases of strabismus, consists (if both eyes have been operated on) in simply bath- ing the parts with cold water; if one eye only has been submitted to opera- tion, the other should be closed Avith a bandage, so as to force the patient to use that of which the tendon has been divided. Advantage may often be subsequently derived from the use of suitably adjusted prismatic glasses, so as gradually to restore binocular vision. These glasses may, indeed, suffice to effect a cure without operation, in slight cases of periodic squint. Instead of dividing the contracted tendon, in cases of strabismus, Dr. Xoyes advises that the opposing or elongated tendon should be shortened, by cutting it near its insertion into the eyeball, bringing the posterior under the anterior portion, and securing it there Avith sutures. Diseases of the Eyelids. Ophthalmia Tarsi (Tinea Tarsi, Blepharitis ciliaris) is the name given to a subacute or chronic form of inflammation, affecting the edges of the eyelids and the follicles of the lashes, which become loosened and fall out. The palpebral edges are red, thickened, and sometimes ulcerated, and become glued together by the drying of the accumulating secretion. In its severer forms, the affection gives rise to the condition known as Lippitudo or Blear-eye. The puncta lacrymalia are often everted or obliterated, giving rise to a constant stillicidium of tears, which excoriate the skin and add to the patient's discomfort. This affection is, according to Roosa, often depend- ent on the existence of ametropia. The treatment consists in removing the dried secretion by warm fomentations, and smearing the edges of the lids with dilute citrine ointment.1 In severer cases the local application of nitrate of silver will be of service, and, if the puncta be everted or obliterated, the canaliculi should be freely slit up, the incision being directed imvards. As this affection commonly occurs in scrofulous children, cod-liver oil may be properly administered in most cases. If the patient be ametropic, relief may be afforded by the instillation of atropia and the use of suitable glasses. Oliver recommends tattooing the edges of the lids with India ink, as a cosmetic remedy in inveterate cases. Hordeolum or Stye is a small boil occurring at the edge of the lid, and often originating in the follicle of an eyelash ; it is met Avith usually in debilitated persons, and occasionally as the result of over-exertion of the eyes, or of exposure to too bright a light, as to the glare reflected from snoAV. When situated just within the edge of the lid, it produces pain by pressing on the globe ; relief may be sometimes afforded under these circumstances by fixing the lid in a position of slight eversion, by means of collodion. The treatment consists in the use of Avarm fomentations, with a puncture if re- quired, the induration Avhich remains being dispersed by the use of dilute citrine ointment. Tonics are usually indicated as constitutional remedies. Trichiasis and Distichiasis___The former term signifies an irregular displacement of the eyelashes, some of which, stunted and inverted, produce Ung. hydrargyri nitrat. 3J ; Ung. aq. rosae 3vij- M. 682 DISEASES OF THE EYE. great irritation by friction on the conjunctiva and cornea, the latter becoming, in extreme cases, cloudy and vascular. In distichiasis a complete double row of lashes exists, the inner toav being inverted, and producing great irri- tation as in the previous case. The treatment of either affection consists in carefully extracting with cilia forceps the offending lashes, or, in severe cases (if the upper lid be involved), excising the Avhole row of cilia, by means of two incisions parallel to the lashes and one on either side, the tarsal cartilage being thus split, and a wedge-shaped strip bearing the cilia removed. The operation may be facilitated by first fixing the lid Avith Snellen's forceps. Herzenstein applies a subcutaneous ligature around the roots of the lashes, while Hayes, of Dublin, induces sloughing of the follicles by the hypodermic injection of the perchloride of iron. If but one or tAvo lashes are involved, an old operation revived by Snellen, AVatson, and Robertson, may be resorted Fig. 357. Snellen's forceps. to. This consists in draAving the displaced eyelash, by means of a fine liga- ture (Watson employs human hair) under the skin of the eyelid, and thus mechanically altering the direction of the lash's growth. For complete dis- tichiasis, Watson employs transplantation, as practised by Arlt in cases of entropion. In the case of the lower lid, it will usually be sufficient to remove an elliptical strip of skin with the subjacent fibres of the orbicularis muscle, thus producing eversion as in the operation for entropion. Entropion, or Inversion of the Lids, may result simply from spasmodic action of the orbicularis palpebrarum (blepharospasm), as in the entropion after cataract operations in old persons, or from long-continued conjunctival inflammation, the injudicious use of caustics, etc. The irritation produced by the friction of the inverted lashes is very great, and sometimes induces opacity of the cornea. The treatment of the spasmodic cases1 consists in 1 Dr. Harlan Teports an obstinate case of blepharospasm cured by inhalations of nitrite of amyl. ECTROPION. 683 358. restoring the lid to its proper position by traction with the fingers, and then fixing it by the application of collodion, the contractile property of which serves to obviate the tendency to inversion. Chronic cases of entropion may be remedied by various operations, such as (1) pinching up, with entropion for- ceps, and excising a small strip of skin with the subjacent fibres of the orbicular muscle, parallel to the ciliary border of the lid—the wound being subsequently closed or not with sutures;1 (2) '• grooving the tarsal cartilage," as recommended by Streatfeild, the operation consisting in the removal of a transverse strip of the cartilage by means of tAvo parallel incisions meeting at the apex of a V—the skin wound being subse- quently closed Avith stitches; (8) excising a narroAv oval piece extending the whole length of the cartilage, as advised by Berlin ; (4) the intro- duction of two or three threads in a longitudinal direction through the cutaneous surface of the lid, the ligatures embracing the ciliary margin and being allowed to cut their way out by ulce- ration, as advised by Pagenstecher, or embracing the skin and muscle of the lid only, as recom- mended by Laurence;2 (5) the excision of a tri- angular portion of skin, with or without a part of the subjacent cartilage, as recommended by Akn Graefe; (6) the removal of the whole row of cilia, as described in speaking of trichiasis ; or (7) transplantation of the cilia to a better position on the lid, as practised in \"arious AvaAs by Arlt, AVarlomont, and AIcKeoAvn. As a pre- liminary to any of these operations, it will often be advisable to slit up the external canthus (can- thoplasty), re-adhesion being prevented by unit- ing the skin and mucous membrane on either side with a stitch. Ectropion, or Eversion of the Lids, may be of an acute character, resulting from spasm of the inner fibres of the orbicularis palpebrarum in cases of purulent conjunctivitis, in Avhich case its treatment is that of the disease Avhich it accompanies, or may appear as a chronic affec- tion, resulting from ophthalmia tarsi, chronic conjunctivitis, etc. Under these circumstances the treatment consists in the application of nitrate of silver to the mucous membrane just within the line of eversion, with slitting of the canaliculi if the puncta, be everted or occluded. Ectropion from the contraction of cicatrices, abscesses, etc., usually requires an operation, which may consist (1) in excising a por- 1 Schneller has modified this operation by circumscribing, without excising, an elliptical strip of skin, and having loosened the lateral portions uniting them with sutures above the central portion, which is thus covered in and serves as a splint to give firmness to the part. 2 A someAvhat similar operation is employed by Solomon, and is said to have been devised by Snellen, of Utrecht. Entropion forceps. 684 DISEASES OF THE EYE. tion of the everted conjunctiva; (2) in removing a triangular-shaped piece of all the tissues of the lid near the external canthus, and bringing the edges of the Avound together with harelip pins, thus shortening the lid (figs. 3.V.), 360); (3) in making a transverse incision through the lid doAvn to the con- junctiva, draAving this through the wound to the requisite extent, and cutting it off Avith scissors ; or (4) in dissecting out the vicious cicatrix and filling Fig. 359. Fig. 360. Adams's operation for ectropion. (Lawson.) the gap by transplanting a flap of skin, from the forehead in case of the upper, and from the nose or cheek in case of the lower, lid, or even, as successfully practised by AVolfe, AVadsworth, and Akn Zehender, from a distant part, the flap being shaved doAvn so as to assimilate the operation to Reverdin's plan of transplanting cuticle. Excurvation of the Eyelids is the name used by Laurence for the peculiar deformity observed, particularly in the upper lid, in cases of in- veterate trachoma; the remedy, according to this writer, consists simply in dividing the outer canthus, and uniting the cut edges of conjunctiva and skin by stitches above and beloAV. Ptosis, or Falling of the Upper Lid, may be congenital, or may result from the increased weight of the part due to inflammatory thickening, from Avounds dividing the levator palpebral or its nerve, or from paralysis of the third nerve. The treatment (in cases of sufficient severity to justify opera- tion) consists in removing an elliptical portion of the skin and subjacent muscle of the lid, the edges of the wound being then approximated trans- versely so as to place the part under control of the occipito-frontalis muscle, which sends fibres to the upper portion of the orbicularis—or in the introduc- tion of ligatures as described in speaking of entropion. In paralytic cases, the endermic application of strychnia has been occasionally resorted to with advantage. Dr. Akn Bidder, of Ncav York, recommends the employment of a delicate India-rubber band, fastened Avith collodion and isinglass plaster to the edge of the lid and to the forehead, so as to supplement the paralyzed muscle, as in Barwell's and Sayre's method of treating club-foot. Dr. Mat- thewson has employed a similar plan in the treatment of spasm of the orbicu- laris (blepharospasm). Lagophthalmos, or Hare-eye, denotes an inability to close the eyelids; it may result from the contraction of cicatrices, when its treatment is that directed for ectropion, but more often depends on paralysis of the orbicular DISEASES OF THE LACHRYMAL APPARATUS. 685 muscle from some local affection of the portio dura, or from intra-cranial causes. If the affection appear to result from the pressure of a tumor on the portio dura, the offending growth should, of course, be removed; a blister to the temple may be of service in cases resulting from exposure to cold; while, if a syphilitic origin be suspected, the iodide of potassium should be administered. Symblepharon is a morbid adhesion of the eyelid to the eyeball, result- ing usually from the cicatrization of burns, ulcers, etc. The treatment con- sists in (1) dividing the adhesions, and uniting the cut edges of conjunctiva Avith sutures (AVilde); (2) covering the raAv surface, left after severing the adhesions, with flaps of healthy conjunctiva taken from unaffected parts of the eyeball (Teale),1 or with a flap from the skin of the eyelid itself, passed through a slit in the tarsal cartilage (C. B. Taylor) ; (3) dissecting back the symblepharon as far as the retro-tarsal fold, doubling it upon itself so as to oppose a mucous surface to the globe, and fixing it in this position by means of a ligature which is armed Avith tAvo needles and passsed through the lid from Fig. 361. within outAvards (Arlt) ; or, (4) employing delicate flaps taken from the cheek or fore- head, and inverted so as to turn the cuta- neous surface tOAvards the eyeball, as success- fully done by Dr. G. E. Post, of Beirut, Syria. Ankyloblepharon is an abnormal adhesion of the free edges of the upper and loAver lids, either congenital or the result of injury, etc. The treatment consists in sever- ing the adhesions Avith a small knife and grooved director, reunion being prevented by touching the CUt edges with collodion. Symblepharon. (Mackenzie.) Epicanthus is a congenital affection, in which a crescentic fold of skin overlaps the inner canthus of the eye, producing considerable deformity ; the treatment consists in excising a longitudinal fold of skin and bringing the ed«res of the avouiuI together Avith sutures, so that the subsequent contraction may expose the previously hidden canthus. Tumors of the Eyelids__Sebaceous, Vascular, and other Tumors occur on the eyelids, and are to be treated as similar growths in other situa- tions. The Chalazion, or common tarsal tumor, appears to originate in a distended state of a Aleibomkn follicle, and often suppurates; the treatment consists in making an incision on the conjunctival surface and squeezing out the contents of the mass. Chisolm recommends, in all cases of palpebral cyst, simple puncture followed by evacuation of the cyst contents, and subse- quent cauterization of the cavity with a silver probe dipped in nitric acid. Diseases of the Lachrymal Apparatus. Diseases of the Lachrymal Gland__This organ may be inflamed (Dacryo-adenitis), or may be the seat of various morbid growths. These affections are, howevTer, rare, and their treatment presents no features calling for special comment. Fistula of the Lachrymal Gland may result from ab- 1 Wolfe, of Glasgow, and Calhoun, of Georgia, have operated successfully by trans- planting a portion of conjunctiva from a rahhit. 686 DISEASES OF THE EYE. scess or wound of this part; it may be treated by paring the edges and intro- ducing a suture, by the application of caustic or the galvanic cautery, or by establishing a free communication with the conjunctival surface by the use of a seton, as has been successfully done by Bowman. Excision of the Lachrymal Gland is recommended by Laurence in eases of obstruction of the canaliculi, in which it is found impossible to restore their permeability ; the operation consists in making an incision beloAV the upper and outer third of the orbital ridge, cautiously opening the orbit, seizing the gland with a double hook, and carefully dissecting it from its attachments; hemorrhage having ceased, the Avound is closed Avith sutures. To avoid the risk of ptosis, Avhich occasionally follows the operation, Air. Laurence suggests that an internal incision should be made through the upper sinus of the pal- pebral conjunctiva, with an external division of the outer canthus ; the sub- stance of the lid Avould not thus be involved in the operation. Xerophthalmia, or Dryness of the Conjunctiva, from deficiency of the tears and mucous secretion Avhich naturally lubricate the part, may be greatly alleviated by the local use of glycerine. Epiphora, strictly speaking, signifies an excessh-e secretion of tears, but the term is often used as equivalent to Sti/licidium Lacrymarum, Avhich is the overflow from obstruction of the canaliculi or nasal duct. Excessive kchrymation may be a symptom of various inflammatory conditions of the eye, or may result from the presence of foreign bodies, entropion, etc., under which circumstances its treatment requires, of course, the removal of the cause to Avhich the epiphora is due. Obstruction of the Canaliculi may occasionally be remedied by diktation of the passage Avith probes of gradually increasing size, but it will usually be necessary to slit up the canal with a delicate grooved director and cataract knife, Avith scissors, or Avith a delicate beaked knife, whicli is perhaps Fig. 362. Bowman's canaliculus knife. the most convenient instrument. The same operation is required in cases of eversion or obliteration of the puncta lacrymalia. The lower canaliculus is the one usually slit, the incision being made tOAvards the conjunctival surface, so as to open a passage for the tears. Reunion is to be prevented by the daily introduction of a probe, by the application of nitrate of silver, or by excising a small portion of the mucous membrane. If the punctum be indis- tinguishable, the lachrymal sac may be opened beneath the tendo oculi, and the canaliculus slit from below upAvards, as recommended by BoAvman, or a bent director may be introduced tlirough the upper punctum and brought around into the lower canaliculus, or vice versa, as advised by Streatfeild. Obstruction of the Nasal Duct usually results from thickening of its mucous lining, as the consequence of chronic inflammation. The treatment consists in effecting gradual dilatation by means of probes, introduced through the punctum, the canaliculus being, if necessary, previously slit. In passing probes through the canaliculi and nasal duct, the position of the instrument is at first longitudinal, then transverse, and then somewhat longitudinal again, with a slight inclination inAvards and backAvards in correspondence with the DISEASES OF THE ORBIT. 687 anatomical disposition of the parts, which must be borne in mind. Metal probes are commonly to be preferred for dilation of the lachrymal passages, though bougies of the laminaria digitata have been successfully employed by several surgeons. Other modes of treatment are the introduction of a style through the slit canaliculus into the nasal duct, the instrument being allowed to remain several days (Bowman), the internal division of the strictured part by nicking the seat of obstruction in several directions with a suitable knife (Stilling), and the forcible dilatation or rupture of the stricture, as in Holt's method of treating stricture of the urethra (Herzenstein). The old plan of introducing a style through an external incision, is noAv generally abandoned. Inflammation of the Lachrymal Sac may be acute (Dacryo- cystitis), or chronic (Blennorrhcsa, Mucocele). The former variety of the affection is to be treated with Avarm fomentations, and an early puncture from the conjunctiA'al surface, if suppuration occur; and the latter by the use of astringent lotions, by slitting the canaliculus and dilating any stricture that may be found, and by washing out the sac with astringent injections intro- duced by means of a canula and syringe. In obstinate cases it may be necessary to excise the anterior Avail of the sac (Akn Ammon, Bowman, LaAvson, Alonoyer), or to obliterate the sac itself by the use of caustic or the galvanic cautery, applied through an incision, Avhich is best made, as advised by AgneAv, of Xcav York, tlirough the conjunctiva. Fistula Lachrymalis, or fistula of the lachrymal sac, may result from either acute or chronic inflammation of the part; the treatment consists in the removal of any obstruction to the natural course of the tears, and in the use of astringent injections; if necessary, the sinus may be laid open with a cataract knife, or its edges may be pared and a suture introduced. Syphilitic Affections of the lachrymal apparatus, both secondary and tertiary, are described by R. AV. Taylor, of New York. Diseases of the Orbit. Abscess of the Orbit may be acute or chronic; the symptoms of the former are those of abscess in general—deep-seated and constantly increasing pain, aggravated by motion or pressure, Avith a SAVollen, glazed, and cedema- * tons state of the eyelids (particularly the upper), chemosis of the conjunctiva, and protrusion of the eye, the displacement being usually someAvhat doAvn- Avards and imvards, as Avell as forAvards. Impairment of sight results from pressure on and stretching of the optic nerve. Fluctuation is finally deve- loped, and pointing usually occurs beloAV the inner portion of the supra-orbital ridge. The symptoms of chronic abscess are much less distinctive, the diag- nosis from encephaloid or other soft tumor being often impossible without the aid of the exploring needle. The treatment of either form of abscess consists in making an incision Avith a knife introduced fktAvise at the point of greatest fluctuation, the subsequent management of the case being conducted on general principles. If a sinus persist after the evacuation of an orbital abscess, it may be stimulated to heal by the use of astringent injections. Periostitis, Caries, and Necrosis of the orbital Avails are occa- sionally observed, usually as the result of constitutional syphilis. The treat- ment of these affections presents no features requiring special comment. Tumors of the Orbit__Various forms of morbid groAvth are met with in this region, as the cystic, cartilaginous, osseous, fibrous, recurrent, vas- 688 DISEASES OF THE EAR. cular, and cancerous. The treatment of these different affections has been sufficiently considered in Chapter XXVI.; in dealing with non-malignant groAvths, the eyeball should, if uninvoh'ed, be, if possible, allowed to remain; but in the case of cancerous tumors of the orbit, it must commonly be re- moved, to alloAv space for complete excision of the morbid groAvth. haw son recommends that, after the removal of a malignant tumor from the orbit, lint spread Avith a paste of chloride of zinc should be carefully applied to the Avhole surface from Avhich the growth sprang. Hydatids of the orbit have been observed by Lawson, Higgens, and others. Aneurisms of the Orbit__The orbit may be the seat of ordinary aneurism, affecting the ophthalmic artery, of traumatic aneurism, or of aneurism by anastomosis. In either of the two first-named conditions there would be exophthalmos, Avith more or less pulsation, but according to Terrier and Rivington, who have ably investigated the literature of the subject, the same symptoms may be equally due to an extra-orbital aneurism of the ophthalmic artery, to an aneurism of the internal carotid, to an extra-orbital aneurismal varix involving the internal carotid and the cavernous sinus, or to dilatation from obstruction of the ophthalmic vein. Aneurism by anasto- mosis appears to involve the orbit only by spreading from neighboring parts, and is not accompanied by exophthalmos. Vascular protrusion Avithout pul- sation may also result from hypertrophy and hypersemia of the adipose tissue of the orbit, as in the peculiar affection known as Exophthalmic Goitre, or Graves's, or Basedow's Disease.1 The surgical treatment of orbital aneu- risms has already been considered. (See pages 526, 555.) Distension of the Frontal Sinus by the accumulation of pent-up fluid, may, by forming a tumor at the upper and inner portion of the orbit, cause displacement of the eyeball, and entail great disfiguration on the pa- tient. The treatment consists in evacuating the fluid by perforating the thinned wall of the sinus and then establishing a free communication Avith the nose, re-accumulation being prevented by the introduction of a drainage tube. CHAPTER XXXVI. DISEASES OF THE EAR. As in dealing with Diseases of the Eye, it is not my intention in the fol- loAving pages to discuss all those subjects Avhich properly belong to the domain of aural surgery, but to refer only to those more common affections of the ear wliich the general practitioner may at any time be called upon to treat, and to describe those operations upon the organ of hearing which every sur- geon should be competent to perform. Diseases op the Auricle. Malformations of the Auricle are occasionally met with, usually in conjunction with other congenital defects ; if the malformation consists in contraction of the orifice of the meatus, from undue projection of the tragus 1 See an able paper by Dr. T. Gr. Morton, in Amer. Journ. of Med. Sciences for July, 1870. DISEASES OF THE EXTERNAL MEATUS. 689 or antitragus, advantage may be derived from the employment of dilatation, or from excision of a portion of the cartilage. Congenital closure of the meatus by an abnormal membrane, may be remedied by an incision and the subsequent use of tents. Supernumerary auricles may be treated by exci- sion, as in cases related by Birkett and Gross. Chronic Inflammation of the auricle, attended Avith great thickening, induration, itching, and tenderness, is chiefly observed in debilitated women Avho have passed the middle period of life ; it sometimes remains after the subsidence of an attack of erysipelas, and is commonly called chronic ery- sipelas of the ear. The treatment consists in the application of nitrate of sih'er or other astringent lotions, with the administration of tonics, if re- quired. The itching may be relieved by the local use of glycerine or collo- dion, and a silver tube may be fitted to the meatus, if this be permanently contracted. Chronic Eczema is another affection of the auricle which produces much annoyance; during the early stages, soothing applications are required, while at a kter period advantage may be derived from the use of astringent lotions, or of slightly stimulating substances such as the dilute citrine oint- ment. Tumors of the Auricle__These may be cystic, fatty, fibrous, Avas- cular, malignant, etc. Those particularly deserving mention are the blood- cyst, Othematoma, or Hematoma Auris, frequently observed in the insane, and the fibrous, cheloid-looking groAvth, which occasionally folloAvs the use of ear-rings. The former affection, which, according to BroAvn-Sequard as quoted by Keller, is due to the existence of a lesion in the left posterior por- tion of the brain, and may be artificially produced in animals, requires the use of evaporating lotions during the acute stage, followed by the introduc- tion of a seton, or, which Dr. Hearder recommends as producing less de- formity, the application of a blistering fluid to the inner surface of the pinna. The cheloid-like growth may be treated by excision, but the disease is apt to return. Diseases of the External Meatus. In some cases, it is possible to obtain a satisfactory view of the meatus by simply placing the patient in a good light and drawing the ear slightly back- wards and upwards, while the tragus is pressed in the opposite direction; it is usually necessary, hoAvever, to Fijr. 363. employ a speculum—the best instruments for general use being, I think, those known as Toynbee's (Fig. 363) and Gruber's, which may be used with either natural or arti- ficial light: in the latter case, a reflector is required, and the same may be employed to utilize diffused daylight, Avhich is usually preferable to the direct rays of the sun. The speculum may be made of polished silver or of vul- canite, the latter being probably the best material for the purpose. For special cases other instruments may be employed, such as Hassenstein's (which is provided with a tube containing a lens and a perforated mirror) the in- genious prism-speculum devised by Dr. Blake, of Boston, or the binocular speculum suggested by Dr. Eysell. Dr. Toynbee's speculum. Blake also employs small reflectors, Avhich can be intro- duced through perforations in the membrana tympani. 690 DISEASES OF THE EAR. Accumulations of Cerumen or Ear Wax, mingled with short hairs and flakes of cuticle, are often met with, and are a frequent cause of deafness ; the treatment consists in the removal of the hardened mass bv syringing, as directed for foreign bodies in the ear (page 311), subsequent irritation being prevented by the application of a little olive oil or glycerine. Vegetable Parasites have been met with in the meatus, causing a con- stant accumulation of dense, white flakes of thickened cuticle ; the treatment consists in frequent syringing Avith lead-Avater or a weak solution of chlori- nated lime. Levi recommends the use of" nitrate of silver, followed by a solution of common salt. Follicular Abscesses occur in the meatus, constituting an extremely painful and annoying affection ; they are chiefly met with in those of debili- tated constitution, and are said to be common among patients Avho suffer from styes of the eyelids. The treatment consists in the use of hot anodyne poultices or fomentations, irrigation with warm water, and evacuation of the pus as soon as its presence is detected, Avith the application of dilute citrine ointment to remove any induration Avhich may be left. The preparations of iron may be administered internally, if a tendency to recurrence be observed. Catarrhal Inflammation of the external meatus, or Otorrhcea, is characterized by the presence of a muco-purulent discharge, and is, according to Hinton, usually accompanied by a similar affection of the tympanic cavity. The treatment (as far as the meatus is concerned) consists in syringing to insure cleanliness, folloAved by the use of astringent lotions or by the insuffla- tion of poAvdered talc, which is particularly recommended by the above- named author. Dr. T. G. Morton, of this city, has employed with advantage a " styptic cotton," prepared by soaking cotton-wool in a dilute solution of the subsulphate of iron. Insufflation of alum is highly commended by Chisolm. Guyon advises the introduction of a drainage-tube. The administration of tonics is usually indicated by the constitutional condition of the patient. Counter-irritation over the region of the mastoid process may often be ad- vantageously employed. Chronic Inflammation of the meatus often results in the production of a thickened state of the epidermis, Avith desquamation, and accumulation of flakes of cuticle. These must be removed by syringing, a solution of nitrate of silver, or the dilute citrine ointment, being subsequently applied. Another occasional result of chronic inflammation is the development of a granular condition of the lower part of the meatus and membrana tympani, somewhat analogous to granular lids. The treatment consists in the use of a solution of nitrate of silver, or in the insufflation of poAvdered alum or tannic acid. The presence of a diphtheritic membrane in the external ear has been noted by Gruber, and by Callan, of New York. Polypi frequently arise from the deeper portions of the meatus, though, according to Hinton, their more common seat is the inner wall of the tympa- num, whence they protrude, distending and finally rupturing the tympanic membrane. Polypi of the ear occur under several forms, but in structure all appear to correspond Avith the fibro-cellular variety of tumor1 (p. 469). They produce, when large, a feeling of distension and irritation, and are sometimes 1 Toynbee describes three varieties, tbe raspberry cellular, the fibrocartilaginous, and the globular cellular polypus. TUMORS OF THE MEATUS. 691 attended with grave cerebral sAmptoms. The treatment, from whateAer position they spring, consists in subduing any existing irritation by the use of lead lotions, counter-irritation, etc., removing the growth, and adopting means to prevent its recurrence. The removal of an aural polypus is usually best effected by means of the " snare" of Sir W. Wilde (Fig. 361), or by Fig. 364. delicate forceps, of Avhich two forms are exhibited in the annexed cuts (Figs. 365, 366). Purves, of London, employs an instrument consisting of a hook provided with a cutting edge, Avhich he calls a "polypus knife-hook." The more vascular polypi may be treated by caustic applications, such as Figs. 365, 366. Forceps for aural polypus. the potassa cum calce, introduced through a glass speculum. If the snare be used, Hinton recommends that it should be armed with the gimp employed by anglers, instead of wire. After the removal of a polypus, its root must be treated with caustic applications, such as chromic acid, chloride of zinc, or potassa fusa—astringent lotions being at the same time used, and the Eusta- chian tube rendered pervious, if occluded. If the membrana tympani be perforated, Hinton's plan of throwing a stream, by the syringe, from the meatus through to the fauces, should also be adopted. When a decided impression has been made upon the root of the polypus, astringents, such as weak solutions of nitrate of silver or lead-Avater, may be substituted for the caustics, or insufflations of poAvdered talc or alum may be employed. Tumors of the Meatus__Exostoses are occasionally met with in the walls of the meatus, and, if large, may encroach so much on the canal as to cause deafness. The treatment, in the early stage, consists in the application of the tincture of iodine to the surface of the growth and behind the ear, and by a perseverance in this plan the increase of the tumor may sometimes be 692 DISEASES OF THE EAR. arrested. At a later period, little can be done beyond preventing the accu- mulation of wax and cuticle by frequent syringing. Sebaceous or molluscous tumors result from the enlargement of sebaceous follicles, and Avhen laid open are found to consist of a cyst-wall containing layers of epidermis. If neglected, they are apt to cause absorption of the bone, and grave or even fatal cerebral complications. The treatment consists in laying open the cyst, evacuating its contents by syringing, and then drawing out the cyst-wall Avith forceps. Diseases of the Membrana Tympani. The Dermoid Lamina of the membrana tympani may be the subject of simple acute, chronic, or catarrhal inflammation, these affections often accompanying similar conditions of the external meatus. Acute inflamma- tion of the dermoid lamina can usually be made to terminate in resolution, by the use of local depletion, hot fomentations, and frequent syringing with warm water. Chronic inflammation often causes an accumulation of epider- mis, requiring the employment of the syringe, and perhaps the use of an astringent lotion, with counter-irritation over the region of the mastoid pro- cess. The catarrhal form of inflammation is of a more serious character, being apt to terminate in the formation of granulations, or even of polypi— or in ulceration, which may extend to the fibrous laminag. The treatment is the same as for the ordinary chronic inflammation. Tonics, especially iron, quinia, and cod-liver oil, are usually indicated by the constitutional condition of the patient. Many of the symptoms of meningitis may, according to Bon- nafont, be simulated by inflammation of the membrana tympani, or by com- pression of this organ by accumulated cerumen or by intra-tympanic mucus ; the diagnosis may, however, be made by observing that in these affections the mental faculties are not involved. The Fibrous Lamina? are also subject to inflammation of an acute or chronic character, very often associated with a gouty or rheumatic state of the system. Chronic inflammation often leads to a dense and rigid condition of the membrane of the tympanum, which may be recognized through the speculum when air is forced into the tympanic cavity, and which is not usually accompanied Avith pain, but with an annoying tinnitus, or ringing in the ears, and with deafness—the latter symptom, however, being in all pro- bability due rather to the state of the tympanic cavity itself, than to that of its membrane. Toynbee recommends for this rigidity of the membrana tympani, the application of nitrate of silver 0ss-j tof^j), and Hinton speaks highly of a combination of ether or tincture of camphor with opium and glycerine, as a means of relieving the tinnitus, when all inflammatory symp- toms have subsided. Section of the tensor tympani muscle has been advan- tageously resorted to in some cases by Weber, and by Turnbull, of this city. In the opposite condition, viz., relaxation of the membrana tympani (which may result from inflammation, or from simple atrophy), temporary benefit may often be derived from inflating the cavity of the tympanum ; and in some instances, advantage may be obtained from the use of astringent lotions with counter-irritation over the mastoid process, or from the application of an artificial membrane. In most cases, however, the treatment must be principally directed to the condition of the Eustachian tube and cavity of the tympanum—the former requiring dilatation by the use of the catheter, while the latter may require syringing, after previous incision of its membrane. Ulceration of the dermoid and fibrous laminae of the membrana tympani may persist for many years, being accompanied Avith a muco-purulent discharge, and constituting one of the varieties of Otorrhoza. If the ulceration extend DISEASES OF THE MEMBRANA TYMPANI. 693 only to, but not through, the mucous lamina, the latter appears at the base of a depression corresponding to the ulcer, and protrudes Avhen the tympanum is inflated. If the mucous lamina be also involved, perforation is apt to occur. The treatment consists in the application of a Aveak solution of nitrate of silver, Avith the administration of suitable constitutional remedies, and the adaptation of an artificial membrana tympani in case of perforation. Calcareous Deposits in the fibrous lamina? of the membrana tympani, may assume a concentric or a radiating arrangement, corresponding to the particular lamina in\olved. They consist chiefly of phosphate of lime, and do not appear to interfere particularly Avith the poAver of hearing, except when complicated with anchylosis of the stapes to the fenestra ovalis, or other deep-seated disease. No treatment is likely to prove of much service, but a trial may be given to the plan recommended by Toynbee, Avhich consists in employing counter-irritation over the mastoid process, and in administering alteratives. Incision of the Membrana Tympani, or even Excision of a por- tion of this structure, is occasionally of service in the management of the various affections Avhich have been described. The chief objection to the treatment by incision, is the temporary nature of the improve- ment, OAving to the rapid healing of the wound; to obviate this, the surgeon may resort to the insertion into the cut, of a grooAred vulcan- ite ring, provided Avith a silken thread to prevent its falling into the tympanum, as suggested by A. Politzer. Excision may be per- formed with an instrument spe- cially devised for the purpose by Fabrizzi, or more conveniently Avith a simple double-edged knife and delicate forceps. In some cases, incision appears to act by diminishing intra-tympanic ten- sion, as shown by the gaping of the Avound ; but in other instances no such effect is observed, though the resulting benefit maybe equally great. Wreden, of St. Peters- burg, recommends the Excision of a Portion of the Malleus with the adjacent membrane, and has de- vised an instrument by Avhich the operation can be accomplished. Simrock, of Ncav York, recom- mends as preferable to incision, perforation of the membrana tym- pani by the application of sulphu- ric acid. Fig. 367. Politzer's method of inflating the tympanum. Perforation of the Membrana Tympani may result from trau- matic causes, from ulceration of this structure itself, or as a consequence of 694 DISEASES OF THE EAR. intra-tympanic inflammation—the mucus Avhich accumulates Avithin the cavity gradually making its way through the membrane, and being discharged ex- ternally. The perforation may be commonly seen by means of the speculum, and the patient can, if the Eustachian tube be pervious, bloAv air tlirough the meatus by making a forcible expiration (or, as suggested by Dr. Schell, yawning) with the mouth and nostrils closed (Valsalva's experiment) ; or the surgeon may do the same by the use of the Eustachian catheter, or by Po- litzer's method, which consists in bloAving air through the nostril into the pharynx wliile the patient swalloAvs—the Eustachian tube opening during this act, and the air thus readily entering the tympanum. The surgeon may simply bloAv through a flexible tube ; or, which is preferable, may use an India- rubber bag provided with a Avell-fitting nozzle (Fig. 367). In using Politzer's method, Hinton advises that the bag should be applied to the nostril of the opposite side to that of the ear which it is intended to inflate, and that the meatus of the sound ear should be firmly closed so as to guard its membrana tympani from the effect of pressure. Gruber has modified Politzer's method by directing the patient instead of swalloAving to pronounce the syllable " huck" or " heck." The treatment of perforation of the membrana tympani should be directed, in the first place, to an attempt to secure closure of the opening, Avhich may sometimes be effected by the application of nitrate of silver or other astringent lotions, the insufflation of talc, etc. If, as often happens, the perforation is prevented from healing by the accumulation of inspissated mucus in the tympanum, the surgeon may resort to Hinton's plan of Avashing out this cavity, first with alkaline and afterAvards with astringent solutions, injected by the syringe from the meatus through to the fauces. The nozzle of the instrument should be attached to a flexible tube which closely fits the meatus. By these means the Fig. 368. parts may usually be restored to a healthy condition, Avhen, even if the perforation persist, the hearing may be but little affected ; if such is not the case, there is reason to suspect some loosening of the connections of Toynbee's artificial membrana tympani. the OSsicuk, and under such circum- stances great benefit may be derived from the adaptation of an artificial membrana tympani, Avhich may consist simply of a plug of cotton-wool dipped in glycerine (Yearsley), an India- rubber djsk or globe, as recommended by Toynbee, a combination of both, as advised by Field, or a delicate metallic ring covered Avith gold-beater's skin, as suggested by Dr. B. Thompson, of New York. If either of the lat- ter contrivances be used, a thread of delicate silver Avire is attached, in order to facilitate removal. Diseases of the Eustachian Tube. It has been shoAvn by Toynbee and Jago, that the Eustachian tube is, contrary to what Avas formerly supposed, closed when in its ordinary condi- t'on,1 and opened in the act of swallowing. In some cases, however, the Eustachian tube is more or less permanently open, giving rise to an abnormal sensibility to sounds originating in the patient's own throat, with a sense of discomfort in the fauces. This condition may arise in the course of catarrhal affections, and usually subsides spontaneously. This is still, however, denied by Riidinger. DISEASES OF THE EUSTACHIAN TUBE. 695 Obstruction of the Eustachian Tube may be due to a thickening of the mucous membrane of the fauces or tympanum, to a relaxed state of the fauces, to contraction of the bony Avails of the tube itself, to the presence of inflammatory adhesions, to accumulations of mucus, etc. The diagnosis may be made by inspecting the membrana tympani through the speculum (the membrane, in cases of Eustachian obstruction, appearing concave, dull, and Fig. 369. Application of the otosc >pe. (Tjynbee.) someAvhat opaque), and by means of the otoscope, an instrument, consisting of a flexible tube, one end of Avhich is adapted to the patient's and the other to the surgeon's ear. If, Avhen the otoscope is adjusted, the patient makes a forcible expiration (the mouth and nostrils being closed), the air, if the Eus- tachian tube be pervious, rushes into the tympanum, producing a sound Avhich is distinctly audible to the surgeon. This sound, in a normal state, has been compared to that of a bullet striking a target at a great distance; it under- goes various modifications as the result of disease, being of a creaking or Avhistlin"1'/i^march, Hill, and Yerneuil. Malignant Tumors of the nostrils usually belong to the Encephaloid or Epitheliomatous varieties. They may be recognized by their rapid growth ; by their im-olving the neighboring bones, forming an elastic swelling; by their tendency to ulcerate and bleed; by the pain Avhich attends their pro- gress, and by the early implication of the neighboring lymphatic glands. In most eases, palliative treatment only is justifiable—complete extirpation being rarely practicable, Avhile a partial removal could but aggravate the disease. If, hoAvever, the nature of the tumor be recognized at a very early period, and it appear that the groAvth actually originates in the nose, and does not (as sometimes happens) spring from the sphenoid or ethmoid cells, or even from Avithin the skull, excision may perhaps be attempted by the folloAving method. An incision carried from the inner angle of the eye downwards, alongside of the nose, lays open the nostril, while another incision across the cheek forms a flap which is to be dissected up. The superior maxilla is divided above its alveolar border, with saAv and cutting pliers, a second section passing from the outer extremity of the first into the orbit; the nasal process and nasal bone are then similarly severed, when a considerable part of the upper max- illary may be removed; the tumor is then to be extirpated, bleeding being checked by the use of the actual cautery, and by stuffing the cavity with lint soaked in Monsel's solution, or in the muriated tincture of iron. In cases not admitting of any attempt at excision, tracheotomy may some- times be required to avert death from suffocation. Rhinolites, or Nasal Calculi, are sometimes met Avith in the cavity of the nostril, Avhen they may be extracted with forceps, etc., as other foreign bodies; or they may be found beneath the mucous membrane, Avhen they must be removed by careful dissection. They consist of phosphate and car- bonate of lime, with magnesia and inspissated mucus, and are usually formed around a nucleus of some extraneous substance. Diseases of the Septum__The septum nasi may be the seat of haematoma or thrombus (the result of injury), of abscess, or of cystic or car- tilaginous groAvths. The treatment of thrombus in this situation, consists in the adoption of measures to promote absorption, Avhile, on the other hand, an early incision is indicated in case of abscess. Cystic tumors may be treated by cutting away a portion of the wall and applying nitrate of silver. Avhile the cartilaginous groAvths require excision by the use of the knife and gouge. If perforation of the septum occur, in any of these affections, a plastic operation may be required to relieve the consequent deformity. Casabianca mentions two cases of chronic thickening of the nasal septum which had been mistaken for epithelioma. Rhinoplasty. The whole, or a portion merely, of the nose may be destroyed by injury, by ulceration with or without caries or necrosis, or by the ravages of lupus, 708 DISEASES OF THE FACE AND NECK. or of constitutional syphilis. Under these circumstances, various rhinoplastic operations may be employed to relieve the deformity, it being, however, an invariable rule, that no operation is to be performed until the destructive process has been completely and permanently arrested. Operation for Partial Restoration of Nose___If the columna and part of the septum only be destroyed, a new columna should be fashioned from the upper lip, by making incisions on either side of the median line, so as to detach a strip of tissue about four lines wide and embracing the entire thickness of the lip ; this strip, with its end suitably pared, is then turned upwards, and attached by means of the tAvisted suture to the lower surface of the nasal tip, Avhich is previously freshened for the purpose. The wound of the lip is united with harelip pins, a few narrow strips of adhesive plaster serving to support the new columna in its place until firm union has occurred. The size of the neAvly-formed nostrils must be maintained by the occasional introduction of gutta-percha or silver tubes. If one ala of the nose only be deficient, the surgeon may, if the loss of tissue be but slight, take a flap from the upper part of the nose itself, and, freshening the edges of the border of the gap, attach the transplanted portion by a feAV points of suture. Under other circumstances the flap may be taken from the cheek (as I did successfully in the case of a woman whose husband, moved by jealousy, bit a piece from her nose), or, if the loss of substance be very considerable, from the forehead ; in the latter case, the pedicle of the flap must be tAvisted upon itself, and, to prevent its sloughing, a groove may be cut for its reception on the dorsum of the nose. When union of the trans- planted flap is complete, the pedicle may be raised and cut aAvay, the groove being then closed Avith sutures. Fistulous Openings through the nasal bones occasionally result from necrosis following scarlet fever, etc. Under such circumstances, a flap may be raised from the cheek or forehead, and attached by sutures to the freshened edges of the gap. Operations for Restoration of the Entire Nose___The whole nose may be restored by several methods, those best known being designated respectively as the Taliacotian and the Indian operation. 1. The Taliacotian Operation (so called from Taliacotius, a distin- guished Italian surgeon of the sixteenth century) consists in fashioning a nose from the fleshy tissues of the arm.1 A flap of sufficient size of skin and areolar tissue is first marked out, and partially detached, being left in this condition for a fortnight to become vascular and thickened by the process of granula- tion ; the remains of the original nose are then pared, and the flap reduced to a proper shape and attached in its new position by numerous points of suture, the arm being approximated to the head, and fixed by a complicated system of bandages. After about ten days, when union may be supposed to be com- plete, the attachment of the flap to the arm is severed, and any trimming of the new organ which may be necessary effected. A columna is subsequently made from the upper lip. This process is so tedious and unsatisfactory, that it is seldom resorted to at the present, day, though it has recently been suc- cessfully employed by MacCormac. It has been modified by Warren and others, by taking the flap from the forearm, and by shortening the time dur- 1 It is scarcely necessary to say that the well-knoAvn Hudibrastic legend, which represents Taliacotius as making noses for his patients from the gluteal regions of other persons, is ufacetia merely, without any foundation in fact. RHINOPLASTY. 709 Fig. 377. ing which the head and arm are fastened together. In order to supply a bony support for the neAv nose, Dr. Hardie, an English surgeon, oddly enough transplanted the ungual phalanx of a, finger, keeping his patient's arm fastened up to her face for three months. 2. The Indian Method, which Avas introduced into England by Carpue, in 1814, is that which is noAv generally preferred. In this procedure, a flap is taken from the forehead to form the greater part of the nose, the columna being subsequently made from the upper lip, though in some cases it is possible to derive the columna from the forehead also. The operation, as usually performed, may be divided into three stages. (1.) The first stage consists in the formation and attachment of the frontal flap. A piece of thin gutta-percha should be first modelled to the size and shape of the organ which it is desired to reconstruct, and then should be flat- tened out and laid upon the forehead so as to form a guide for the incisions, as shown in Fig. 377. As the flap—Avhich may be taken from the middle or from either side of the forehead—is sure to shrink after its formation, a margin of a quarter of an inch should be alloAved on all sides of the pattern, and it is con- venient to mark out the lines in Avhich it is designed to cut, with the tincture of iodine. If the patient have a very high forehead, the central portion of the flap may be prolonged so as to form a columna, but, under ordinary circum- stances, it is better to leave this part of the operation until a subsequent occa- sion. In raising the frontal flap, the surgeon should cut fairly down to the periosteum, beginning at the root, which should be made long, so that its circu- lation may not be interfered with Avhen it is twisted. The flap should embrace all the soft tissues of the forehead down to the periosteum ; and, indeed, it has been suggested that even this tissue should be included, in hope that osseous matter would be developed in the structure of the new nose. It does not appear, however, that such a result would be attended by any particular benefit, while the removal of the periosteum from the frontal bone exposes that part to the risk of necrosis. The flap, having been raised, is laid back upon a piece of wet lint, Avhile the stump of the nose is pared and made ready for its re- ception. The integument should be dissected up in such a way as to form a groove for the reception of the frontal flap, the edges of which should themsehes be shaved so as to furnish tAvo raAv surfaces. All hemorrhage having been checked (if possible, without the use of ligature), the flap is to be twisted upon its root and adjusted, being held in place by means of the interrupted suture, or, Avhich is better, the "tongue and groove suture" employed by Prof. J. Rhinoplasty by Indian method. (Fergusson.) Fig. 378. Tongue and groove suture. 710 DISEASES OF THE FACE AND NECK. Pancoast, of this city, the mechanism of which can be readily understood from the annexed diagram (Fig. 378). The flap should be supported by gently introducing beneath it a plug of oiled lint, or, if the columna have been made at the same time, Iavo small plugs, one corresponding to each nostril. The extent of raAv surface left upon the forehead may be diminished by the use of harelip pins. The patient is then put to bed in a warm room, with a fold of oiled lint over the part to preserve its temperature. The dressings should not be disturbed for several days, when it will usually be necessary to reneAv the plug, the sutures being allowed to remain until union has occurred. (2.) The second stage of the operation consists in the formation of a columna, if this has not already been done in the previous part of the pro- ceeding. The columna may be formed from the upper lip in the Avay directed at page 708. (3.) The third and last stage consists in the separation of the root of the frontal flap, which may be done after an interval of about a month. A nar- row bistoury being introduced beneath the twisted pedicle, is made to cut upwards, a wedge-shaped portion being removed, so as to make a smooth bridge to the nose ; or, as recommended by Fergusson, the root of the neAvly- formed nose may itself be cut into a wedge and laid into an incision made for it in the forehead. The size of the nostrils must be maintained by the patient's wearing, for some months after the operation, tubes of gutta-percha or silver. Rhinoplasty is usually a very successful procedure, though failure may ensue from slough- ing of the flaps, or from a recurrence of the disease which caused the original deformity. Hemorrhage on the ninth day occurred in one of Liston's cases, and death even has folloAved the procedure, in the hands of so distinguished an operator as Dieffenbach. 3. Syme's Method__The late Prof. Syme, of Edinburgh, devised an ingenious operation for the restoration of the nose, taking flaps of skin from the cheeks, as shown in the diagram, Fig. 379. uniting them in the middle by sutures, and fixing their outer edges to raw surfaces previously prepared at a suitable distance from the nostrils. I have myself employed this method with a fairly satisfactory result. 4. Wood's Method. — Mr. John Wood has restored the nose by taking lateral flaps from the cheeks, and uniting them over an inverted flap, derived from the upper lip and elongated by splitting its mucous from its cutaneous surface, from the root of the flap to, but not through, its free border. 5. Ollier's Method consists in taking from the forehead a flap embrac- ing the periosteum, and, having inverted this, covering it in with side flaps taken from the remnant of the nose. Operation for Depressed Nose.—The nose may be flat and sunken from disease of its bones and cartilages, without external ulceration. Fer- gusson, modifying a proceeding of Dieffenbach's, remedied a deformity of Diagram qf Syme's rhinoplastic operation. DISEASES OF THE LIPS. 711 this kind by separating the soft parts from the subjacent bones with a narroAv knife, introduced Avithin the nostril, and then bringing the whole organ for- Avard by passing long steel-pointed silver needles across from cheek to cheek, and tAvisting them over a piece of perforated sole-leather. A columna was subsequently formed in the way already described. Diseases of the Frontal Sinuses. Distension of the Frontal Sinuses from an accumulation of the natural secretion of the part has already been referred to (see p. G88). These cavi- ties may also be the seat of Abscess, or may give origin to Polypi, which subsequently descend into the nostrils. In either case the application of a trephine to the anterior wall of the sinus may be required. Diseases of the Cheeks. The cheeks may be the seat of Encysted Tumors, of Epitheliomatous or Cancerous Growths, of Rodent Ulcer, Lupus, Warts, Moles, etc. Encysted tumors may be removed by careful dissection, the operation Fig. 380. being done from Avithin the mouth if the cyst be nearer the mucous membrane than the skin. Cancer or epithelioma, occurring in this situation, if recognized at a very early period, might possibly admit of removal by excision; operative interference is, howeAer, rarely justifiable in these cases, and Avould be positively contra- indicated by the existence of glandular implication. The treatment of rodent ulcer and lupus has already been con- sidered (pp. 502, 503). If it be thought desirable to remoA'e a wart or mole of doubtful nature from the face, this may be con- veniently done by excision, the ensuing gap being closed, as advised by Stokes, of Dublin, by what is known as Burow's operation. A triangle of skin embracing the growth having been dissected off, the base of the triangle is extended to three times its length, and a similar triangle denuded in a reversed position, as shown in the diagram. Tavo flaps (a b c and def) are thus marked out, Avhich are to be dissected up and slid in opposite directions, the edges of the wound coming readily together, and a linear cicatrix resulting. Salivary Fistula usually results from accidental injury, but may occur as a consequence of operations on the cheeks, of the opening of abscesses, etc. For the treatment of this affection, see page 342. Diagram of Burow's plastic operation ; the triangles a db and e/c are dissected off, the flaps a b c and def loosened, and the lines a d—ab and ef—ef brought together. Diseases of the Lips. Contraction, or even Closure, of the Buccal Orifice is occa- sionally met with as a congenital affection, or may result from the cicatriza- tion of a burn, etc. The deformity may be remedied by a plastic operation, 712 DISEASES OF THE FACE AND NECK. the details of such a procedure varying, of course, with each particular case. As a rule, the skin and mucous membrane should be separately divided, in the direction in Avhich it is meant to enlarge the mouth, the cut surfaces being then pared and the mucous membrane everted, so as to form a new prokbium. Hypertrophy of the Lips may depend upon the existence of the scrofulous diathesis, or may be caused by the irritation produced by fissures or ulcers, or, according to R. W. Taylor, by any affection such as asthma, or whooping cough, Avhich induces violent and long-continued coughing, or vio- lent efforts in respiration. In some rare cases, hypertrophy exists without any apparent cause, and under such circumstances the surgeon maybe called upon to retrench the pouting lips, which, hoAvever charming in poetry, may, in real life, by the resulting deformity, occasion their owners no little annoyance. The operation consists in making two transverse incisions, so as to remove a sufficient slip from the thickness of the part, and then approximating the edges with delicate sutures. A similar operation may be employed to relieve the deformity known as double lip. Tumors of the Lips__Cystic tumors should he removed by careful dissection, mere excision of a part of the cyst wall not being sufficient in this locality. Erectile or vascular tumors of the lip may he treated by the application of caustic, by ligation, or by exision, according to the size of the growth and other circumstances of the case (see pages 525-527). Epithelioma___The lower lip is the favorite seat of epithelioma, though the disease occasionally attacks the upper lip. Epithelioma (Avhich in this situation constitutes the affection commonly known as cancer of the lip) may begin either as a wart, or as an indurated fissure. It is much commoner in men than in women, rarely occurs before fifty years of age, and appears in many instances to be predisposed to by the use of a short pipe. This affec- tion is to be diagnosticated from rodent ulcer, lupus, and labial chancre. Rodent ulcer is as rare in the lower as epithelioma is in the upper lip, while chancre may be distinguished by the early implication of the neighboring lymphatic glands, and by the effect of antisyphilitic treatment, whieh should ahvays be tried in a doubtful ease. The diagnosis of epithelioma from lupus may occasionally be very difficult, and indeed a lupous ulcer may sometimes become the seat of a true epitheliomatous formation. Lupus is, however, essentially a local disease, and does not involve the neighboring glands. The prognosis of epithelioma in this situation, if left to itself, is extremely unfavor- able, death eventually ensuing from pain and exhaustion, or, if the disease extend to the neck, perhaps from hemorrhage. On the other hand, if sub- mitted to early and thorough extirpation, the chances of permanent recovery are more favorable than in almost any other case of malignant disease. The treatment consists in free excision with the knife, which is in almost all cases preferable to the application of caustics. As in some instances an ordinary ulcer may be so irritated by the presence of a broken tooth, or by the accumulation of tartar, as to assume an epitheliomatous appearance, any such sources of irritation should be first removed, when, if non-malignant, the ulcer will quickly heal under simple applications. Glandular implication does not necessarily forbid the excision of an epithelioma, provided that the affected glands are so situated as to render their oavii removal possible. The operation must be modified according to the exigencies of each indi- vidual case : in most instances a simple V-shaped incision will be sufficient, CHEILOPLASTY. 713 Fig. 381. an assistant compressing the lip and thus restraining the bleeding, while the surgeon transfixes the part from within, and cuts from below upwards, taking care to re- move with the diseased part a Avide margin of healthy tissue; the cut surfaces are then brought together Avith harelip pins, one of wliich serves to acupress the labial artery, Avhile the accurate adjustment of the prokbium is secured by the introduction of a delicate silk su- ture. If a considerable extent of the margin of the lip be involved, it may be better simply to shave off the diseased portion, the mucous membrane being then brought for- Avard, as advised by Serres, and stitched to the skin, so as to form a neAv prokbium. The result of such an operation is sIioavii in the annexed Avood-eut, from the pho- tograph of a patient in the Episcopal Hospital. When a large portion of the lip has been removed, it may be necessary to close the gap by means of a cheiloplastic operation. In all cases, advantage may be obtained by freely dissecting the lip from its attachments to the jaw. Prof. Michel, of Charleston, has lately revived a suggestion of Richerand's, that the mucous lining of the lip (which is seldom involved) should be spared, the groAvth being carefully dissected away from it. The plan is ingenious, but I confess seems to me less safe than the ordinary method. Cheiloplasty—Various operations for restoration of the lower lip have been practised, the most generally applicable being, probably, those recom- Formation of prolabium by Serres's method. (From a patient in the Episcopal Hospital.) Fig. 382. Fig. 383. Serres's cheiloplastic operation, modified. (Erichsen.) mended by Zeis, Malgaigne, Serres, Mutter, Buchanan, and Syme. The operation practised by Chopart, consisted in the dissection of a quadrilateral flap from beneath the chin, as far as the position of the hyoid bone, this flap being then brought forward and attached in the normal position of the lip, while the head Avas flexed on the chest to prevent tension. In Zeis's operation, which is a modification of Chopart's, the diseased struc- tures are removed by means of a rectangular incision, and the tissues of the chin then included between oblique cuts, dissected up, and brought forward in the form of an inverted A to supply the gap. 711 DISEASES OF THE FACE AND NECK. In Malgaigne's, and in Serres's operation (Figs. 382, 383), as in the old Celsian method, the tissues of the cheek are utilized in forming the new lip, wliile in Mutter's and Buchanan's methods the flaps are derived from the chin. The diseased mass is first excised by an elliptical cut, from the centre of which1 two incisions are carried downwards and outwards, the outline of Fig. 384. Fig. 385. Cheiloplasty by Buchanan's method. (Erichsen.) the flaps being completed by tAvo more incisions, parallel and corresponding to the branches of the first. These flaps are then raised and brought together in the median line by means of the twisted suture. Syme's method differs from the above in that the diseased structure is re- moved by means of a V-shaped incision, passing from the angles of the mouth to the apex of the chin, the flaps Fig. 386. to supply the gap being taken from below the ramus of the jaAV and curved at their lower angle, so that by a little stretching the Avhole wound may be accurately closed with sutures, and union by adhesion thus obtained. In both methods, the new prokbium is formed by Serres's plan of uniting the mucous and cutaneous edges of the original Avound of excision. The result of Syme's method is shown in the annexed illustration from a patient of mine in the Episcopal Hospital. Restoration of a portion of the upper lip and of the angle of the mouth may be occasionally re- quired to remedy the destructive effect of lupus. In a case of this kind at the Episcopal Hospital, I made a lozenge-shaped incision, as seen in Fig. 387, A B C D, when, by slitting the cheek transversely in the line B E, enough tissue Avas brought forAvard, as in Serres's operation, to close the gap in the lip, a neAv prokbium above and below being formed by stitching together the skin and mucous membrane. The result is shown in Fig. 388. Ingenious operations for the restoration of large portions of the upper lip 1 The late Mr. Collis, of Dublin, modified this procedure by leaving a space betAveen tbe oblique incisions, as in Teale's operation (Fig. 158), having found that the central pillar, on which the new lip Avas elevated, gave better support if made square and not angular. Result of cheiloplastic operation by Syme's method (From a patient in the Episcopal Hospital.) HARELIP. 715 have been performed by Sedillot, Gurdon Buck, and other surgeons. The annexed cuts show the general plan and result of such an operation (Figs. 389, 390). Fig. 387. Fig. 388. Diagram of operation for restoration of Result of operation for restoration of the upper lip the upper lip and angle of the mouth. and angle of the mouth. (From a patient in the Ej iscopal Hospital.) Fig. 389. Fig. 390. Restoration of upper lip. (Sedillot.) Harelip___This term is used to signify a congenital deformity, consisting of one or more fissures in the upper lip, resulting from an arrest of develop- ment. The fissure in harelip does not occupy the median line, as in the lip of the animal which has given the disease its name, but corresponds to the line of junction between the intermaxillary and superior maxillary bones, this line of junction being itself often deficient. When one side only is involved, the harelip is said to be single; in double harelip the intermaxillary portion is often displaced forwards, and may even be attached to the base of the nose, giving a peculiar snout-like appearance. In these cases one or both fissures 716 DISEASES OF THE FACE AXD NECK. may extend into the nostril, and the affection is not unfrequently complicated with cleft palate. Age for Operation.—As the deformity of harelip can only be remedied In- operative interference, the age at which this should be attempted becomes an important matter for consideration. Some surgeons have deprecated early operations, and have even advised that all treatment should be postponed until adult life ; wliile others, going to the opposite extreme, have operated within a feAV hours of birth. Although it is impossible to give any positive rule upon this subject, it may be said, in general terms, that from six Aveeks to three months after birth is, in most instances, the period during which this operation should be by preference performed. If, hoAvever, the deformity in- terfere with the nutrition of the child, by preventing suckling, or by allowing regurgitation of food, the surgeon should not hesitate to operate at a much earlier period. The popular opinion that operations in infants are apt to be followed by convulsions, though sanctioned by the authority of Sir Astlev Cooper, is, according to Butcher and Fergusson, incorrect; shock Avas, Iioav- ever, the cause of death in two cases of harelip operated on by the last-named surgeon. Operation___The operation for harelip consists essentially in paring the edges of the fissure, approximating the cut surfaces, and adopting means to prevent tension during the process of healing. Ether or chloroform may be properly used if the patient be beyond the period of early infancy, but in children less than three or four months old, it is, I think, better, on the whole, to dispense with any anaesthetic. The child should be firmly Avrapped in a sheet and held by an assistant, the surgeon sitting behind the patient, and fixing its head betAveen his knees Fig. 391. Diagram of common single harelip. (Holmes.) rated from the upper jaw by dividing the framum and any membranous ad- hesions ; an assistant then grasps the lip so as to control the labial artery, while the surgeon, seizing with toothed forceps the extremity of one side of the fissure, transfixes the part near the summit of the gap, with a small straight bistoury, and cuts downwards in a slightly curvilinear direction, concave imvards, so as to insure sufficient length to the cicatrix when the parts are brought together. The opposite side of the fissure is then pared in a similar manner, the incisions being evenly united above the summit of the gap, and extending far enough outwards to cut away the rounded edges of The lip should be first freely sepa- Fig. 392. sZJJJj^* Cheek compressor. (Fergusson.) HARELIP. 717 the prokbium at the base of the fissure. The cut surfaces are then accu- rately adjusted and held together Avith tAvo or more harelip pins, the lowest of which is made to acupress the cut labial artery on either side. These pins should enter and leave the tissues at least a quarter of a inch from the lines of incision, and should embrace the Avhole thickness of the lip except its mucous lining. The more accurate adjustment of the prokbium may be ef- fected by inserting a single interrupted suture through the mucous membrane, just behind the edge of the lip. In applying the twisted suture over the harelip pins, a separate thread or Avire should be employed for each ; the points of the pins being cut off, a strip of adhesive plaster is placed beneath them to protect the skin, and the dressing completed by supporting the tis- sues on either side by the use of gauze and collodion. Tension may be still further lessened by the use of DeAvar's or Hainsby's cheek compressor (Fig. 392). or, in the absence of such an apparatus, by simply applying a long strip of adhesive plaster across the Avound and around the head, as recommended bv Coote. The pins and interrupted suture may commonly be remoA'ed on the third or fourth day, but the parts should be supported Avith adhesive plas- ter for at least a week or ten days longer. The above description will suffice for Avhat may be considered the simplest form of operation in a typical case of single harelip. Various modifications are required under different circumstances; thus, if, as often happens, the sides of the fissure be of Fig. 393. different lengths, the red edge pared from the shorter side may be left attached at its base to the lower border of the lip, and fastened to the previously sloped border on the other side, as advised by Langenbeck and Holmes ; or a flap may be taken from the longer, and attached to the base of the shorter, side. To obviate the notch, Avhich is apt to be left at the lower border ",r Z~Z~ Z f. TT n , . . V,,, , i-iri- . i Malgaigne s operation. The dot- of the cicatrix, Clemot s and Malgaigne s plan ted lineg mark the flssure- may be folloAved, the incisions being made as shoAvn in the annexed cut, or Nelaton's method may be adopted; this con- sists in surrounding the fissure with an inverted A-shaped cut, and bringing down the flap, which is left attached at both sides, so as to com'ert the wound into one of a diamond y form. Many other very ingenious operations have been devised by Giraldes, Collis, Stokes, and other surgeons, but, while more complicated than those in common use, have not, as far as I am aware, been proved to possess any practical superiority. Butcher and others operate with scissors, instead of the knife, while the use of harelip pins has been aban- doned by Mr. Erichsen in favor of the simple interrupted suture, as was likewise done by the late Mr. Collis ; the latter surgeon used horsehair as a material for his sutures, Avhile the former giAes the preference to fine silver wire. Should the approximation of the cut surfaces be hindered by the pro- jection of the intermaxillary bone, this may be cut away, as advised by Fer- gusson, with gouge or bone-forceps. Double Harelip.—The treatment of double harelip is conducted on the same principles as that of* the simpler form of the affection, both fissures being pared, and pins inserted so as to transfix the middle flap, and close both gaps at once ; Coote, hoAvever, advises that the fissures should be ope- rated upon on different occasions. In some instances, it is better to cut away the median portion, or to carry it upwards and backwards, so as to increase the length of the columna of the nose. The chief difficulty in cases of double 718 DISEASES OF THE FACE AND NECK. Fig. 394. Double harelip ; projecting inter maxillary portion. (Holmes.) harelip is in the management of the intermaxillary bone, if, as often happens, this interferes with the operation by its anterior projection. If it be small, the intermaxillary bone may be cut away (and indeed Fergusson recommends that this should ahvays be done), but it is sometimes better to fracture its base, and bend it backAvards into its proper position, with broad forceps covered with vulcanized India-rubber ; this proceeding may be sometimes facilitated by dividing the attach- ment of the projecting bone to the septum with cutting forceps, as advised by Blandin and others, or by grooving its base with ingenious forceps devised for the purpose by Butcher, of Dublin; in case the intermaxillary portion should be found too large for the gap Avhich it is meant to fill, its sides may be cut away with forceps, when the edges of the superior maxillary bones should be similarly freshened at the same time. In making these bone-sections, particu- larly in dividing the attachment of the projecting intermaxillary bone to the nasal septum, there is often free hemorrhage, Avhich may require the use of the actual cautery ; hence, in a case of this kind, chloroform should be used as an anaesthetic in preference to ether. Should it be thought necessary, the intermaxillary bone may be fastened by means of silver sutures to the adjoining maxilla;, as advised by Sims and Whitehead. Primary union is usually obtained without difficulty in cases of harelip operation, but if it should fail (Avhich may happen from too early withdrawal of the pins, or from a depressed state of health in the patient), the surgeon should not despair, but should re-approximafe the parts, in hope that union of the granulating surfaces will occur ; in this way I have obtained a much more satisfactory result than might at first have been anticipated. If it be neces- sary to repeat the entire operation, an interval of at least a month should be allowed to elapse, in order that the parts may have time to return to a healthy condition. After the operation for harelip, the child, if an infant, may be allowed im- mediately to take the breast, the action of sucking tending rather to keep the parts together than to separate them ; if al- ready weaned, abundant nutriment in a fluid form should be supplied, and may be most con- veniently administered with a spoon. For further information with regard to the treatment of harelip, the reader is respectfully invited to refer to the chapter on this subject in Mr. Holmes's well-knoAvn Avork on the Surgical Treatment of Children's Diseases, where will be found an excellent account of the more complicated forms of the affection, and of the special operations required for each. Fig. 395. Macrostoma, or congenital fissure at the angle of the mouth. (From a patient under Dr. Harlan's care, at the Children's Hospital.) Congenital Fissure of the lower lip is occasionally met with, as is the same deformity at the angle of the mouth, where it constitutes DISEASES OF THE NECK. 719 the affection knoAvn as Macrostoma; these rare conditions require to be treated on precisely the same principles as those which have been laid down for the management of ordinary harelip. Diseases of the Neck. Bronchocele or Goitre is a hypertrophied state of the thyroid gland, and may exist in an independent condition, or in connection -with anamiia and protrusion of the eyeballs, as in the affection knoAvn as Graves's or Base- dow's disease (Exophthalmic Goitre). Other varieties are recognized by systematic writers, such as the Fibrous Bronchocele, the Cystic Bronchocele,1 in Avhich cysts are developed in the structure of the thyroid, with or without hypertrophy of the gland tissue itself, and the Pulsating Bronchocele (an affection Avhich may be mistaken for Fig. 396. carotid aneurism), in Avhich the tumor has a distinct ex- panding pulsation, synchronous with the cardiac systole, and evidently depending upon the intrinsic vascularity of the growth itself. Bronchocele commonly appears as a soft, fluctuating, indolent tumor, occupying the situation of the thyroid gland, of Avhich either lobe, or the isthmus, may be alone or chiefly involved, though in other cases the whole gland is equally implicated. The causes of bronchocele are someAvhat obscure ; it prevails in certain localities, as in the Tyrol and some parts of England, as an endemic affection, but is occasionally met with sporadically in all parts of the world, and as an acute Bronchocele. (Greene.) affection has been observed as an epidemic. Goitre is much commoner in Avomen than in men, and, according to A. Ollivier, is in many instances a result of pregnancy. In some cases, the prevalence of the disease appears to be traceable to the use of melted snow or of Avater impreg- nated Avith certain saline constituents, for drinking purposes ; but in other cases 'no such cause can be assigned. The use of a tightly-fitting military stock, or other source of constriction about the neck, appears sometimes to have been an exciting cause of the affection. AVhen of moderate size, bronchocele gives rise to no particular incon- venience, except by the deformity produced, and by a certain amount of dyspnoea Avhen stooping, with occasional pain in the head. In its more ag- gravated conditions, howe\Ter, it may cause serious if not fatal interference Avith the functions of respiration and deglutition, cerebral congestion, organic disease of the air-passage, etc. When very large, as in a remarkable case under the care of Mr. Holmes, inflammation and suppuration of the mass may occur, and the patient may eventually sink under the drain thus occasioned. Treatment___The treatment of goitre is not very satisfactory; the remedy Avhich has acquired most reputation in this affection is iodine, which may be given in the form of the Liq. iodin. compositus, of the U. S. Pharma- copoeia, and should be continuously administered for a considerable time. Iodine may also be used externally, in the form of the Ung. plumbi iodid., or the iodide of cadmium incorporated with simple cerate Oj-^j), or, which is particularly recommended by Mouat, the biniodide of mercury ointment (gr. xa-j-3j). Pressure sometimes forms a valuable adjunct to iodine inunc- tion, but care must be taken not to irritate the skin, lest the disease should 1 Cohnheim has recorded a case in which cystic bronchocele was followed by meta- static deposits in the lungs and bones. 720 DISEASES OF THE FACE AND NECK. be thereby aggravated. Change of residence Avould naturally be recom- mended in any case in which the affection appeared to be due to climatic or other hygienic influences. Various Operative Measures have been employed in the treatment of bronchocele, each having been occasionally successful, but often resulting in failure, if not even more disastrously. The injection of iodine, alcohol, or perchloride of iron, and the formation of a seton, are probably the safest of these measures. The injection treatment is said by Lubka and Mackenzie to be equally efficient in cases of the serous and in those of the hard or fibrous variety. Injection of the perchloride of iron Avould be specially indicated if the growth were of the character described as pulsating bronchocele. The seton is particularly recommended by Lennox Browne, Avho has in several cases successfully employed it for fibrous goitre. DaCosta and Coghill have derived advantage from the hypodermic use of ergotine. Ligation of the thyroid arteries, so as to cut off the vascular supply of the diseased gland, is a dangerous mode of treatment, and one Avhich, on account of the freedom of the collateral circulation, is very apt to result in failure. Division of the fascia in the median line is recommended by Meade and Mackenzie as a means of relieving the pressure on the air passages, while, with the same object, Gibb advises that the thyroid isthmus itself should be divided or removed, hemorrhage being prevented by making the section be- tween two ligatures. A similar operation was performed (unsuccessfully) by Prof. Hamilton, of NeAv York, in 1849. Extirpation of the gland is an ex- pedient fraught with the highest risk to life, and can only be justifiable in very exceptional cases ; Avhen resorted to, care should be taken to plan the incisions so that the large vessels may, if possible, be encountered in an early stage of the proceeding, in order that, being secured once for all, the risk of subsequent bleeding may be less. Several successful operations upon this plan have been recently reported by Greene, Fenwick, Maury, Watson, Michel, Nelson, and other surgeons. Exophthalmic Goitre (Graves's or Basedow's disease) comes more often under the care of the physician than of the surgeon ; its treatment demands the adoption of means to improve the general health, rather than of measures specifically directed to the cure of the thyroid enlargemeut. Ancona, an Italian physician, reports a cure from galvanization of the sympathetic nerve in the neck. Gangrene of the thyroid gland has been observed by Gascoyen and other surgeons. Inflammation of the Parotid Gland may occur as an epidemic and probably contagious affection, Avhen it constitutes the disease known as Parotitis or Mumps ; or as the more serious condition denominated Parotid Bubo, Avhich occurs as a sequel of several of the exanthemata. The former affection very rarely, but the latter frequently, runs on to suppuration, de- manding an early incision for the evacuation of matter, and the free adminis- tration of tonics and stimulants to support the strength of the patient. These cases are never unattended by danger, and in one case Avhich I saw in con- sultation some years ago, death ensued from secondary hemorrhage into the cavity of the abscess. Tumors of the Parotid__Most of the tumors met Avith in the parotid region do not, probably, involve the gland, though they overlay and compress its structure ; in some cases, however, the parotid itself is implicated in the morbid growth, which may be of a fibrous, cystic, fatty, cartilaginous, or cancerous nature. The only treatment applicable to these cases is extirpa- tion of the growth, and, if the tumor be of a non-malignant character, such an TUMOKS OF THE SUBMAXILLARY GLAND. 721 operation may be commonly undertaken with the probability of a favorable result. If, hoAvever, the growth be cancerous, its attachments will probably be so deep as to forbid any hope of successful operative in- terference. The mobility of such groAvths is, according to Fergusson, the best criterion by which to decide Avhether or not to operate; and in any case in which it can be deter- mined that the tumor, though perhaps bound doAvn by super- incumbent tissues, is not firmly fixed to the parts beneath, the inference is reasonable that an operation may be attempted Avith hope of benefit. Another point of importance is the rate of increase of the tumor, one of a non-malignant being of much slower growth than one of a malignant character. In attempting the removal of tumors from the parotid region, the external incisions should be free, and may be made in any direction that may be indicated by the shape of the growth; after dividing the superincumbent tissues, and thus loosening the tumor, the surgeon should accomplish the rest of the operation as far as possible by pulling and tearing Avith his fingers, aided with the handle of the knife, being chary of employing the cutting edge in the deeper portions of the Avound. The accidents to be particularly guarded against are wounds of the temporo-maxilkry artery and facial nerve, division of the latter of which AA-ould of course entail paralysis of the corresponding side of the face. Excision of the Parotid Gland itself is probably less often done than is supposed; yet so many cases of this operation have been recorded by perfectly competent and trustworthy observers, that it is impossible to deny the practicability of the procedure. In this operation, which is one of the gravest in the Avhole range of surgery, the external carotid artery and portio dura nerve are necessarily cut across, and in some instances it is said that the internal jugular vein, and even the spinal accessory and pneumogastric nerves have been likewise divided. Extirpation of the parotid, which is said to have been performed by Heister, is chiefly known in this country throuo-h the operations of the late Dr. George McCkllan, of this city, who reported eleven cases Avith only one death. Tumors of the Submaxillary Gland__Cysts of the submaxillary gland are occasionally met with, and may be treated by incision, the cavity of the cyst being stuffed with lint so as to promote healing by granulation, or by excision, Avhich operation may also be required in cases of cartilaginous, adenoid, or cancerous, groAvths. The gland should, as far as possible, be enucleated Avith the fingers and handle of the knife; the only large vessel 46 Tumor of parotid region. (Fergusson.) 722 DISEASES OF THE MOUTH, JAWS, AND THROAT. necessarily severed is the facial artery, which Avill be found at the upper and posterior part of the Avound, and may usually be secured before it is divided. Tumors of the Neck__Various morbid groAvths are met Avith in the side of the neck, where they may occupy the submaxillary space, or one of the triangles of this region. The most common varieties of cervical tumor are the cystic, fatty, fibrous, and glandular, though cancerous and epithelio- matous growths are also met with in this part. The remarks which were made with regard to the excision of parotid tumors, are equally applicable here ; if the tumor be movable and of slow growth, its extirpation may, if the other circumstances of the case are favorable, be properly undertaken. If, however, the deep attachments of the mass are firm, and if its rate of increase has been such as to render its malignancy probable, the surgeon will, as a rule, do wisely to avoid operative interference. Hydrocele of the Neck is a name applied by Maunoir, Phillips, Syme, and other surgeons, to a cystic tumor, usually met Avith in the posterior inferior cer\rical triangle, and containing a fluid which may be of a limpid yellow color, or of a deep, grumous, chocolate hue. The treatment consists in the evacuation of the contents of the cyst, with a trocar and canula, followed by the subsequent injection of iodine, the establishment of a seton, or the conver- sion of the cyst into an abscess, by cutting aAvay a portion of its anterior wall. A similar course may be adopted in the treatment of Cysts of the Parotid Region (unconnected with the gland itself), of Hygromata of the Hyoid Bursa, and of similar enlargements of the subcutaneous bursa some- times found in front of the larynx, which constitute the '' Superlaryngeal Encysted Tumors" of Professor Hamilton. Enlargement of the Cervical Lymphatic Glands is often observed as a manifestation of scrofula. Its treatment has been already described in the chapter on that subject (see page 418). Congenital Tumor or Pnduration of' the Sterno-mastoid Muscle is an ob- scure affection Avhich has been described by several surgeons, particularly Bryant, Holmes, T. Smith, H. Arnott, and Planteau. In some cases the affection appears to originate from injury received in birth, but in other in- stances is a simple inflammatory or hypertrophic condition, with no apparent cause. It is probably sometimes a syphilitic lesion. No treatment is re- quired, as the induration subsides spontaneously in the course of a few weeks or months. CHAPTER XXXYIII. DISEASES OF THE MOUTH, JAWS, AND THROAT. Diseases of the Tongue. Glossitis, or Acute Inflammation of the Tongue, may occur from trau- matic causes, from the abuse of mercury, or as an idiopathic affection. The tongue rapidly sAvells, beeomes oedematous, and protrudes from the mouth, preventing the patient from speaking or SAvalloAving, and perhaps threatening actual suffocation. There is profuse salivation, and the teeth often become covered with sordes. The treatment consists in the local use of ice, with de- tergent and astringent gargles, the administration of tonics (if the patient can swalloAv), and, if necessary, the use of nutritive enemata. Free incisions on DISEASES OF THE TONGUE. 723 the dorsum of the tongue may be required if the symptoms are urgent, and commonly afford great relief, by alloAving the escape of the blood and serum by Avhich the organ is distended. Tracheotomy may possibly be required to avert suffocation. Sub-Glossitis___Under this name, C. Holthouse has described a case in which inflammatory SAvelling, occurring Avithout obvious cause, Avas limited to the sublingual and submental regions ; the tongue was retracted instead of being protruded, and there Avas no dyspnoea, though speech and deglutition were both rendered difficult; there Avas profuse salivation. Incisions on the dorsum of the tongue Ave re productive of no benefit, but rapid recovery fol- loAved the use of borax gargles, with cataplasms externally, and the adminis- tration of quinia. Similar cases are described by Dolbeau under the name of acute ranula. Abscess of the tongue is occasionally met Avith, and requires a free in- cision for the evacuation of pus. An abscess beneath the tongue may, by pressing on the glottis, threaten suffocation, in which case the incision must be made below the chin, through the mylo-hyoid muscle. Hypertrophy or Prolapsus of the Tongue may be met with either as a congenital or as an acquired affection. The protruded organ is very much swollen, with enlarged papillae, of a purple or brownish hue, and dry from exposure to the air. The saliva constantly dribbles from the mouth, and, in chronic cases, the alveolus and teeth of the lower jaw are displaced forwards by the pressure of the hypertrophied mass. The treatment consists in the use of astringents, with the application of compression by means of a pad and bandage, supplemented, if necessary, by excision of a V-shaped piece from the tip of the organ, with the knife, galvanic cautery, or ecraseur. Liga- tion is objectionable on account of the proximity of the organ of smelling to the point at Avhich the slough Avould be produced, and the risk of septic poisoning which would be necessarily entailed. The statistics of these various modes of treatment have been investigated by Fairlie Clark, who finds that 20 cases in which cutting instruments were employed gave 19 recoveries and 1 death ; 10 cases in which compression alone was employed gave 9 recoveries and no deaths (one patient having been much benefited though not entirely cured); 4 cases in which either the galvanic cautery or the ecraseur was used gave 3 recoveries and 1 death ; while 9 cases in which the ligature was used gave 7 recoveries and 2 deaths. Dr. Gurdon Buck, of New York, suggested that, as the thickness of the protruding portion is commonly more obnoxious than its breadth, the flaps for excision should be made antero-posteriorly rather than from the sides of the organ. Atrophy, affecting only one side of the tongue, has been noticed by several observers, including Dupuytren, Holthouse, Hughlings Jackson, Budd, Habershon, Jaccoud, Fagge, Weisser, Fairlie Clark, and Paget. In the case recorded by the last-named surgeon, the disease was connected with ne- crosis of the occipital bone, and yielded upon the extraction of sequestra from that part. Ulceration of the Tongue may be due to the irritation caused by broken or carious teeth, to disorders of the digestive system, to the existence of various diseases of the skin (such as psoriasis), to syphilis, to the presence of a malignant groAvth, to a deposit of tubercle, etc. The differential diag- nosis betAveen these various forms of ulceration is highly important in a thera- 721 DISEASES OF THE MOUTH, JAWS, AND THROAT. peutic point of view, as the treatment required varies Avidely, according to the cause of the ulceration in each case. In most instances, the diagnosis can be readily made by careful observation of concomitant symptoms; the most diffi- cult cases being, perhaps, those in which a chancre or tertiary syphilitic de- posit is to be distinguished from an epithelioma (see pages 448, 454), or the latter from an ulcerated mass of tubercle. The Tuberculous Ulcer has been particularly studied by Trelat,1 avIio re- marks that any chronic, intractable, superficial ulcer, Avith red, irregular borders, which occurs, without appreciable cause, and without enlargement of the neighboring lymphatic glands, on the tongue or in the mouth, is probably a tuberculous ulcer; and that the probability is increased, if the patient be phthisical or tuberculous, or even predisposed to tuberculosis. The diagnosis, be adds, may be considered certain, if the surgeon can detect the presence of peculiar spots or patches, which are very slightly elevated, round, from half a line to two lines Avide, of a yellowish, pus-like color, at first covered Avith epithelium, and exhibiting one or more follicular orifices—the epithelium disappearing in the course of a few days, and leaving an ulcerated surface. The only topical remedy which proved of benefit in M. Trekt's case was the application of the actual cautery, but Verneuil has successfully employed chromic acid, wliich, according to Hybord, is a preferable remedy. Ichthyosis of the Tongue is the name given by Hulke to a chronic condition of this organ (characterized by the appearance of white or silvery patches), which may persist without change for years, but which ultimately leads to the development of epithelioma in the parts affected. According to Dr. R. W. Taylor, however, there are two varieties of ichthyosis; one in which the papilla? are primarily involved, giving the tongue a warty appear- ance, and the other beginning in the rete Malpighii. The first variety alone is, in Dr. Taylor's opinion, liable to malignant change. The treatment of this disease, of Avhich examples have been reported by H. Morris, Fairlie Clarke, Goodhart, Weir, of New York, and others, consists in excision, or, if this be not practicable, in removing sources of irritation, with attention to the diges- tive functions and, as suggested by Fayrer, the administration of arsenic. Tongue-tie consists in a congenital shortening of the frenum lingue, which prevents the tongue from being protruded beyond the line of the teeth. If present in an aggravated degree, this deformity may interfere Avith suck- ling, and, under any circumstances, the operation for its relief is so trifling, that it may properly be done, if, as usually happens, the parents desire its performance. The operation consists simply in dividing the fraenum for about an eighth of an inch with blunt-pointed scissors, the cut being made towards the floor of the mouth, so as to avoid the ranine vessels, and then separating the parts with the forefinger. There is a popular notion that tongue-tie may cause dumbness, and myotomy of the lingual muscles, tlirough an incision beneath the chin, has even been performed, Avith a vieAV of restoring the power of speech—a totally useless operation, since, as justly remarked by Holmes, the whole tongue itself may be extirpated, and yet the power of speech remain. Tumors of the Tongue.— Cystic Tumors may occur in various parts of the tongue, but are most common beneath this organ, or in the floor of the mouth below the buccal mucous membrane, constituting in these situations the affection known as Ranula. The common form of ranula has thin walls, Archives Gen. de Mddecine, Janv. 1870. TUMORS OF THE TONGUE. 725 and contains a fluid someAvhat resembling saliva, AA'henee it was formerly supposed to be a dilatation of the duct of the submaxillary gland. Such is, indeed, probably the case in some instances, as when occlusion of the duct is by the presence of a caused foreign cuius ; ranulae Ranula, between floor of mouth and mylo-hyoid muscles. (Fergusson.) body or a salivary cal- but the majority of appear to be distinct cystic formations, analogous to those which are met with in other organs. Masses of adi- pocere Avere found in a ranula in a case recorded by Waren Tay, and numerous rice-like bodies in one described by J. G. Richardson, of this city. True hydatids have been no- ticed in the tongue by Laugier, Molliere, and other surgeons. The common form of ranula may be treated by the forma- tion of a seton, or by excision of a portion of its anterior Avail, the cavity being subsequently alloAved to heal by granulation. Panas advises the injection of chloride of zinc. That variety of the disease Avhich is met Avith between the floor of the mouth and the mylo-hyoid muscles, often forms a more decided prominence in the neck than in the buccal cavity, and hence Avould appear to be most accessible through an external incision. The risk of hemorrhage, howeA-er, in any attempt at complete extirpation is so great, that it is. as a rule, better to lay open the tumor f'r< m within, and turn out its contents, thus converting the cyst into an abscess, the healing of which may be promoted by stuffing the cavity with lint. Acute ranula, in which the tumor forms in the course of a feAV hours, is believed by Tillaux to consist in an accumulation of saliva (from obstruction and rupture of Wharton's duct) in a serous sac known as Fleischmann's bursa; the existence of this bursa is, however, denied by Sappey, Lefort, and others, and Duplay considers the acute ranula to consist in a dilatation of the duct itself. Dolbeau includes under the head of acute ranula, cases Avhich are analogous to those already referred to under the name of sub- glossitis. Erectile, Vascular, and Papillary Tumors are occasionally seen in the tongue, and may be treated by the ligature, by excision, or by strangulation with the ecraseur, according to the size and situation of the groAvth. Dr. Busev, of Washington, D. C, reports a case of papilloma of the tongue suc- cessfullv treated by the injection of acetic acid. Fatty, Glandular, and Fibrous Tumors of the tongue may be treated by excision, the organ being draAvn well forwards Avith a tenaculum or cord passed through its tip. Hemorrhage in these cases is sometimes rather trou- blesome, but may usually be arrested by passing a metallic suture deeply around and across the bleeding point, by means of an ordinary naevus needle or one with a spiral extremity. Excision Avould appear to be a safer opera- tion than ligation, in cases of tumor involving the root of the tongue. Apart 726 DISEASES OF THE MOUTH, JAWS, AND THROAT. from the risk of inflammatory SAvelling and oedema of the glottis, which at- tends the use of the ligature in this situation, severe or even fatal cerebral complications may be developed as reflex phenomena (as in a case recorded by Hunt), from injury to fibres of the glosso-pharyngeal nerve. If the tumor were situated very far back, and were pedunculated, the ecraseur might be properly employed, as has been successfully done by BigeloAv and Pooley. Malignant Tumors of the Tongue axe almost invariably of an epithelioma- tous character, though true lingual cancers, both of the scirrhous and ence- phaloid kinds, are described by systematic Avriters. The only treatment wliich offers any prospect of benefit, consists in removing the diseased mass, Avhich, when a portion only of the organ is affected, may be accomplished by the galvanic cautery, or by the application of the ecraseur, or of ligatures as in cases of naevus, or by excision, which is the preferable operation when the tip only is involved. H. Lee employs, in addition to the ordinary ligature, one wliich is elastic, so as to pre- 399. vent any risk of imperfect stran- gulation and consequent absorp- tion of septic material. The elastic ligature has also been em- ployed by Despres, Delens, and other French surgeons. The tongue may usually be sufficiently exposed in these cases by draw- ing it Avell forwards, the jaws being held apart and the cheeks retracted, by such an instrument as is shown in Fig. 399. If, hoAvever. a large portion of the organ is to be removed, the ecra- seur, galvanic cautery wire, or ligatures, may be introduced through an incision in the cheek as advised by F. Jordan, or be- tween the genio-hyoid muscles, as practised by Cloquet, Arnott, and Whitehead, of Manchester; or Regnoli's plan may be adopted, in which the buccal cavity is opened from beloAV (Fig. 400), and the tongue draAvn out between the loAver jaw and hyoid bone. Southam has devised forceps to grasp and draw forwards the base of the tongue, so as to allow the ecraseur to be used Avithout making an external wound. A clamp to prevent bleeding during operations upon the tongue has also been devised by H. Lee. Complete Extirpation of the Tongue was first performed by Syme, of Edinburgh, and has since been repeated by Fiddes, Nunneley, Heath, Annandale, Langenbeck, Buchanan, and other surgeons, some ope- rators having employed the knife, and others the ecraseur; Whitehead has removed the whole tongue Avith scissors. Whichever instrument be chosen, access to the organ may be facilitated by Syme's plan of dividing the loAver lip and the symphysis of the jaw, the parts being wired together again after the completion of the operation. Annandale advises that the tongue should be split longitudinally, and each half removed separately with the ecraseur. Nunneley's experience in extirpation of the tongue appears to have been unusually large; he has, he declares, done the operation 19 times "Avithout any untoward symptom following in a single instance." Langenbeck prefers Wood's gag for operations on the tongue. DISEASES OF THE JAWS. 727 to Syme's median operation, an incision from the angle of the mouth to the thyroid cartilage, the jaw being then sawn through betAveen the first and second molar teeth, and the shorter portion turned outAvards and upwards. Fig. 400. Fig. 401. Tongue exposed by Eegnoli's method. Removal of tongue by division of lower jaw and (Erichsen.) icraseur. (Erichsen.) These operations are all dangerous in themselves, and are seldom produc- tive of more than temporary benefit; they are of course only applicable to cases in which the disease is limited to the tongue itself, implication of the floor of the mouth or of the neighboring lymphatic glands being a positive contra-indication. Hilton and Moore have recommended as a palliative mea- sure, in cases not admitting of excision, the division of the gustatory nerve— an operation which may also be resorted to as a preliminary to the application ofTigatures. The nerve may be reached just behind the last molar tooth, by an incision crossing its course, made from Avithin the mouth, and carried freely doAvn to the bone. Ligation of the lingual artery has been also prac- tised as a means of arresting the progress of malignant disease of the tongue, and, according to Coote, Demarquay, and Haward, Avith encouraging results. The same operation is recommended by Weichselbaum, Hirschfeld, and Shrady, as a preliminary measure to extirpation of the tongue ; the risk of hemorrhage is thus reduced to a minimum, and the operation can be safely completed with the knife. Shrady urges that the vessel should be secured near its ori- gin, before the giving off of the dorsalis linguae. Contrary to Avhat might perhaps be expected, the power of swalloAving is not affected by extirpation of the tongue, Avhile speech, though at first rendered imperfect by the operation, is eventually completely restored. Diseases of the Jaws. Abscess of the Gum f Gum-boil, Alveolar Abscess) is a common affection, resulting from the irritation of necrosed or carious teeth. The abscess forms in the socket of the tooth, and may extend inwards—bursting tlirough the gum—or may spread outwards through the cheek. In the early stage of a gum-boil, the application of a feAV leeches to the inflamed gum will often afford great relief from pain, and may even prevent the occurrence of suppuration ; if, hoAvever, pus have actually formed, it should be evacuated by an early and free incision, made from Avithin the mouth as soon as fluctu- 728 DISEASES OF THE MOUTH, JAWS, AND THROAT. ation can be detected in that position. As it is very desirable to avoid the deformity caused by an external opening, an effort should be made to obtain resolution on the side of the cheek, pointing being at the same time encour- aged Avithin the mouth. For this purpose it will usually be advisable to aA-oid the use of poultices, substituting an embrocation of the extract of belladonna, diluted with glycerine. The patient may be at the same time directed to Avash out the mouth frequently Avith warm water, or the domestic remedy of a hot fig may be applied to the inner side of the inflamed gum. As soon as the acute symptoms have subsided, Avhether by the occurrence of resolution or of suppuration, the services of a dentist should be invoked, to remedy the diseased state of the offending tooth, and thus avert a recurrence of the affection. Lancing the Gums is a little operation often required in cases of difficult dentition. It is most conveniently performed with the instrument knoAvn as the "gum lancet," though, in an emergency, the small blade of an ordinary penknife will serve the purpose, perfectly well. The child's hands should be restrained by the mother or nurse, while the surgeon, separating the jaAvs with the left forefinger, introduces the blade of the lancet guarded with the right forefinger; this serves to guide to the point at which the incision is to be made, and at the same time keeps the child's tongue out of the Avay of injury from the knife. Ulceration of the Gums may depend upon the presence of a scorbutic or syphilitic taint, or may result simply from a disordered state of the diges- tive system, the accumulation of tartar around the teeth, etc. The treatment consists in the adoption of means to improve the patient's general condition, with the enforcement of cleanliness of the part, and the local use of astringent and detergent washes. Epulis___This is a general term signifying an outgrowth of the gum, the growth in these cases being rather of the nature of a continuous hypertrophy than of a distinct tumor. ' The ordinary epulis is of a fibrous structure, but myeloid, cancerous, and epitheliomatous growths are also met Avith in this locality. The disease chiefly affects the loAver, but is also met Avith in the upper jaAv, rarely occurs before adult Fig. 402. lite, and is equally common in either sex. It is usually traceable to the irri- tation produced by a decayed tooth. The Fibrous Epulis appears as a red, smooth, lobukted mass, covered by the natural structures of the gum, the mu- cous glands of which are sometimes ab- normally developed. The growth is at first firm and resisting, but may become Fibrous epulis. (Bryant.) softened by central disintegration, or may ulcerate superficially. The Malig- nant Epulis, as it is commonly though improperly called, is usually of a myeloid character; in some instances, however, as already observed, these groAvths are really malignant, being of an epitheliomatous or cancerous nature. The malignant differs in appearance from the simple or fibrous epulis, in being softer, of a darker color, more vascular, and of more rapid growth, and in its tendency to recur after removal. The only available mode of treatment, in any case of epulis, is excision, and as the growth commonly involves the periosteum, this, with a thin layer of the subjacent bone, should be removed with the gouge-forceps, so as to ABSCESS OF THE ANTRUM. 729 prevent a recurrence of the disease. In ordinary cases, the Avhole operation may he done from Avithin the mouth, but if the tumor be large, and particu- larly if of a myeloid character, it may be necessary to make an incision through the median line of the lip, and then dissect off the cheek so as to freely expose the Avhole growth. A tooth should be extracted on either side of the diseased mass, and the alveolus divided with a strong but small saw as far as the base of the tumor. Cutting pliers, with the blades at a right angle to the handles, are then to be applied, one blade on either side of the jaw, Avhen the whole growth, with the hone from Avhich it springs, can be readily cut away. The base of the lower jaw should always be allowed to remain, in order to preserve the symmetry of the part; the removal of the Avhole thickness of the bone appears to be quite unnecessary, epulis, according to Heath, neAer involving the loAver border of the jaAV. If the bone be very thick, it may be desirable, before applying the cutting forceps, to make a horizontal groove Avith a Hey's saAv ; but in most instances this will probably be found unnecessary. Hemorrhage is to be checked by compression, or, if this fail, by the use of the actual cautery or of Monsel's solution of iron, the external Avound, if one have been made, being then accurately adjusted with harelip pins and the tAvisted suture. The bleeding is often profuse, in opera- tions for the removal of malignant epulis, requiring the free use of the hot iron ; in these cases, also, it may be necessary to remove the entire thickness of the bone, by means of an external incision beneath the horizontal ramus of the jaw. Necrosis of the Jaws may result from traumatic causes, from syphilis, from the abuse of mercury, or from the contact of the fumes of phosphorus (as in the makers of lucifer matches) ; it is, moreover, sometimes met with as a sequel of the eruptive fevers, and may even occur Avithout being trace- able to any definite cause. In the upper jaAv, the disease is almost invariably limited to the alveolar border, but in the lower jaw, may inArolve the whole thickness of the bone. The treatment consists in the administration of nutri- tious food and tonics, with the use of detergent lotions, and an early removal of sequestra ; as long as a portion of dead bone remains in the mouth, the patient is constantly exposed to the risks of septic poisoning. Removal should, if possible, be effected a\ ithout resorting to external incisions; in the upper jaw this can be readily accomplished, but if the Avhole thickness of the lower jaw be involved, an incision below the ramus may be absolutely necessary ; Perry and Boker have, hoAvever, each succeeded in removing the whole lower jaAv, in a state of necrosis, through the mouth, and Hutchison, of Brooklyn, has in a similar manner removed the whole upper jaw and the malar bone. Linhart, of Berlin, has removed the greater portion of both upper jaws, wliile preserving the muco-periosteal co\'eringof the hard palate and the incisor teeth. Abscess of the Antrum—Suppuration may occur in the antrum as the result of traumatic causes, or of the irritation produced by a diseased tooth or by a sequestrum resulting from syphilitic or other disease of the jaw. The symptoms are those of deep-seated suppuration in general, Avith en- largement of the part, causing swelling of the cheek, protrusion of the eyeball, occlusion of the lachrymal duct and nostril, and bulging of the hard palate. If the accumulation of purulent matter be very great, the Avails of the antrum may become so attenuated as to crackle under pressure. Point- ing may take place on the cheek, or within the mouth, or the abscess may possibly discharge itself through the nostril. The treatment consists in making a free opening into the antrum, and, subsequently, in daily Avashing out the cavity by syringing with warm water. If one of the molar teeth be 730 DISEASES OF THE MOUTH, JAWS, AND THROAT. carious, this may he extracted, and an opening made by thrusting a trocar, small perforator, or, Avhich Fergusson recommends, an ordinary gimlet, through the socket, but, under other circumstances, it is better to make the opening through the front wall of the antrum beneath the cheek ; the bone is here thin, and can be readily perforated Avith a strong knife or scissors. Ex- ternal pressure may be afterAvards employed to restore the part to its original shape. Cysts of the Antrum (Dropsy of the Antrum)__The antrum is not unfrequently the seat of a collection of thin glairy mucus, or of a broAvnish serous fluid containing crystals of cholestearine. The older surgeons looked upon these cases as the result of an obstruction of the orifice of the antrum, causing accumulation of the natural secretion of the part, and hence applied to them the term hydrops antri, or dropsy of the antrum. Modern patholo- gists, however, believe that; at least in the large majority of instances, these are (as first pointed out, by Giraldes) examples of true cystic disease, analo- gous to those which are met with in other parts. The symptoms of a cyst of the antrum are very much the same as those which characterize abscess of that cavity, except that no evidence of an inflammatory condition is present. The diagnosis is important, as these cases are curable by a very slight ope- ration, whereas solid tumors of the antrum demand a much graver procedure for their removal; hence, in any case of doubt, the surgeon should make an ex- ploratory puncture before resorting to more serious measures. The treatment of cystic disease of the antrum consists in perforating the anterior Avail of the cavity from within the mouth, the cheek being previously dissected up if necessary. A small portion of the anterior Avail may be excised, so as to allow thorough exploration of the part, and prevent re-accumulation. If, as sometimes happens, a tooth be Fi<>-. 403. discovered Avithin the antrum (in which case the cyst is said to be dentigerous),1 the tooth should be removed with suit- able instruments, introduced through the opening already made. Solid Tumors of the Upper Jaw__These are of various kinds. Apart from those Avhich have already been described under the name of epulis, there may be exostoses springing from the surface of the jaAv, and pro- jecting in different directions, requiring removal with gouge, saw, or cutting pliers. Tu- mors, again, may originate from either Avail of the an- trum, from the malar bone, Encephaloid of the antrum, encroaching upon the face. from the pterygo-maxillary (Liston.) fossa, or from behind the 1 According to Magitot, maxillary Cysts of spontaneous origin are invariably con- nected with some portion of the dental system. SOLID TUMORS OF THE UPPER JAW. 731 jaAv; fibrous, myeloid, and encephaloid growths are probably those most fre- quently met with in these situations, though fatty, cartilaginous, bony, and epitheliomatous tumors have also been observed in the same localities. These various groAvths, as they increase in size, produce swelling of the cheek ; encroach upon the orbit, causing protrusion or compression of the eye, and sometimes interfering with vision ; occlude the nostril, simulating nasal poly- pus; project into the pharynx, causing dyspnoea or dysphagia; and depress the alveolus and hard palate, causing bulging of the roof of the mouth. Beside the deformity produced, they eventually endanger life, by interfering with respiration and deglutition, by giving rise to profuse and repeated hemorrhages, or by involving the base of the skull, and inducing cerebral complications. Diagnosis___Solid tumors, involving the antrum, may be distinguished from cysts or abscesses of the same part, by noting the history of the case, by observing the uniform, elastic, and semi-fluctuating character of the enlarge- ment, in the case of a fluid collection, and, finally, by means of an explora- tory puncture. It may, however, happen, as in a patient under my care at the Episcopal Hospital, that the entrance to the antrum is blocked by a solid growth, the natural secretion of the part accumulating as a consequence, and constituting a true dropsy of this cavity. Under such circumstances the diagnosis Avould necessarily be obscure, until the gradual increase of the solid tumor should render its nature apparent. It is sometimes a matter of great difficulty to determine the point of origin of a tumor involving the upper jaAv ; those groAvths Avhich spring from the malar bone, dip dowmvards between the gum and cheek, causing the latter to project at an early period, and only secondarily involve the antrum ; tumors, again, which originate in the antrum, distend its Avails in various directions, and render the line of the teeth irregular; wliile, finally, growths which originate behind the jaw (as naso-pharyngeal polypi), thrust the latter downwards and forwards as a Avhole, without altering the line of the teeth, or changing the relative position of the several parts of the bone. These dis- tinctive points are, however, in practice, often obscured by the fact that a tumor arising in one position may send prolongations in several different directions, so that, in any particular case, it may be almost impossible to decide from what part the growth originally sprang. The diagnosis between malignant and non-malignant tumors of the an- trum, is often extremely difficult, as long as the morbid growth is confined within the walls of that cavity. A malignant affection may, however, be suspected, if the increase of the tumor be rapid, if the patient be past the period of middle age, and particularly if the submaxillary glands be enlarged and indurated. When the groAvth has spread beyond the cavity of the an- trum, the diagnosis is comparatively easy, the ordinary characters of a malignant tumor being, under these circumstances, speedily developed. Treatment___The only treatment Avhich can be of any service in cases of tumor of the upper jaw, is extirpation of the growth, Avhich may require the removal, partial or complete, of the superior maxillary and perhaps of the malar bone. In the case of a non-malignant growth, springing from the antrum, there can be no question as to the propriety of the operation ; and even if the tumor originate behind the jaAv, excision, though attended with danger from hemorrhage and from the implication of the base of the skull, may be properly attempted, if the general condition of the patient be favor- able to such a procedure. In the case of a malignant groioth, provided that the glandular implication be not extensive, excision maybe properly resorted to, if the case be seen before the tumor has spread beyond the cavity of the antrum ; if, however, the soft structures of the cheek be involved, or if the 732 DISEASES OF THE MOUTH, JAWS, AND THROAT. submaxillary glands be much enlarged and indurated, even though the growth he still limited by the Avails of the antrum, operative interference is, as a rule, to be aAoided ; complete extirpation Avould scarcely be practicable under such circumstances, wliile a partial remoAral of the disease could but render the patient's condition Avorse than before. LaAvson has. hoAvever, reported a case in wliich he removed as much of the groAvth as could be reached, with the implicated integument, and then applied the hot iron, and dressed the wound Avith chloride of zinc paste ; the cauterization Avas subse- quently tAvice repeated, and the patient ultimately recovered. Excision of the Upper Jaw__To Lizars is justly ascribed the credit of having first proposed excision of the Avhole upper jaw for tumor of the antrum, and to Gensoul (in 1827), that of Fig. 404. having first actually performed the operation, though partial excisions had been previously done by Dupuytren, Jameson, of Baltimore, and others. Various incisions are recommended by different surgeons, the best, in my judgment, being that advised by Fergusson, which consists in dividing the upper lip in the mesial line, laying open the nostril corresponding to the side of the tumor, carrying the knife (if more space be necessary) from the root of the ala, between the side of the nose and the cheek, as far as the nasal bone, and then cutting transversely opposite the loAver border of the orbit to the zygomatic process of the malar bone. The flap thus marked out being dissected up, sufficient room is afforded for the removal _ of (Fergusson.) the largest tumor. Lizars employed an incision from the angle of the mouth across the cheek to the malar bone, supplementing this cut, if necessary, by one through the lip into the nostril, and by a short longitudinal incision at the malar extremity of that first made. Liston's method, Avhich, Avith various slight modifica- tions, is still often adopted, consists in making one incision from the exter- nal angular process of the frontal bone tlirough the cheek to the corner of the mouth ; a second along the zygoma, joining the first; and a third from the nasal process of the maxilla, detaching the ala of the nose, and cutting through the lip in the mesial line. By any of these methods, the Avhole upper jaw may be readily removed, the flaps being dissected aAvay from the surface of the tumor, and the bony connections of the part severed Avith a Hey's, or other small saw, and strong cutting pliers. One, or, if necessary, two incisor teeth being extracted, the saAv may be applied to the ah'-eolus, to the floor of the nostril, or to both, so as to cut a deep groove in Avhich the blades of the cutting forceps may be applied ; the hard palate is then cut through with the latter instrument, the soft palate being detached by a transverse incision, or, if practicable, the mucous covering of the roof of the mouth being turned backAvards in the form of a flap. The malar bone is next cut across into the spheno-maxillary fissure, or, if this bone is itself to be removed, its orbital and frontal pro- cesses, and the zygoma, are similarly divided. Finally, one blade of the forceps is introduced into the nostril, and the other into the orbit (the im- portant structures in the latter cavity being pushed and held out of the Avay Avith the handle of a knife or spatula), and the inner angle of the orbit cut across. The tumor may then be grasped with the lion-jaAved forceps devised by Fergusson (Fig. 296), and forcibly depressed, the infra-orbital nen^e EXCISION OF THE UPPER JAW. 733 being carefully divided far back, and any remaining attachments severed Avith a few strokes of the knife. Hemorrhage being arrested by ligation of any vessel that can be reached, or by the application of the hot iron, if neces- sary, the large cavity that is left is to be stuffed Avith pledgets of lint furnished with a string, to facilitate withdraAval through the mouth, and the external incisions accurately adjusted Avith the interrupted or tAvisted suture. Partial Excision of the Jaw may often, in cases of non-malignant tumor, be advantageously substituted for complete extirpation : thus, if the orbital plate be not involved, this may be left, a groove being cut with the saAv across the bone beloAV the orbit, and the cutting pliers subsequently applied in the same line ; or if, on the other hand, the alveolus and hard palate be healthy, the saAv may be applied above and parallel to the alveolar border of the jaAv, and again in a line perpendicular to this, so as to connect the former section Avith the orbit; the inner angle of the orbit being then cut across, the upper part of the jaw may be separated with the lion-jaAved forceps, as already described. Finally, it may be advisable, in some instances, to adopt Fergusson's suggestion of cutting into the centre of the diseased mass, and Avorking AA-ith cuiwed forceps and gouge towards the circumference, instead of undertaking a formal excision. The feeling of surgeons, generally, is un- questionably opposed to these partial operations, the professional mind being probably still influenced by Liston's unqualified condemnation of such "nib- bling and grubbing" procedures; as justly remarked, hoAvever, by Mr. Heath, it remains to be seen Avhich practice gives the best results. In the case of small tumors, or of necrosis, excision may be sometimes accomplished from Avithin the mouth, without any external incision. The results of excision of the upper jaw are quite as favorable as could be expected, in view of the severity of the operation ; 17 cases, quoted by Heath from the Medical Times and Gazette, gave 14 recoveries; and 20 cases tabulated by Ohleman, of Bremen, gave 17 recoveries; while 12 cases of partial excision collected by the same writer were uniformly successful. The chief dangers of the operation appear to be from shock, from hemor- rhage, and (if an anaesthetic be used) from entrance of blood into the air- passages. (1.) Shock is not so much a source of risk in cases of excision of the jaAv merely, as in those cases in which the jaw is removed as a preliminary step in the extirpation of retro-maxillary tumors. It is diminished by the use of chloroform, wliich, as the hot iron may be required in the latter stages of the operation, should in these cases be substituted for ether, on account of the inflammable nature of the latter agent. (2.) Hemorrhage is always pretty free in these operations, during the early stage, particularly if the incision through the cheek is adopted, when the facial artery is cut at a point at which its calibre is considerable; the surgeon may, if he think proper, apply a ligature to this vessel before proceeding to the other steps of the operation, but, as a rule, the pressure of an assistant's fingers, or the application of a serre-fine, will suffice to control the bleeding until the Avhole excision has been completed. At a later stage of the opera- tion, there is again pretty free bleeding from branches of the internal maxil- lary, which are necessarily cut or torn across where the jaw is removed; these branches may be secured by ligation, or may be occluded by a few touches of the hot iron, which will often be found a more conA'enient application in this situation. In order to prevent hemorrhage during the operation, Lizars pro- posed and practised ligation of the carotid artery, as a preliminary proceeding; this plan is, however, abandoned at the present day, both as unnecessary, and as, in itself, seriously complicating the patient's condition. The tendency of modern surgical writers, indeed, is to speak very lightly of the risk of hemor- 734 DISEASES OF THE MOUTH, JAWS, AND THROAT. rhage in excision of the upper jaAv, and Prof. Gross, in alluding to this subject, goes so far as to say that " no skilful surgeon noAv even employs compression of the carotid artery in these operations," and that " there are no structures in the body of the same extent, in their natural and diseased condition, the removal of which is attended Avith so little hemorrhage." With due diffidence, I must express my dissent from this opinion. I believe that profuse bleeding is a more frequent cause, if not of death, at least of danger, in excision of the upper jaAv, than is commonly acknoAvledged, and should consider compression of one or even both carotids, during the operation, a highly proper and judicious precaution. Another plan, which is suggested by Fergusson, might also be adopted Avith advantage ; this is to notch, if not fairly divide, the ascending process of the superior maxilla, with the alveolus and hard palate, before dissecting up the cheek or even cutting into the cheek at all—the most tedious part of the operation being thus accomplished, before any incision is made into the most vascular parts. Ligation of the carotid may occasionally be rendered necessary by the occurrence of consecutive or secondary hemorrhage, as in a fatal case under the care of Le Gros Clark, in which Wagstaffe tied the carotid for profuse bleeding occurring on the seventh day, and a successful case recently recorded by W. H. Pancoast, of this city. (3.) The risk of suffocation from blood flowing into the air-passages, during the operation, is of course greater when the patient is in a state of anaesthesia, than it Avould be if chloroform were not employed ; and in Mr. HeAvett's Avell-knoAvn case,1 the fatal result was attributed to this cause. To prevent such an occurrence, anaesthesia should not be pushed further than absolutely necessary, and assistants should constantly mop out the mouth Avith sponges attached to sticks of a suitable length. Nussbaum believing that this is the principal source of risk in jaAv operations, advises the preliminary per- formance of a temporary tracheotomy, the glottis to be closed Avith a piece of oiled lint, and chloroform to be administered through a tracheal tube; this plan has, with various modifications, been adopted by other surgeons, includ- ing Little, of NeAv York, and Cheever, of Boston, but, I confess, seems to me rather adapted to complicate than to facilitate the operation, and I can but say the same of Rose's and Burow's suggestion, that the patient's head, during the operation, should be thrown back so far as to allow the blood to floAV through the nostrils. Excision of the greater part of both Upper Jaws Avas performed by Rogers, of NeAv York, in 1824, and complete extirpation has since been practised by Heyfelder, Maisonneuve, Simon, Carrothers, Brigham, and others; the whole number of operations on record, is about two dozen. The incisions for this operation, which is one of the gravest character, consist of a median division of the upper lip, with separation of both nostrils—a duplication, in fact, of the operation recommended for excision of either jaw separately. AVhen portions only of the jaAvs are to be removed, the surgeon may adopt a plan suggested and successfully employed by Porter, of Boston. This consists in making a Y-incision, the long arm of the Y dividing the upper lip, and the small arms entering the nostrils, Avhich can then be pushed upwards so as to afford a considerable amount of room. In all operations upon the upper jaAv, the skin covering the tumor should be scrupulously preserved, no matter how thin and distended it may appear. To complete the subject of excision of the upper jaw, the folloAving statistics of the operation are quoted from Heyfelder. 1 Med.-Chir. Trans., vol. xxxiv., p. 43. EXCISION OF THE LOWER JAW. 735 Nature of operation. Whole No. of cases. Cured. Relapsed or died Result unknown. Complete excision of one jaw . . . Partial " " ... Complete excision of both jaws . . Partial " " ... 141 153 11 8 51 48 5 7 33 35 6 1 57 70 H. Braun has tabulated 23 cases of double excision, classified as follows:__ Nature of operation. Whole No. of cases. Recovered. Died. Complete extirpation for tumor...... Partial or consecutive extirpation for tumor . 11 5 7 7 5 6 4 1 Tumors of the Lower Jaw.— Cystic, Fibrous, Fibro-cellular, Car- tilaginous, Bony, Myeloid, and Encephaloid groAvths are met with in this situation, commonly originating in the cancellous structure in the centre of the bone, and projecting both into the mouth and dowmvards into the side of the neck, in the form of rounded or irregularly lobed masses. The remarks which Avere made as to the importance of a correct diagnosis, in cases of tumors of the upper jaw, are equally applicable Avith regard to those of the inferior maxilla—simple cystic growths being usually readily curable by lay- ing open the cyst and stuffing its cavity Avith lint—non-malignant, solid tumors requiring excision with saAv and cutting pliers—and cancers of this part, on the other hand, often not admitting of any operative interference whatever. Maunder has succeeded in tAvo cases in removing solid tumors of the loAver jaAv, without making any external incision. Excision of the Lower Jaw__It is occasionally possible, as recently advised by Heath, and as long ago done by the late J. Rhea Barton, of this city, to remove non-malignant solid tumors of the lower jaAv, Avithout sacri- ficing the Avhole thickness of the bone ; and it is certainly desirable, under such circumstances, to preserve the base of the jaw, for the reasons already given in speaking of necrosis of this part. If, however, the whole thickness of the bone on one side be involved, excision may be performed by making a single incision along the base of the jaAv, prolonging the cut, if necessary, in a line corresponding to the position of the ascending ramus, and curving the anterior extremity of the Avound upAvards, toward but not through the pro- kbium. If the portion of bone to be removed extend beyond the median line, a ligature should be passed through the tip of the tongue, to prevent its retraction Avhen the muscles of the floor of the mouth are divided. In this first incision the facial artery will be cut, and should be immediately secured with ligatures. The flap, formed as above directed, should be carefully dis- sected up, and the inner side of the jaAv cautiously cleared, by separating the soft tissues of the mouth—a tooth having been previously extracted on either side of the tumor: the saAv is to be applied so as to cut a deep notch through the alveolus, the bone section being subsequently completed either with the saw or cutting pliers. The part to be removed is then seized with the lion- jawed forceps, and wrenched out, any remaining attachments being severed with a feAV strokes of the knife. 736 DISEASES OF THE MOUTH, JAWS, AND THROAT. If the morbid groAvth involve the angle of the jaAv and part of the ascend- ing ramus, it Avill be necessary to disarticulate the bone upon that side; in this case, the incision should be pro- longed to the back of the articulation, Avhen the bone, having been divided in front of the tumor, is to be cleared by careful dissection, the surgeon then depressing the body of the jaAv, so as to render tense and facilitate the division of the attachment of the temporal muscle to the coronoid process; the jaAv being tAvisted somewhat outwards, the joint may noAv be opened from the front, and disarticulation completed. The edge of the knife should, through- out, be kept close to the bone, lest the internal maxillary or even the exter- nal carotid artery should be accident- ally Avounded. Hemorrhage being checked by ligatures, or, if from the dental artery in the cut surface of bone, by the application of Monsel's salt or the actual cautery, the external incis- ion may be closed by means of the in- terrupted or tAvisted suture. Until union is completed, the patient's diet should be limited to liquid food, which may be given through a tube. In order to avoid wounding the portio dura nerve or parotid duct, J. L. Lizars, of Toronto, recommends instead of the incision above described, one passing from the commissure of the lips out- wards towards the ear, disarticulation being readily effected from within the mouth Avhen its orifice is thus enlarged. As already mentioned, Maunder has reported tAvo cases in which he succeeded in removing large tumors of the lower jaw, Avithout any external incision whatever. Metallic caps, to fit the teeth of the remaining portions of the jaw, and connected Avith a spring to a similar contrivance applied to the teeth of the upper jaw, are sometimes employed to prevent distortion from the action of the muscles. Such an apparatus, is, hoAvever, according to Heath quite unnecessary, as the bone quickly resumes, unaided, its normal position. If the tumor be very large, involving both sides of the jaAv, a U-shaped incision dividing both facial arteries may be employed, as recommended by Fergusson; or, as advised by Heath, the loAver lip may be divided in the median line, and the flaps dissected back on either side. Excision of a part of the lower jaw for tumor, Avhich Avas first performed by Deaderick, of Tennessee, in 1810 (though his case Avas not published until thirteen years later), has been practised a great many times; and, except in cases of malignant disease, with very good results. The proportion of fail- ures under the latter circumstances (twenty-one out of thirty-nine cases, ac- cording to Heyfelder), authorizes the question Avhether, in a case of cancer of this part admitting of any operation, complete extirpation Avould not be better than any less sweeping measure. The following statistics of excision of the lower jaw, for all causes, are taken from Heyfelder. Disarticulation of lower jaw. (Fergusson.) DISEASES OF THE PALATE. 737 Nature of operation. Whole No. of cases. Cured. 14 90 84 Relapsed or died. Result unknown. Disarticulation of half tbe jaw . Partial excision ....... 15 133 138 1 43 33 21 Anchylosis or Closure of the Jaws may folloAV sloughing resulting from the abuse of mercury or from cancrum oris, or occurring in the course of low fevers.; it may also be caused by rheumatoid arthritis, by the contraction of the cicatrix of a burn, or by a Avound of the temporo-maxilkry articulation. If the anchylosis be confined to one side, it may be remedied by a resort to Rizzoli's or Esmarch's operation (see p. 303), the latter procedure being probably the better of the tAvo. The section of the bone should ahvays be made in front of the cicatrix. If both sides of the jaw are anchylosed, pro- vided that the Avhole thickness of the cheek be not involved, an attempt may be made to restore the mobility of the part by dividing the cicatricial bands from Avithin, and gradually separating the jaAvs by means of a screAv dilator, or, Avhich Heath prefers, by the use of metal shields adapted to the teeth, and forced apart with wedges. This mode of treatment, though both tedious and painful, can, according to Heath, be made, Avith care and attention, to yield very good results. An ingenious arrangement of pulleys and leather straps lias been successfully employed by Dr. B. J. D. IrAvin, of the U. S. Army. Diseases of the Palate. Cleft Palate___This is a congenital deformity consisting of a division in the median line of the part, Avhich may be confined to the uvula (Bifid Uvula), or to that and the soft palate, or may im^olve the Avhole roof of the mouth, being, perhaps, additionally complicated by the coexistence of harelip. More rarely, the hard palate is cleft (in connection with harelip), the soft palate and uvula escaping. In some cases, there is a double fissure anteriorly, the intermaxillary bone projecting between the two clefts. If the deficiency lie extensive, a cleft palate may interfere seriously with deglutition by alloAV- ing regurgitation through the nose, and in all cases it causes indistinct articu- lation, with a disagreeable modification in the tone of the A^oice. Treatment___If very slight, and limited to the soft parts merely, a cure may sometimes be obtained by Cloquet's plan, recently revived by Mason, of repeatedly cauterizing the angle of the cleft, and then waiting for cicatriza- tion to produce contraction. As a rule, however, cleft palate can only be remedied by the use of the knife, the operations applied to the soft palate being called Staphyloraphy and Staphyloplasty, and that to the hard palate, Uranoplasty. Staphyloraphy.—If the case be complicated Avith harelip, this should be operated on in infancy, the patient wearing subsequently a suitable cheek- compressor, so as to encourage contraction of the fissure. As the operation of staphyloraphy is both painful and tedious, it Avas formerly considered neces- sary to Avait until the patient should be old enough to be himself anxious for a cure, and Avilling to co-operate with patience and fortitude in the surgeon's efforts for his relief. At the present day, hoAvever, with the aid of anaesthetics, and particularly with the facility afforded by the use of one or other of the ingenious gags devised by Coleman, T. Smith, Wood, Mason, Whitehead, 47 738 DISEASES OF THE MOUTH, JAWS, AND THROAT. Fig. 406. v*?< "•y ............. Whitehead's gag and tongue depressor. Weir, and other surgeons, it is no longer thought imperative to Avait in all cases until adult life, and numerous highly successful operations upon young children have now been performed under these circumstances. The great object of operating at an early period, in these cases, is that the fissure may be closed before the child has acquired the pe- culiar nasal tone of voice a\ Inch habitually accompanies the de- formity ; and the age at Avhich the operation should ordinarily be attempted, in suitable ca-es, may be given, upon the author- ity of Holmes, as about three years. The first successful staphylor- aphyAvas donebyRoux,in 1819, and the operation has since been illustrated by the Warrens, father and son, Miitter, Dieffenbach, Liston, Fergusson, Sedillot, Mettauer, J. Pancoast, Avery, Collis, Pollock, and others. In its simplest form, the operation consists in fresh- ening the edges of the cleft, and then bringing them together with a sufficient number of interrupted sutures. In order to diminish the tension upon the stitches, Roux employed transArerse incisions, for which Dieffenbach judi- ciously substituted incisions parallel to the fissure. Warren, in 1813, intro- duced a further improvement, which consisted in dividing the muscles con- tained in the posterior pillar of the fauces ; but to Fergusson, in 1844, is due the credit of first distinctly pointing out the importance of a preliminary myo- tomy, so as temporarily to paralyze the velum, and thus prevent disturbance of the line of union by the muscular action of the parts. Fergusson's operation consists in dividing the leATator palati on either side, by introducing a curved knife through the fissure and cutting from above— then dividing the pakto-pharyngeus by snipping the posterior pillar of the fauces (as Avas done by War- ren), and, if necessary, similarly dividing the anterior pillar, containing the palato-glossus. Pollock and Sedillot divide the levator palati by Avhat might be called a submucous section, thrusting a knife through the palate near the hamular process on either side, and severing the muscular fibres by raising the handle and depressing the blade of the instrument. This division of the muscles is often attended with more bleeding than any other part of the operation, and hence, if chloroform is to be used, may be advanta- geously postponed, as recommended by T. Smith, until after the introduction of the sutures, or, on the other hand, may be done, as advised by Callender, Sedillot's operation for without chloroform, a few days before the rest of the staphyloraphy. operation is performed.1 Fig. 407. 1 According to Lawson Tait, myotomy by any method is occasionally followed by atrophy of the palate. Willett and Marsh have met Avith secondary hemorrhage requiring the operation of plugging the posterior palatine canal. STAPHYLORAPHY. 739 Paring the edges of the fissure may be either the first or the second step of the operation, according as myotomy has or has not been previously per- formed. The surgeon may seize the tip of the uvula on either side and pare the edges from before backwards, by transfixing the part with a sharp-pointed bistoury near the angle of the cleft, the angle itself being subsequently fresh- ened ; or, as advised by Smith, may cut from behind forAvards—the advan- tage of this plan being that the blood flows backAvards, and thus does not obscure the line of incision. Drs. Packard and Cohen, of this city, have adopted Avith advantage the plan of splitting instead of paring the edges, as practised by Langenbeck and Collis in cases of vesico-vaginal fistula, and Dr. Forbes has, in cases of slight extent, ingeniously adapted Nelaton's harelip operation, surrounding the fissure Avith an inverted \ incision, the resulting AA'ound becoming, by the dropping of the flap, of a diamond y shape. (See page 717.) The introduction of the sutures is probably the most difficult part of the operation for cleft palate. If the ordinary silk suture is to be used, the plan suggested by Avery Avill be found very convenient. This consists in intro-" ducing, with a small nawus needle, on one side a single thread, and on the other side a loop of silk : one end of the single thread being then passed through the loop, the latter is withdrawn, carrying the single thread Avith it, and thus readily bringing the suture into place. By this mode of proceeding the needle is introduced on either s\o\efrom below, thus enabling the surgeon to regulate the distance betAveen his stitches with greater accuracy than Avould otherwise be possible. Instead of the silk suture, T. Smith employs fine cat- gut or horsehair, Avhile many American surgeons consider silver Avire prefer- able to any other material. If wire be used, a short curved needle should be employed, its introduction being facilitated by the use of suitable forceps. The mode of fastening the suture is a matter of some importance : Fergus- son passes one end through a slip noose formed upon the other, and draAving this noose tight, runs it up so as to approximate the edges of the fissure, securing the whole with an ordinary surgeon's knot. If horsehair be used, a triple instead of the common double knot, is, according to T. Smith, neces- sary to prevent slipping. The Avire suture maybe secured by clamping upon it a perforated shot, both ends being passed through the same shot, or one shot applied to either side of the cleft, according to the surgeon's fancy. From three to five sutures are usually required, and they should enter and leave the palate about a quarter of an inch from the freshened edge on either side of the cleft: they must not be drawn too tight, it being ahvays remembered that they are meant not to pull, but merely to hold the edges together. The ante- rior suture is usually introduced first, and Avhen all are secured, if, in spite of the relaxation afforded by myotomy, the parts appear tense, free lateral inci- sions should be made on either side. The sutures, as a rule, should not be removed until the eighth or tenth day, and then one or tAvo at a time—the patient during the interval being fed on liquid but nutritious food, and kept as quiet as possible, though not neces- sarily confined to bed. After the operation, the voice is occasionally observed to have undergone immediate and decided improvement, but in most cases, at least in adults, a considerable length of time and a long course of vocal gymnastics will be found necessary to restore distinct articulation. The impairment of voice which persists in these cases, is, as pointed out by F. Mason, due to the tension of the palate which forms a curtain tightly stretched across the fauces, while the air enters the posterior nares above; to remedy this, Mason supplements the ordinary operation by severing the attachments of the palate to the fauces on either side. 740 DISEASES OF THE MOUTH, JAWS, AND THROAT. Staphyloplasty is a name employed by Dr. Schbnborn, a German sur- geon, for an operation Avhich consists in taking a flap of mucous membrane from the posterior AA'all of the pharynx, and dove-tailing it betAveen the fresh- ened edges of the palatal cleft; the advantage claimed for this method is that the improvement in voice is greater than after the ordinary operation. Uranoplasty ; Uraniscoplasty___The merit of first devising an operation for the cure of fissure of the hard palate, is due to the late Dr. J. Mason Warren, of Boston, avIio published an account of his procedure in 1843. His plan was to dissect up, Avith a long double-edged knife curved on the flat, the mucous covering of the hard palate, beginning on either side of the fissure, and carrying the dissection back to the alveolar processes; the pendulous flaps thus formed Avere then united in the median line. Another plan, which Fergusson prefers, is to make an incision parallel to the ahTeolus on either side, and carry the dissection towards the free margin of the fissure.1 Langenbeck uses a blunt instrument, with Avhich to separate the periosteum from the bone, in order to take advantage of the osteo-genetic power of that membrane ; and his operation, Avhich has been frequently performed in Ger- many, has been successfully repeated in this country by Dr. Wm. R. White- head, avIio published an excellent paper on the subject, Avith an analysis of 55 cases, in the American Journal of Medical Sciences for October, 1868. Fergusson, reviving a suggestion of Dieffenbach's, has proposed, as an im- provement upon Langenbeck's method, to divide the hard palate on either side Avith a chisel, and then forcibly press and Avire the segments together so as to diminish the median fissure. Eighty-two cases had thus been treated by Sir Wm. Fergusson up to the end of 1875, and, with some few exceptions, with very remarkable success. It is a disputed point amongst surgeons, Avhether, in dealing with a fissure of both hard and soft palate, an attempt should be made to close the Avhole gap at once, or whether the operation should be divided betAveen several sit- tings : no positive rule can be giA'en upon this point, but Holmes's advice appears judicious, viz., to be content with closing a portion of the hard palate at the first operation, provided that the parts come easily together, but, if it should be found necessary to detach the soft parts through the Avhole extent of the cleft, then to attempt complete closure at one operation. According to T. Smith, if staphyloraphy be performed at an early age, the fissure of the hard palate will subsequently undergo contraction to such an extent as to render it possible, in most cases, to dispense with any further operation. In cases of cleft palate not admitting of surgical treatment, and in most cases of Acquired Perforation of the Hard Palate, particularly as the result of syphilis, obturators of metal, ivory, or vulcanized India-rubber, may be worn; one of the best instruments of the kind is that devised by Kingsley, of New York; it is provided with a soft curtain of India-rubber, to take the place of the natural velum. A judicious caution as to the use of obturators in cases of necrosis, is given by Heath. This is, that no ping should be in- troduced into the aperture itself, which AA-ould inevitably become still further enlarged by the pressure on its edges, but that the occluding apparatus should consist of a properly fitting plate, arching below the palate, and attached to the teeth. Elongation of the Uvula__This affection is usually remediable by the use of astringent gargles or caustic solutions, but, if persistent, may re- 1 Lannelongue reports a case successfully treated by detaching and bringing down the nasal mucous membrane. DISEASES OF THE TONSILS. 741 quire a surgical operation for its relief. This operation consists simply in cutting off the pendulous part with scissors, at about a third of an inch from the root, of the organ. The tip of the uvula may be seized with forceps held in the left hand, while the scissors are applied with the right, or an instru- Fig. 40S. Forceps-scissors for cutting uvula. ment may be used, which has been constructed for the purpose, and by which the part to be removed is caught and cut off at the same moment. (Fig. 408.) Tumors of the Palate.—Adenoid, fibrous, and cartilaginous tumors of the palate have been observed by Nekton, Marjolin, Laugier, Watson, King, Bickersteth, Dobson, and other surgeons. As the growths increase in size, they affect the tone of the voice, and ultimately interfere with deglu- tition ; the treatment consists in enucleation, which is usually readily effected with the finger introduced through an incision corresponding to the long axis of the tumor. In Watson's and King's cases, it aa as thought necessary to facilitate access to the tumor by a preliminary section of the loAver jaAv. Meplain reports a case of mucous polypus of the palate, successfully treated by the injection of acetic acid. Diseases of the Toxsils. Tonsillitis, Inflammation of the Tonsils, or Quinsy, may terminate in resolution, or may run on to suppuration—in Avhich case the patient may suffer a good deal from dyspnoea, before relief is afforded by the spontaneous opening of the abscess. Local depletion, by scarification of the part Avith a probe-pointed knife, may sometimes be of service in these cases, and, if the presence of pus can be determined, an incision may be made for its evacua- tion ; the ordinary gum lancet is a safe and convenient instrument for this purpose. In diphtheritic tonsillitis, Menzel has derived advantage from the injection into the gland of a few drops of the liq. iodinii compositus. Chronic Enlargement or Hypertrophy of the Tonsils may occur in healthy children as the result of frequent attacks of tonsillitis, croup, diphtheria, etc., or may be a manifestation of the scrofulous diathesis, occur- ring without any obvious exciting cause. If excessive, this hypertrophy may lead to unpleasant results, such as snoring during sleep, obstruction to nasal respiration (giving rise to a habit of keeping the mouth open), and even perma- nent dyspnoea—producing perhaps contraction of the chest, and eventually interfering Avitli the general nutrition of the patient. Deafness, also, is often attributed to tonsillar enlargement. The treatment consists in the use of astrin- gent gargles, the application of nitrate of silver, in substance or solution, the muriated tincture of iron, or the tincture of iodine, and in the adoption of means 742 DISEASES OF THE MOUTH, JAWS, AND THROAT. to improve the general health. Inhalations of diluted creasote vapor, or the use of the atomizer, may also prove of service. As a last resort, excision of a portion of the enlarged tonsil may be performed, either by seizing the pro- jecting part Avith forceps and cutting off a slice Avith a Fig. 409. probe-pointed bistoury, Avrapped so as to protect the lips, or by means of an instrument devised for the pur- pose by Fahnestock, and since modified by others, which is knoAvn as a tonsillotome or tonsil guillotine. If the simple knife be used, care should be taken to keep its edge directed someAvhat tOAvards the median line, so as to avoid the possibility of wounding the internal carotid artery. J. Wood advises that the section should be made from below upwards. The surgeon may stand behind the patient in operating on the right tonsil, and to the patient's right side in operating on the left. Hemorrhage is rarely troublesome after these operations, usually yielding readily to the application of ice or simple astringents ; if bleeding should, hoAvever, persist, a tur- pentine gargle, as advised by Erichsen, might be tried, or the part might be lightly touched with a brush or sponge dipped in Monsel's solution. Panas recommends digital compression through the mouth, with counter- pressure externally. Malignant Affections of the Tonsils__The tonsil is occasionally, though rarely, the seat of cancer, which may be either scirrhus or encephaloid, the latter U» being (according to Poland, who has particularly inves- tigated the subject) the commoner form of the disease ; epithelioma, also, is said to have been observed as a primary growth in this locality. The diagnosis from simple hypertrophy may be made by observing the greater hardness of the tumor, its tendency to ulcera- tion, and the implication of neighboring lymphatic glands. From syphilitic disease of the tonsil, the diag- nosis is sometimes very difficult, but may be aided by observing the efficacy, or Avant of efficacy, of anti-syph- ilitic treatment. In most cases of malignant disease, in this situation, palliative measures are alone applicable, but if the nature of the affection is recognized at an early period, Avhile the disease is as yet confined to the tonsil itself, excision may be properly attempted. Ex- Fahnestock's tonsiiio- tirpation from within the mouth has been practised by tome. Velpeau, Warren, and Demarquay—the latter surgeon having employed the ecraseur—but, upon the whole, the operation by external excision, as successfully resorted to by Cheever, of Boston, Avould appear preferable. In the case recorded by this surgeon, two incisions were made, one from within the angle of the jaAv downwards, in a line parallel to the sterno-mastoid muscle, and the other along the loAver border of the jaAv ; by dissecting away the parts on either side, an enlarged lymphatic gland Avas first exposed and removed, and then, the digastric, stylo-hyoid, and stylo-glossus muscles being cut, the fibres of the superior pharyngeal constrictor Avere separated so as to alloAv the finger to enter the pharynx, when the tonsil Avas readily enucleated. The largest vessel divided DISEASES OF THE PHARYNX AND (ESOPHAGUS. 743 Avas the facial artery, twelve ligatures in all being required. The transverse Avound Avas closed with a single suture, and recovery Avas complete in about a month. Diseases op the Pharynx axd (Esophagus. Erysipelas of the Pharynx is occasionally met Avith, either as a pri- mary affection, or as a complication in cases of ordinary facial erysipelas ; the treatment consists in the administration of tonics and stimulants, with the local use of a solution of nitrate of silver, and of gargles of chlorate of potassium. Should sloughing occur, the mineral acids may be employed, both internally and topically. Laryngotomy may become necessary in the event of the sudden supervention of oedema of the glottis, while free incisions into the affected parts would be indicated by the occurrence of suppuration. Retro-Pharyngeal Abscess__Abscesses are occasionally met Avith behind the pharynx, originating either in the areolar tissue in front of the vertebral column, or in the lymphatic glands Avhich exist in that situation. The formation of pus in some cases evidently depends upon disease of the cervical vertebra. Retro-pharvngeal abscess is commonly a grave affection, 41 out of 07 cases collected by Gautier having proved fatal, though Bokai reports 144 cases observed by himself, of which only 11 terminated in death. Xo age is exempt from the disease, though it is most common among young children. The early symptoms are in no wise distinctive, but when pus has formed, a distinct tumor may be observed, by the touch if not by sight, usually involving one side of the pharynx only, and soon leading to unilateral SAvelling of the neck, and often to stiffness of the loAArer jaAv. The treatment, Avhich should be promptly applied to prevent suffocation, consists simply in making a free opening (preferably through the mouth) for the evacuation of the pus, either with a wrapped bistoury, a trocar and canula, or an instrument devised for the purpose and knoAvn as a pharyngotome. Pharyngeal Tumors may arise in the post-pharyngeal areolar tissue, may descend from the nasal cavities, or may spring from the epiglottis. They may be of the nature of polypi (fibrous or fibro-cellular tumors, myxo- mata, etc.), or may be malignant growths, either of a cancerous or epithelio- matous nature. As they increase in size, they impede both deglutition and respiration, and may thus lead directly to a fatal termination. Operative interference, further than tracheotomy to avoid suffocation, can rarely be justi- fied in a case of malignant growth in this situation, but the treatment of inno- cent pharyngeal tumors may be more hopefully undertaken. In some cases, it may be possible to remove the mass through the month by avulsion or enu- cleation, or by the use of the ligature, ecraseur, galvanic cautery, etc., but in dealing Avith groAvths springing from the epiglottis or adjoining parts, such a course would rarely be practicable, and under these circumstances the opera- tion knoAvn as Sub-hyoidean Pharyngotomy might be properly performed. This process appears to have been first described by Malgaigne, under the name of Sub-hyoidean Laryngotomy, and has been recently revived by Lan- genbeck. In a case narrated by this surgeon, a preliminary tracheotomy having been performed and a tube introduced, the operator made a small transverse incision, close beneath the loAver edge of the hyoid bone, and divided the sterno-hyoid and omo-hyoid muscles. The thyro-hyoid membrane being opened, the finger of an assistant Avas placed in the pharynx, pushing forward the tumor for the removal of which the operation Avas undertaken, Avhen the mucous membrane of the gullet Avas divided, and the epiglottis, 744 DISEASES OF THE MOUTH, JAWS, AND THROAT. which was found to be healthy, drawn forward with a strabismus hook. The tumor—a fibro-myxoma, the size of a pigeon's egg—Avas now seen arising from the left aryteno-epiglottic fold, and extending by a broad base to the left side of the pharynx. Excision was accomplished by drawing out the groAvth Avith forceps, and carefully separating it from its attachments, blood being kept from entering the larynx by pressing a sponge over the glottis. For several weeks it was necessary to feed the patient through a tube, but the ultimate result of the case was quite satisfactory. This operation has also been successfully employed by Baum, in a case of round-celled sarcoma, and by Leffert, in a case in Avhich a foreign body had been fixed in the larynx for four years. Spasm of the (Esophagus, or, as it is often called, Spasmodic Stricture of this tube ((Esophagismus), may be met Avith in connection Avith other hysterical phenomena, or may be a reflex condition depending upon slight inflammation or ulceration of the part, upon hepatic disease, upon the irrita- tion caused by hemorrhoids, etc. The diagnosis from actual obstruction may be made by observing the intermittent character of the affection, and by the use of the oesophageal bougie, which, in a case of this description, will meet with little if any resistance. According to Hamburger and Mackenzie, infor- mation may also be gained by auscultation of the oesophagus, regurgitation of food, etc., being heard to take place instantly in cases of spasm, but after an appreciable interval in cases of organic stricture. The treatment consists in removing any source of reflex irritation Avhich can be detected, and in the administration of tonics, antispasmodics, and laxatives, with the use of cold bathing, and attention to the quality of the food, which should be unirritating and thoroughly masticated. Paralysis of the (Esophagus may occur as a symptom of disease of the central nervous system, and may be distinguished from oesophageal spasm by the absence of pain or any sense of choking. Food may be cautiously administered in these cases through a stomach-tube, or the strength of the patient may be sustained by the use of nutritive enemata. The application of electricity is said to have occasionally proved beneficial. A Dilated and Sacculated Condition of the (Esophagus is sometimes met Avith—usually, however, as a consequence of organic stricture. A comparatively slight degree of obstruction, and one wliich does not prevent the passage of a bougie, may yet alloAv the temporary retention in the gullet of a portion, at least, of the food swalloAved, and thus gradually lead to dilata- tion of the part, and the formation of pouches extending among the muscles of the neck in A'arious directions. Such a condition existed in the case of the late Dr. Marshall Hall. The treatment of oesophageal dilatation, without stricture, can be pallktiA-e merely, consisting in the administration of liquid food through a tube, or in the use of nutrient enemata. Stricture of the (Esophagus__Dysphagia, which is the prominent symptom of oesophageal obstruction, may depend upon a number of conditions totally independent of any organic disease of this part. Thus, as has been already mentioned, difficult deglutition may be due to the existence of en- larged tonsils, of pharyngeal tumors, or of retro-pharyngeal abscess ; it may also be caused by various affections of the larynx, by the pressure of cervical or intra-thoracic tumors, by aneurism of the carotid, innominate, or aorta, by displacement of the sternal extremity of the clavicle, or by the presence of a foreign body. Hence, the diagnosis of stricture of the oesophagus should STRICTURE OF THE (ESOPHAGUS. 745 only be made after a careful investigation of the history of the case, and of all its circumstances; and the surgeon should beware of hastily thrusting in a bougie. Avhich, if it might, by perforating the Avail of an abscess, effect a cure. Avould, if it should perforate the sac of an aneurism, as certainly cause death. Jarieties of Stricture.—Apart from the condition knoAvn as spasmodic stricture, Avhich has already been referred to, Ave may recognize two varieties of the disease, the fibrous and the malignant. The fibrous stricture is usu- ally due to traumatic causes, especially the contact of hot water, or of caustic alkalies or acids, but is also said to have been occasionally observed as a lesion of constitutional syphilis. It may occur in any part of the tube, and varies in extent from a feAV lines to several inches, involving sometimes a part only, and sometimes the Avhole calibre, of the gullet. The oesophagus above the seat of stricture is usually dilated, and often ulcerated, that portion which is beloAV being normal, or slightly contracted. The malignant stricture is due to the presence of a cancerous (usually scirrhous) or epitheliomatous deposit, Avhich forms a more or less distinct tumor, and is often recognizable by external examination. The rational symptoms of these tAvo forms of stricture are much the same; in both there is gradually increasing difficulty in deglutition, which culminates at last in total inability to SAvalloAv—food of all kinds being arrested at the point of obstruc- tion, and ultimately rejected by vomiting after Fig. 410. a longer or shorter interval. The diagnosis between fibrous and malignant stricture may, however, usually be made by hwestigating the etiology and previous history of the case, and by exploration with a gum-elastic bougie, or ivory-headed probang; the sensation given to the surgeon by the passage of the instrument through the stricture differs according to its nature. Thus, a fibrous stricture is felt to be smooth and evenly resisting, and the Avith- drawal of the bougie is unattended with bleed- ing ; whereas a malignant groAvth gives the sensation of a rough and ulcerated surface, and a discharge of pus and blood is apt to folloAV the exploration. Treatment—The treatment of stricture of the oesophagus is very unsatisfactory. The strength of the patient must be maintained by the administration of liquid or finely chopped food, and, if necessary, by the employment of the stomach-tube, or the use of nutritive ene- mata. If the stricture be of a fibrous charac- ter, temporary adA7antage, at least, may be stricture of the oesophagus. (Druitt.) often gained by the cautious use of bougies of gradually increasing size; by the employment of fluid pressure, applied by means of a flexible catheter surrounded Avith a tube of vulcanized India- rubber, which can be distended with air or Avater after introduction ; or by the use of an ingenious instrument recently described by Dr. Morrell Mac- kenzie under the name of esophageal dilator, Avhich acts much on the prin- ciple of Holt's instrument for stricture of the urethra. Instruments for the dilation of oesophageal strictures have also been devised by Fletcher and Wakley, but seem to be inferior to that of Dr. Mackenzie. The application of caustic, as recommended by Home and others, is seldom resorted to at the 746 DISEASES OF THE MOUTH, JAWS, AND THROAT. present day. Internal section of the strictured part of the oesophagus, by means of an instrument consisting of a shaft with concealed blades, which can be protruded after introduction, has been practised by Maisonneuve, Lannelongue, Dolbeau, and Trelat, the tAvo former "surgeons dividing the stric- ture from above doAvnwards, and the tAvo latter from beloAV upwards. Four cases operated on by the former method gave but one recovery and tAvo deaths (the result of one case being uncertain), while three cases operated on by the latter method all terminated favorably. Great caution must, hoAvever, be exercised in using any of these instruments; Demarquay records cases in which attempts at catheterization of the oesophagus proved fatal from the passage of the bougie tlirough the oesophageal Avail into the bronchi or pleural cavity. If the stricture be of a malignant character, the use of bougies, or other means of dilatation, will in most instances be rather prejudicial than advan- tageous ; the bougie may, indeed, be cautiously employed, as a palliative measure, in the early stages of the disease, but after the establishment of ulceration, can scarcely be expected to be of much benefit. Under these cir- cumstances, the best that can be done is probably to sustain the strength of the patient with nutritive enemata, and to relieve his sufferings by the free use of anodynes; excision of the affected part has indeed been suggested by Billroth, and is said to haAre been successfully performed by Czerny, but the case must be considered rather as a curiosity of surgery than as a guide to practice. Tracheotomy may sometimes be required to prevent suffocation in the latter stages of the disease. It occasionally happens that, even in a case of non-malignant stricture, the passage is so tightly occluded that the smallest instrument cannot be intro- duced, and the patient is in consequence reduced to a state in Avhich death from starvation is imminent. Under such circumstances, it has naturally been suggested that an opening should be made into the alimentary canal beloAV the seat of stricture, and a fistulous orifice thus established, through which the patient might be fed ; and it has been reasonable argued that though such an operation might not be justifiable in a case of malignant dis- ease, from Avhich the patient must inevitably perish at no remote period, yet that in a case of impermeable fibrous stricture, the circumstances Avould be altogether different. The operations Avhich have been performed in these cases are oesophagotomy and gastrotomy, or, as Sedillot, its introducer, has more acurately termed it, gastrostomy. (Esophagotomy for Stricture is manifestly best adapted to cases in which the obstruction is in the uppermost part of the tube, and unfortunately the stricture usually extends to such a point as to prevent the surgeon from reaching the oesophagus beloAV it. In a suitable case, hoAvever, the operation might be tried, the necessary incisions being those described in speaking of oesophagotomy for the removal of foreign bodies (p. 356), though the pro- cedure, in the case of stricture, Avould, of course, be more difficult on account of the impossibility of introducing an instrument into the gullet as a guide upon which to cut. If the stricture Avere of a non-malignant character, it might be proper to attempt a radical cure by extending the incision through the contracted part, as in the analogous operation of external urethrotomy. Oesophagotomy for stricture appears to have been suggested by Stoffel, but was first practised in a case recorded by Taranget, whose patient survived sixteen months. The operation has since been repeated by J. Watson, De Lavacherie, Monod, Richet, Von Bruns (tAvice), Willett, Billroth, Evans, Horsey, Bryk, and Schede (twice). Of the Avhole 14 cases, at least ten terminated fatally in a period varying from a feAV hours to three months. INTRODUCTION OF THE STOMACH TUBE. 747 This record is certainly not very encouraging, but, as will be presently seen, is far more so than that of gastrostomy—and as the operation, though diffi- cult, is not necessarily dangerous, it may, I think, be looked upon as a legiti- mate surgical resource. Gastrostomy is, as its name implies, an operation designed to establish an artificial mouth, communicating directly Avith the stomach. Its perform- ance is naturally suggested by observation of the success Avith which gastric fistula; can be established in the lower animals, of the recoveries Avith per- sistent fistula? which are occasionally met Avith after penetrating wounds of the stomach, and of the remarkable success which has attended gastrotomy, or gastric section for the removal of foreign bodies (see p. 374). Sedillot, who first performed the operation, recommends a crucial incision on the left side of the abdomen, over the gastric region ; the peritoneal cavity being opened, the surgeon feels for the left border of the liver, which is the guide to the stomach, and having reached the latter organ, draws it forAvards with forceps, and fixes it in the wound by perforating the gastric Avail Avith a steel- pointed ivory cylinder, secured externally on a disk of cork ; after some days, Avhen adhesions haA^e formed, an opening is made into the middle of the sto- mach, at a point equidistant from either curvature, and from either extremity. Forster, Durham, Verneuil, and others, prefer a single incision in the line of the left linea semilunaris, open the stomach immediately, and stitch the mar- gins of the aperture closely to the abdominal parietes. Verneuil insists that the gastric opening should be a small one. Xo attempt should be made to introduce food into the stomach until several days after the operation, lest primary union should be interfered with. Gastrostomy has noAv been performed in 34 cases, Sydney Jones having operated three times, and Forster and Sedillot each twice, Avhile single cases have been recorded by Fenger, Curling, Durham, Vonthaden, Lowe, Maury, T. Smith, MacCormac, Clark, Troup, F. Mason, Bryant, Jackson, Jacobi, Tay, Hjork, Heath, Mackenzie, Verneuil, Lannelongue, Risel, Bradley, Trendelenburg, Kuester, Callender, HoAvse, and Schonborn; Maunder attempted the operation, but after the death of his patient found that the colon had been opened instead of the stomach. Of the 34 cases above enumerated, all but tAvo (Verneuil's and Trendelenburg's) appear to have terminated fatally in periods varying from a feAv hours to three months—a gloomy record which affords little encouragement for a repetition of the pro- cedure. Enterostomy, or an operation designed to provide an opening for the intro- duction of food into the small intestine, has been suggested by Surmay. a French surgeon, but does not appear to have been practised on the human subject. Introduction of the Stomach Tube—This may be required in cases of narcotic poisoning, in Avhich vomiting cannot be excited, or as a means of administering fluid nutriment, in cases in Avhich the patient cannot or will not SAvalloAv. The tube is introduced in the same manner as an oesophageal bougie, and the folloAving description Avill apply to the use of either instrument. The patient is placed in a sitting posture Avith the head throAvn backAvards, so as to bring the mouth and gullet as nearly as possible into the same line ; the mouth being held widely open (by means of a gag if necessary), the surgeon pusses the tube, previously warmed and oiled, directly backAvards to the pharynx Avithout touching the tongue, and guiding the in- strument over the epiglottis with the forefinger of the left hand, cautiously presses it onAvards into the stomach. If any obstruction be met with, the 748 DISEASES OF THE MOUTH, JAWS, AND THROAT. instrument should be slightly withdraAvn and then again pushed forAvards, very gently, however, lest the oesophageal Avail should be perforated. When food is to be introduced into the stomach, the surgeon may employ a small gum-elastic bag, provided Avith a nozzle Avhich closely fits tbe projecting por- tion of the tube; when it is designed to wash out the stomach, a pump is required, by Avhich one or two pints of tepid water may be injected and a less quantity immediately pumped out again, the process being repeated until the returning fluid is colorless : the object, of not completely emptying the stomach at once, is to prevent the mucous coating of the organ from being sucked into the orifice of the tube and thus lacerated. The risk of passing a stomach-tube into the trachea instead of the oesopha- gus is not entirely imaginary, as is shown by cases in Avhich, after death, food and medicines have actually been discovered in the lungs. Diseases of the Air-Passages. Laryngitis, Tracheitis, Croup, Diphtheria, and other affections involving the larynx and trachea, are commonly treated by the physician, and are described in Avorks on the Practice of Medicine. These diseases are chiefly interesting to the surgeon on account of the necessity Avhich occasionally arises for a resort to the operation of laryngotomy, or to that of tracheotomy, the comparative merits and modes of performing which have been already suffi- ciently discussed in a previous portion of the volume (pp. 3~>1-351). The results of tracheotomy for diphtheria, in this country, have, I believe, not been very favorable, but the statistics of Wilms, of Berlin, show 103 recove- ries in 335 cases, a proportion of nearly 31 per cent. Abscess of the Larynx is a rare affection which has been well de- scribed by Parry, of this city, and by Stephenson, of Edinburgh; the treatment consists inmakingan early incision, and preferably in the median line of the neck. Tracheocele, or hernia of the lining membrane of the trachea, is a rare affection Avhich has recently been Avell described by Devalz, of Bordeaux. It appears to originate from violent and repeated attacks of coughing, and is chiefly interesting from the likelihood of its being mistaken for goitre; it admits of no treatment. Tumors, Warts, or Polypi of the larynx are sometimes met Avith, belonging usually to the fibro-cellular, papillary, or epitheliomatous varieties of tumor. They produce hoarseness, aphonia, croupy cough, and dyspnoea, the difficulty of breathing recurring paroxysmally, and eventually causing death by suffocation. A flapping sound may often be heard as the tumor moves up and doAvn in the act of breathing, and, by the use of the laryngoscope, the size and position of the morbid groAvth may be sometimes accurately determined. Treatment___In any case in Avhich respiration is or has been at any previous time seriously embar- rassed, there should be no delay in opening the trachea and inserting a tube ; for experience sIioavs that fatal dyspnoea may in such a case supervene at any moment, and, besides, a preliminary tracheo- tomy Avill greatly facilitate any operation for the Epithelioma of larynx. (Erich- removal of the tumor. Various plans may be 8en-) adopted in dealing with the neAv groAvth itself: thus DISEASES OF THE AIR-PASSAGES. 749 an attempt may be made to extract it by means of a wire snare or ecraseur (Fig. 412), as has been successfully done by Walker, Gibb, Johnson, and Fig. 412. Glbb's laryngeal icraseur. others ; or delicate laryngeal forceps, as advised by Mackenzie, may be used to twist off or crush the tumor ; or, if too firmly attached, this may be cau- tiously excised with the knife, scissors, or " laryngeal guillotine," or may be severed by the application of the galvanic cautery; simple puncture may suffice in the case of a cystic groAvth, while in other instances a.cure may perhaps be effected by the repeated application of nitrate of silver in substance or solution. The latter mode of treatment may also be employed to prevent repullulation of the tumor after extirpation. In all of these methods, the ap- plication of the instrument should be guided by the use of the laryngoscope. Voltolini has removed soft polypi by simply swabbing out the larynx with a sponge attached to a flexible wire. To facilitate treatment by any of the above plans, Eysell suggests that the tumor should be pushed upAvards by means of a needle introduced from beloAV in the median line of the trachea. To render the larynx less sensitive, Tiirck and Schrotter advise the successive application of chloroform and of a saturated solution of acetate of morphia. Another method is to open the crico-thyroid membrane and divide the thyroid cartilage, so as to expose the interior of the larynx and allow free excision of the morbid groAvth Avith knife or scissors : this operation appears to have been first successfully performed by Ehrman, and has since been repeated by Holt- house, Holmes, Durham, Buck, Sands, Cohen, Czerny, and others. Krish- aber, of Paris, has recently recommended, under the name of Restricted Thyroideal Laryngotomy, an operation in which the thyroid cartilage alone is divided in the median line, this incision being in his opinion ample for the removal of polypi situated in the ventricle of Morgagni ; the vocal cords are not interfered Avith, and the voice is consequently uninjured by the operation, Avhich is in this respect decidedly preferable to that of Ehrman. Finally, in some cases, Malgaigne's operation, described at page 743, under the name of Sub-hyoidean Pharyngotomy, may perhaps be preferred to any other. Dr. Sands has tabulated 50 cases of laryngeal tumor treated by operation ; in 11 the growth Avas removed by external incision, and in 9 of these the patients recovered ; in 3'J cases the tumor was removed by the mouth, and recovery folloAved in 38. The operation Avas performed with the aid of the laryngoscope in 34 cases. Still more extended statistics have been published by Mackenzie and Durham, those of the former author showing conclusively that, Avhen applicable, laryngoscopic treatment is much preferable to the ope- ration by external incision. The following table is condensed from Durham's article in Holmes's System of Surgery, and from a paper by the same Avriter in the Medico-Chirurgical Transactions, vol. Iv. r50 DISEASES OF THE BREAST. Operation. Whole No. of cases. Complete-ly success-ful. Partially success-ful. Unsuc-cessful. Died. x>t termi-nated. Application of caustics, etc. . Forceps ....... Galvanic cautery .... Operation by external section 16 37 32 5 20 4 40 12 33 28 3 14 4 22 4 3 3 2 5 7 "i i i ... "2 "2 Extirpation of the Larynx has been performed by several surgeons, including Billroth, Heine, Bottini, Schmidt, Schbnborn, Maas, Gerdes^ Wegner, and Foulis. In most if not in all of these cases the operation Avas done for papilloma or some form of malignant disease, and Heine has also excised the anterior portion of the larynx for chronic thickening of the cartilage. Langenbeck has excised not only the entire larynx, but the hyoid bone, and portions of the tongue, pharynx, and oesophagus ; a week after the operation, the patient Avas reported as doing well. Lennox BroAvne has collected 13 cases of extirpation of the larynx, of Avhich 6 terminated fatally. Stricture of the Trachea has been already referred to at page 344. CHAPTEE XXXIX. DISEASES OF THE BREAST. Hypertrophy of the Breast may occur during the early months of pregnancy (Avhen it may disappear spontaneously after confinement), or may be met with in young girls, originating usually Fk. 413. at the period of puberty, and increasing until the bulk and Aveight of the enlarged gland prove a source of great inconvenience, and even of suf- fering. Labarraque has collected 32 cases of this affection, in one of Avhich (Durston's) the en- larged breast attained the enormous Aveight of 64 pounds. Both mammas are commonly affected, though not to the same extent. The treatment of this affection is usually unsatisfactory. Local applications of belladonna and iodine, with com- pression, may be tried, Avhile attention is given to the state of the patient's general health, and to the removal of any uterine disorder that may be present. As a last resource, excision of the hypertrophied mass may be employed, but the operation should be reserved for extreme cases. Occasionally the removal of one hypertrophied Simple hypenrophy of breasts, breast has been folloAved by rapid diminution (Bryant.) in the size of the other, and recovery of the FISSURES AND EXCORIATIONS OF THE NIPPLE. 751 patient. Hence, though both mamma? be enlarged, only one should be re- moved at first, in hope that the other may return to its normal condition. The enlargement sometimes disappears spontaneously after matrimony. Galactocele or Milk-Tumor consists in an accumulation of milk, in either a fluid or a concrete condition, due to obstruction of one or more of the lactiferous ducts, from inflammation, or from the presence of a calcareous nodule—the latter constituting Avhat is called a lacteal or mammary calculus. The quantity of milk which is found in these lacteal tumors is sometimes enormous. Birkett quotes from Scarpa the case of a Avoman aged twenty, in Avhom, tAvo months after delivery, the breast Avas thirty-four inches in cir- cumference, and rested on the thigh. The introduction of a trocar and canula allowed the evacuation of ten pints of fluid, wliich, by chemical ex- amination, Avas shoAvn to be normal human milk. Le Gros Clark has recorded a remarkable case in which two pints of milk Avere found in a large cystic adenocele. The treatment in these cases consists in making an opening into the tumor, this being probably best done, as advised by Cooper, by introducing a trocar and canula, obliquely from the nipple tOAvards the seat of accumulation, so as to leave a fistulous passage for the discharge of the milk. The child should, at the same time, be Aveaned (if the Avoman is suckling), and an attempt should be made to arrest the secretion by the local use of belladonna, the internal administration of iodide of potassium, etc. In those cases in Avhich the accumulated milk is coagulated, an effort should be made to promote ab- sorption by gentle friction and kneading Avith warm olive oil, or some other unirritating substance. Should these means fail, the tumor must be incised, Avhen suppuration and subsequent healing Avill follow. The operation should not, however, be performed during pregnancy, lest abortion follow, an event which did occur, and with a fatal result, in one of the cases collected by Birkett. The treatment of lacteal calculus, Avhich appears to be the result of calcareous degeneration in the seat of old inflammation, consists in ex- cision. Fissures and Excoriations of the Nipple and Areola consti- tute the affection commonly known as Sore or Cracked Nipple, and are par- ticularly apt to be met with in the early periods of lactation, and after first labors. Beside interfering Avith the process of suckling, on account of the in- tense pain produced by putting the child to the breast, these cracks or fissures are apt, if neglected, to lead to acute inflammation of the nipple, if not of the mammary gland itself. This affection is sometimes traceable to contact of the delicate skin of the part Avith aphthous ulcerations in the child's mouth. The fissures, if deep, sometimes bleed, and the blood, being swallowed by the child while nursing, may be subsequently vomited. I have knoAvn a child only a feAV Aveeks old to be .dosed Avith styptics, by direction of the practitioner in attendance, in order to check supposed lnematemesis, until an inspection of the Avet-nurse's breast, by another physician called in consultation, revealed the source of the vomited blood in a fissured state of the nipple. The treatment of cracked nipple consists in the employment of frequent ablutions, and in the use of astringent washes, such as those containing borax, alum, tannin, or catechu, with emollient ointments, such as that of oxide of zinc. The-application of nitrate of silver, in substance or solution, to the bottom of the crack, is an efficient but very painful remedy. Collo- dion, or the styptic colloid of Prof. Eichardson, is useful in protecting the part from irritation. A large number of salves and ointments of different kinds are in popular use in the treatment of excoriated nipples, but are, Avith 752 DISEASES OF THE BREAST. feAV exceptions, more often injurious than otherwise. The compound resin cerate of the U. S. Pharmacopoeia has, under the name of Deshler's salve, acquired in this community a high reputation as a remedy for sore nipples. Fleischman speaks very favorably of a preparation containing lactate of zinc Avith glycerine and starch, Avhile Charrier highly commends a solution of picric acid. Whatever substance be employed, it should, for obvious reasons, be carefully Avashed off before applying the child to the breast. Nipple-shields of lead or other metal, or of India-rubber, are recommended by some authors as a means of protecting the part during the act of suckling. I should add that Le Diberder advises the administration of quinia in large doses, and considers local treatment of secondary importance. Abscess of the Areola is to be treated by the application of emollient poultices, and by the early evacuation of the contained pus. The incision made for this purpose should be in a line radiating from the nipple towards the circumference of the breast, so as to avoid Avounding any of the milk- vessels—an accident, the occurrence of wliich might lead to the formation of a troublesome fistula, or to permanent occlusion of the duct. Condition of the Areola preceding Mammary Cancer__ Paget has recently described a granular state of the nipple and areola, in Avhich the part resembles the glans penis when attacked by balanitis, and which he has observed in fifteen cases, in each of which cancer attacked the neighboring mammary gland within tAvo years. Should such a condition be recognized, early excision would be indicated as a prophylactic measure. Mammitis (Mastitis, Mazoitis, Inflammation of the Breast, Mammary Abscess, Gathered Breast)___Inflammation of the breast may occur during any stage of lactation, more rarely during pregnancy, or even at other periods. It is, perhaps, most common a few days after delivery—when it occurs as an exaggeration of the natural raptus, or determination towards the mammary glands, which accompanies the establishment of the fioAV of milk—and again tOAvards the end of lactation, when, the functional activity of the glands being exhausted, these organs appear to resent the effort to force a continuance of the secretory act. The occurrence of this affection is often traceable to expo- sure to cold, to injury (as from sleeping with the distended breast compressed between the arm and body), to overdistension, from a neglect to suckle the child at proper intervals, or to the irritation produced by a cracked nipple. The symptoms of mammitis vary somewhat according to the seat of the inflammation, Avhether in the supra-mammary or submammary areolar tissue, or in the structure of the gland itself. In supra-mammary inflammation, the symptoms are those of ordinary phlegmonous inflammation in any situa- tion ; the affection is usually circumscribed, the resulting abscess rarely (ac- cording to Birkett) exceeding one or two inches in diameter. The skin over the seat of inflammation is, in these cases, red from the very beginning of the affection, the redness often preceding the other signs of the disease. The symptoms of submammary inflammation are more obscure ; the form of the swelling is, however, characteristic in these cases, the whole breast being thrust forwards, and assuming a conical appearance. This is a more serious affection than that last described, suppuration folloAving more constantly, and the abscess sometimes discharging itself by numerous openings around the circumference of the gland. In inflammation of the mammary gland itself, one or several lobes may be involved, the SAvelling in the latter case sometimes presenting a distinctly lobukted appearance. The skin over the inflamed MAMMITIS. 753 part becomes oedematous, and, when suppuration is impending, assumes a dusky-red and polished appearance. Treatment__The constitutional treatment of inflammation of the breast consists in the administration of mild laxatives and anodyne diaphoretics, during the early stages of the affection, Avhen there is often much fever and general sympathetic disturbance, folloAved by tonics, Avhen suppuration has occurred. The patient's diet should be nutritious and abundant throughout the Avhole course of the affection, and malt liquors, or even more powerful stimulants, are often required in the later stages of the disease. An almost infinite variety of topical remedies has been recommended, and every nurse and neighbor of the patient, is usually provided with at least one infallible cure ; these volunteered prescriptions are, hoAvever, more often adapted to aggravate than to alleviate the patient's condition. Leeches are advised by many authors, but, beside debilitating the patient by the abstraction of blood, often seem to hasten, rather than to prevent, suppuration ; if employed at all, they should be applied, as advised by DeAvees, beloAV rather than immediately over the affected surface. Rest of the inflamed organ is of the highest im- portance ; to secure this, the breast should be supported in a sling, or in an elastic suspensory bandage (such as is in this city made for the purpose), and the arm should be kept to the side, so as to prevent motion of the pectoral muscle. The application of cataplasms, or of Avarm, emollient fomentations, is commonly both more soothing to the patient and more eflicient than the use of evaporating lotions. Gentle and methodical friction with warm olive oil and laudanum, when it can be borne, is a valuable adjuvant to the other remedies employed. Belladonna plasters are used by many surgeons, and are supposed to arrest the Aoav of milk ; they have, in my own experience, rarely been of much service. Dr. Dugas, of Georgia, recommends methodical pressure with a bandage. As long as there is a prospect of obtaining resolution, the breast should be kept constantly exhausted, either by suckling, or, if this give too much pain, by the use of a breast-pump. When suppuration has occurred, the child should, I think, as a rule, be weaned; few women can, Avithout injury, sus- tain the drain of a mammary abscess superadded to that of lactation, while the milk furnished under these circumstances is necessarily unsuited for a child's nutriment. When an abscess has formed, the use of poultices should be continued, and as soon as decided fluctuation is manifested, a free incision should be made, in a line radiating from the nipple to the periphery of the breast. In most instances, the exact spot at Avhich the opening should be made will be indi- cated by the occurrence of pointing, but should this indication not be present— as Avill often be the case if the abscess originate in the submammary region— the incision should be made where fluctuation is most distinct, and, if possible, preferably I think at the upper part of the breast; this advice is contrary to that usually given, an opening in the most depending situation being com- monly recommended ; but the advantage of the superior incision, is that, in the after-dressings, it allows the walls of the abscess to be more closely brought together by strapping. As prolonged suppuration is undesirable, poulticing should be discontinued a feAV days after the opening of the abscess, and a piece of oiled lint, or a little simple cerate, laid over the wound. The breast should then be carefully strapped (Fig. 414), strips of adhesive plaster being applied in an imbricated manner, so as to firmly support and gently compress the whole organ. In some instances, particularly if the case have been neglected in its early stages, several openings form, Avhich may persist and degenerate into troublesome sinuses; these may usually be induced to heal by careful strapping, and by 48 754 DISEASES OF THE BREAST. the use of stimulating or astringent injections—tonics and concentrated food being at the same time freely administered—and if these means fail, the establishment of a seton (as recommended by Dr. Physick) should be tried, before resorting to the extreme measure of laying open the sinuses with the knife. Fig. 414. Mode of supporting the breast by strapping. (Druitt.) Chronic or Cold Abscess of the Breast is to be treated by making an opening in a convenient situation, and, if necessary, introducing a drain- age tube, the breast being supported by strapping, while the general condi- tion of the patient is improved by the administration of tonics and nutritious food. The arm should be kept to the side and supported in a sling. Encysted Abscess is chiefly interesting on account of its having been frequently mistaken for solid tumor, and excision of the breast having, as a consequence, been unnecessarily performed. The diagnosis may be made by observing that abscess almost invariably originates during the pregnant or puerperal state, is not distinctly circumscribed, nor freely movable, is accom- panied with subcutaneous oedema, and is commonly elastic, if not positively fluctuating. The exploring needle may be used in any case of doubt, and should ahvays be employed before resorting to excision. The treatment of encysted abscess consists in the evacuation of the contained pus, and the sub- sequent formation of a seton or the use of stimulating injections, to promote the healing of the cavity. External support should at the same time be af- forded by strapping. The induration in these cases may persist for a very long period. Neuralgia of the Breast.—This is a distressing affection Avhich may occur in connection with small glandular or other mammary tumors, or may exist independently of any discoverable local lesion. It is, according to Erichsen, commonly associated with uterine derangement. The treatment is that of neuralgia in general; tonics, such as iron and the valerianate of TUMORS OF THE BREAST. 755 zinc, are usually indicated, and, as topical remedies, plasters of belladonna or opium Avill often be found serviceable. If the neuralgic condition be depen- dent upon uterine irritation, this must of course receive due attention. Tumors of the Breast. The female breast is very frequently the seat of tumors, the chief forms of morbid groAvth of a non-malignant character met Avith in this situation being the cystic (simple or proliferous) and the glandular, though fibrous, sarcoma- tous, cartilaginous, and osseous tumors are likewise occasionally found in the breast, as are also true hydatids, scrofulous and tuberculous deposits, etc. Of the malignant groAvths, scirrhus is by far the most frequent, encephaloid coming next, and colloid and melanoid cancer being comparatively rare. Cystic Tumors of the Breast—1. Simple Cysts___These are com- monly single or unilocular, although multiple or multilocular cysts are also found in the breast. The most common variety is the serous cyst, but oily cysts are also sometimes met with in the mammary region. The pathology and general characters of these groAvths have already been considered (pp. 4G3, 464). and it merely remains to be stated that they commonly occur in young and otherAvise healthy persons, increase very sloAvly in size, are rarely painful (except perhaps at the period of the menses), have a globular appear- ance, and an elastic or even fluctuating feel, are movable, occupy usually a limited portion of the breast, do not implicate the neighboring lymphatic glands, and are rarely attended Avith retraction of the nipple, or discoloration of tbe superjacent skin. If, hoAvever, a unilocular cyst be very large, and the skin over it thin and tense, the hue of the contained fluid may be apparent through the integument, or the tumor itself may be translucent, the affection being then sometimes designated as Hydrocele of the Breast. If, as sometimes happens, the cyst communicate with a milk duct, pressure may cause a small quantity of fluid to exude from the nipple. Diagnosis___The diagnosis of simple mammary cysts, if superficial, is attended with little or no difficulty, but if deep-seated these growths may be readily mistaken for cancer. Hence, in any case of doubt, the surgeon should not neglect the use of the exploring needle. Fig. 415. Brodie's sero-cystic sarcoma. (Druitt.) Treatment___If the cyst be single or unilocular, a cure may sometimes be effected by the application of stimulating embrocations, such as the tincture of camphor with lead-water, or the tincture of iodine. Should these means 756 DISEASES OF THE BREAST. fail, the cyst may be punctured and a seton established, or stimulating injec- tions, with pressure, may be employed, so as to induce adhesion of the cyst walls ; or a free incision may be made, and the cavity stuffed with lint, so as to convert the cyst into an abscess. Finally, if the cyst Avail be thick, tbe whole tumor may be dissected out, the mammary gland itself being alloAved to remain. In cases of multiple, or of multilocular cysts, excision is the only mode of treatment, to be recommended ; and it may even be proper, in some instances, to remove the whole gland, so as to insure thorough extirpation. 2. Proliferous Cysts with Vascular Intra-cystic Growths—The breast is the favorite seat of this A-ariety of cyst, Avhich constitutes the Sero-cystic Sar- coma of Sir Benjamin C. Brodie (Fig. 415). Its pathology, mode of growth, and symptoms, and the means by Avhich it may be diagnosticated from a cancerous growth, have already been sufficiently referred to (page 405). The only treatment likely to result in a permanent cure, is complete excision of the affected breast. Glandular Tumor of the Breast (Adenoid Tumor, Adenocele, Chronic Mammary Tumor)__This affection appears sometimes to originate as a proliferous cyst, the intra-cystic groAvth gradually encroaching upon and filling the cavity of the cyst, Avhich is thus converted into a solid tumor. The glandular tumor usually occurs in young women, and often accompanies irri- tation or other derangement of the reproductive organs. It is usually of sIoav growth (occasionally, hoAveA-er, increasing very rapidly), commonly painless, except, perhaps, at the menstrual periods, movable, circumscribed, and Avith a curved outline ; it is someAvhat nodulated, and does not implicate the neigh- boring lymphatic glands. Though often apparently isolated and unattached, this form of tumor is, according to Birkett, invariably connected with the tissue of the mammary gland—sometimes by a narrow peduncle—and is in- closed Avithin the fascia of that organ. A section of the growth presents a somewhat granular appearance, and is at first of a bluish-white color, becom- ing, by exposure to the air, pinkish, and finally quite red. A viscid, glairy, synovia-like fluid may be sometimes expressed from the cut surface of the tumor, but is very different in character from the " cancer-juice" of scirrhus. By microscopic examination, the chronic mammary tumor is found to consist of gland-structure in various stages of development, surrounded by an invest- ment of areolar tissue which divides the groAvth into minute lobules (see Fig. 209); the caecal terminations of the gland-tubes contain epithelial scales. According to Eanvier, VirchoAv, and other modern pathologists, these groAvths are really fibrous, sarcomatous, or myxomatous tumors, in which the presence of hypertrophied gland structure is a mere secondary phenomenon. These tumors frequently contain cysts, and sometimes attain to a very large size ; as in a case reported by Le Gros Clark, in which an adenocele weigh- ing in all eleven pounds contained in a cyst no less than two pints of milk. Treatment—These growths sometimes cause little or no inconvenience, and remain without change for many years ; this circumstance, together with the fact that their removal has sometimes been followed by a development of cancer in situ, should make the surgeon hesitate to recommend excision in any case in which the tumor is indolent and not increasing. Under such circumstances, the treatment should consist simply in the adoption of mea- sures to improve the general health, with the application of sorbefacients and compression. Should, hoAvever, the tumor assume a rapid growth, or should its presence be the source of anxiety to the patient, excision may be prac- tised, and usually with excellent results. In such a case, it Avill commonly be sufficient to remove the tumor itself, with that lobe of the gland to which it is attached. CANCER OF THE BREAST. 757 Painful Mammary Tumor (Irritable Tumor of the Breast)___Two varieties of tumor are embraced under this name, one of an adenoid or glan- dular character, and the other a.true "painful subcutaneous tubercle" (see page 478). The treatment consists in the administration of tonics, with com- pression, and the local use of anodynes—or in excision, which may be con- fidently expected to giAe permanent relief. Sarcomata of the Breast are chiefly of the round-celled or spindle- celled (fibro plastic) variety, though myeloid (giant-celled) growths are also occasionally met with in this locality. Mammary sarcomata often contain cysts, Fig. 416. and are sometimes indistinguishable from encephaloid groAvths without microscopic examination. The treatment consists in excision, but the growth is apt to recur. Cancer of the Breast. — The breast is the favorite seat of Scirrhus, which is also the most frequent form in Avhich cancer occurs in this locality. Atrophic Scirrhus is a term used by Collis, and some other Avriters, for those forms of scirrhous cancer which reduce the organ in Avhich they are seated below the normal size, while the term Larda- ceous Scirrhus is used to designate those tumors in which, along with the Cancer Mammary sarcoma with large cysts; the ,, , . , , . ,. . tumor weighed over six pounds. (From a Cells, there IS also a deposit of a large patient In the Episcopal Hospital., quantity of fat—the name aptly indicat- ing the braAvny feel and appearance (like that of a hog's skin) which is ob- served in these cases. The lardaceous cancer must not be confounded with the cancer " en cuirasse" (p. 487), which commonly runs a course as chronic as that of the other is acute. Encephaloid of the breast is a much rarer affection than scirrhus, the pro- portionate number of cases being variously estimated, by different writers, as from one-tiventieth to one-fifth. In some cases, the tumor appears, micro- scopically, to occupy an intermediate position betAveen scirrhus and encepha- loid, and to such growths the terms Acute Scirrhus and Firm Medullary Cancer have been applied. Melanoid and Colloid Cancer are also occasion- ally, but very rarely, found in the breast. Many cases Avhich Avould formerly have been considered examples of encephaloid cancer of the breast, are classed by modern pathologists as cases of round-celled or spindle-celled sarcoma. They are clinically quite as malignant as true cancers. Diagnosis.—The structure and microscopic appearance of these various forms of cancer, as Avell as their course and sympto.ms, have already been suf- ficiently described in Chapter XXVI., and I shall, therefore, in this place merely recapitulate those points which may serve to aid in the diagnosis be- tAveen scirrhus and non-malignant solid mammary tumors ; encephaloid is not likely to be confounded Avith any other tumor, except certain varieties of sarcoma which, clinically, are equally malignant. 758 DISEASES OF THE BREAST. Non.-malignant Tumors are somewhat no- dulated, not very hard, occasionally par- tially elastic, movable, and non-adherent. They are covered Avith healthy skin, except in the ulcerative stage of the sar- comata, and tbe skin even then does not appear infiltrated, as in the case of scir- rhus. The nipple is rarely retracted, and the superficial veins are not markedly dilated. There is seldom much pain, except in the case of the "irritable tumor," and then continuous, and of a neuralgic character. The neighboring lymphatic glands are not involved; there is no tendency to multiplication in internal organs, and, therefore, no cachexia; and the tumor, which grows slowly, rarely recurs if it have been thoroughly excised. (Sarco- mata, however, grow rapidly and are very apt to recur.) Non-malignant mammary tumors may occur at any age, but are most common in women less than forty years old. Scirrhus, on the other hand, originating as a small nodule, is from the first of a stony hardness, and soon becomes fixed and adherent to subjacent tissues, being evidently infiltrated1 among the structures in which it is developed. Tbe skin becomes widely involved, hav- ing a peculiar pitted or dimpled appear- ance, from the shortening of various sub- cutaneous fibres. In an extreme degree, this pitting gives the whole breast a brawny or lardaceous appearance. The nipple is commonly retracted, ft»d tKe superficial veins dilated. The pain is severe, but not continuous, of a lanci- nating or "electric" character. The neighboring lymphatic glands, par- ticularly those in tbe axilla and above the clavicle, become involved in the disease, which is often attended by a marked state of cachexia. The tumor usually grows pretty rapidly, is attended with ulcera- tion, often of a peculiar character (p. 484), and frequently recurs after apparently thorough removal. Scirrhus is seldom met with in persons under forty years of age. Prognosis___The prognosis of cancer of the breast is, of course, unfavora- ble. The most rapidly fatal cases are those of encephaloid, and of lardaceous scirrhus, and the least so, those which assume the atrophic form. The latter are chiefly met with among old persons, and, the course of the disease being chronic, death may ensue from some other cause. In the cuirass-tike form of the affection, again, life is often prolonged for a considerable period ; in these cases the virulence of the disease appears to be expended mainly upon the skin, the lymphatic glands and internal organs not being implicated until at a comparatively late stage. Treatment—The only treatment Avhich offers any prospect of permanent benefit, in cases of mammary cancer, is excision of the tumor, together Avith the Avhole mammary gland—though, as palliative measures, compression and the application of cold may occasionally be of service (see page 493). If the tumor, though in the region of the breast, do not appear to involve the mam- mary gland, it will usually be sufficient to remove that portion of this organ which is nearest the cancerous mass—unless the tumor be below or on the sternal side of the gland, Avhen, as the latter becomes infiltrated at an early period, total excision should be practised. Operative measures are not, however, to be indiscriminately resorted to in every instance. Certain cases are totally unsuited for excision :—such are those in wliich there are multiple tumors ; in which there is extensive impli- cation of the lymphatic glands, particularly of those above the clavicle ; in which the disease appears to have involved internal organs ; in which there is Avide-spread ulceration; or in which the whole integument of the breast is braAvny and lardaceous. The presence of any of these conditions Avould forbid the hope of being able to effect thorough extirpation, and Avould therefore render operative interference improper. Nor, again, would excision be, as a 1 A remarkable case of capsulated scirrhus has, however, been recently recorded by Cullingworth, of Manchester. EXCISION OF THE MAMMARY GLAND. 759 rule, advisable, in a case of atrophic or cuirass-like cancer, occurring in an old person, nor in any case in Avhich, from the general condition of the pa- tient, or from other circumstances, the operation vyould probably be in itself attended with unusual risk. Excluding all these cases, however, there re- main a large number—probably a majority—in which early excision is highly desirable, and in Avhich the surgeon should urge its performance. The rea- sons upon which this advice is grounded have already been given (page 494). Slight brawniness of the integument, limited ulceration, moderate adhesion to subjacent structures, or even slight lymphatic implication, though unfavor- able circumstances, do not necessarily contra-indicate the operation. While no rule of universal application can be laid down upon this subject, the sur- geon Avill not, I think, haA'e cause to regret his decision, Avho operates in those cases (and those only) in which it appears practicable to safely extir- pate the entire mass of disease. When excision is to be done at all, it should be done as soon as the nature of the case has been ascertained, there being no advantage to be gained by delay. Caustics may be employed in some rare cases to Avhich the knife may be deemed inapplicable (see page 494). Re- current growths should be removed as soon as detected, Avith the same limi- tations as in the case of the primary tumor. Excision of the Mammary Gland__The operation is thus per- formed : The patient, being in the recumbent posture, is thoroughly ether- ized, and her clothing so arranged as fairly to expose the breast and upper extremity. The arm is then held out of the Avay by an assistant, in such a manner as to render tense the fibres of the pectoral muscle. If the tumor be non-malignant and of moderate size, a single incision Avill suffice ; this may be a simple oblique cut in the direction of the muscular fibres ; or, if more room be required, may be made in the form of a double curve, or S. In the removal of malignant groAvths, hoAvever, the affected portion of integument must itself be excised; and here tAvo semilunar incisions may be employed, one below and the other above the nipple, Avhich is included between them, or a double S incision (Fig. 230), or, if the tumor be very large, an oblique Fig. 417. Excision of the breast. (Fergusson.) incision over its upper part, and tAvo shorter longitudinal incisions meeting beloAV the nipple, Avhich is thus removed with a triangular portion of the skin. In other cases, again, the surgeon may prefer a circular or an oval incision around the nipple, as advised by the late Mr. Collis, of Dublin. The par- 760 DISEASES OF THE BREAST. ticular line of incision is a matter of but small importance, provided that care be taken to remove every part of the integument which appears adherent or infiltrated. Having completed his external incisions, the surgeon dissects rapidly down to the pectoral muscle, and turns up the edge of the mammary gland (Fig. 417), Avhich may then often be separated by the fingers, aided by a feAV strokes of the knife. In other cases, a portion of the pectoralis itself may require removal, and I have occasionally been obliged to carry the dissec- tion so deep as to expose even the surface of the ribs and the intercostal muscles. When by careful examination of both tumor and Avound, the surgeon has satisfied himself that all the diseased structure has been removed, attention should be directed to the state of the axillary glands. It may happen that a single gland is enlarged, but not markedly indurated, and that it is so, appa- rently, as the result of transmitted irritation, rather than from being itself carcinomatous. Under such circumstances, the axilla should not be inter- fered Avith, the gland being AAratched, hoAvever, and, if necessary, subsequently removed by a separate operation. If the axillary glands are evidently in- volved in the disease, though not so extensively implicated as to forbid opera- tive treatment altogether, it is usually advised that they should be removed, the upper extremity of the incision being extended as far as necessary for this purpose. This is the course which I have myself ahvays pursued, and it is, as mentioned, in accordance Avith the teaching of most authors. It is but right to add, hoAvever, that the late Mr. Collis (for whose opinion I have the highest respect) deprecated incisions into the axilla in almost all cases, be- lieving that such incisions were apt to be followed by the development of lardaceous cancer of the arm and side, and that they Avere likely to hasten the death of the patient. When axillary glands are to be removed, they should as far as possible be enucleated with the fingers and handle of the scalpel, rather than excised—the use of the edge or point of the knife being, in the deep portions of the axilla, attended with considerable risk. If the implicated glands should unfortunately be so deeply attached as not to admit of complete removal, the best that can be done is to draw doAvn the mass and throAv a strong ligature around its base, cutting off the part below the seat of strangulation, in hope that the remainder may be destroyed by sloughing. The Avound left by the operation of excision of the breast, should be simply dressed. A few ligatures only are commonly required; the lips of the Avound are brought together Avith a few points of suture, or with adhesive strips, a piece of oiled lint, covered Avith oiled silk, being then applied, and held in place with strips of plaster or a light bandage. The arm should be laid across the chest, so as to relax the parts, and thus facilitate union, but should not be closely confined. The mortality from the operation is small, in view of the extent of the Avound, being, even in hospital practice, less than ten per cent. Of 147 cases of mammary cancer operated on by Syme, only 10 terminated fatally, Avhile the result in ok excisions of the breast for non- malignant tumors Avas uniformly successful. The chief risks are from the development of erysipelas or pyasmia. Dr. B. W. Richardson has excised the breast with scissors, the parts being previously rendered insensible by using the ether spray, and the same plan has been since successfully adopted by Mr. Thomas Moore. The Mammary Gland in the Male may occasionally be the seat of disease ; thus it has been found hypertrophied, and has been known to furnish a secretion of milk, Avhile it is sometimes the seat of cystic groAvths, or of cancer. Wagstaffe has collected 71 cases of the latter form of disease occur- ring in this situation. The treatment is the same as for similar affections in the female. CAUSES OF HERNIA. 761 CHAPTER XL. HERNIA. The term Hernia signifies a protrusion of any portion of the viscera through an abnormal opening in the Avails of the cavity Avithin Avhich the protruded part is naturally contained. A protrusion through a normal aperture is not a hernia ; thus the term is never applied to a protrusion of the boAvel through the anus, or of the Avomb through the vulva. Hernia? of the brain and of the thoracic viscera, have already been considered in previous portions of the volume ; and the subject for discussion in this place is therefore limited to Abdominal Hernia, or, as it is famikrly called, Rupture. Any part of the abdominal parietes may give passage to a hernia, but rup- ture is most likely to occur Avhere the muscular and tendinous structures are comparatively weak, as Avhere the spermatic cord or round ligament issues from the abdomen, Avhere the femoral vessels pass into the thigh, or at the umbilicus. Causes of Hernia. The Predisposing Causes of rupture may be divided into such as pertain to the general condition of the patient, as age, sex, etc., and such as pertain to the local condition of the part in Avhich the hernia subsequently occurs ; the latter are called by Birkett the Inciting Causes. The Immediate or Exciting Cause of rupture, when any such can be alleged, is usually some violent exertion, as in lifting, coughing, or straining. General Predisposing Causes—1. Age—The majority of cases of hernia are developed in infancy, or early adult life ; more, that is, before the age of thirty-five years than afterwards. This statement is contrary to the ordinarily received doctrine, but has been clearly established by the researches of Mr. Kingdon (of the City of London Truss Society), Mr. Birkett, and Mr. Croft. As, however, the number of infants and young persons in every community is much larger than that of adults, the relative frequency of hernia is greater as old age approaches. Thus advancing age may be considered a predisposing cause of hernia. 2. Sex___The male sex is unquestionably more predisposed to the occur- rence of hernia than the female, the proportion for all ages and forms of the disease being, according to Croft, about three to one. The difference is most marked in infancy and early childhood, on account of the frequency of a con- genital malformation in the male, Avhich will be presently referred to. 3. Occupation___The majority of cases of hernia occur among the labor- ing classes, but there does not appear, according to Kingdon, to be any direct connection treaceable between the development of rupture and the pursuit of any particular occupation. 4. Inheritance___A predisposition to hernia is frequently inherited, the first year of life being that in which the hereditary influence is most marked. The anatomical peculiarities on Avhich the frequent occurrence of hernia at this early age depends, are, (1) imperfect closure of the ventral orifice of the vaginal process of the peritoneum, and persisting patulousness of that canal, 762 HERNIA. and (2) abnormal lengthening of the mesentery. The first-named malforma- tion is always, and the second often, probably, of congenital origin ; they will be again referred to under the heading of inciting causes. Local Predisposing or Inciting Causes—1. Wounds, etc—The occurrence of hernia is occasionally predisposed to by wounds or subcutane- ous lacerations of the abdominal parietes. Ventral hernia usually results under these circumstances (see page 367), but if the Avound be suitably situ- ated, inguinal, or any other form of hernia may ensue. 2. Weakening of the Abdominal Parietes, as the result of previous inflam- mation, abscess, etc., or from over-distension by the pressure of the gravid uterus, by the accumulation of fat in the omentum or mesentery, or by the development of ovarian tumors, or of ascites, may act as a predisposing cause of hernia. 3. A Patulous Condition of the Vaginal Process of the Peritoneum, or of its Ventral Orifice, is a frequent predisposing cause of hernia. It is known that the testicles are, in the earlier periods of foetal life, situated in the lum- bar region, whence they gradually descend into the scrotum. During their descent, they are behind and partially invested by the peritoneum, a prolon- gation of Avhich membrane accompanies them into the scrotum, where it forms the tunica vaginalis on either side. This vaginal process of the peritoneum at first forms one common sac with that of the peritoneum itself, and the communication between them often persists at birtb, or even a month or two later. Usually, hoAvever, about the period of birth, the vaginal process divides into tAvo portions, by the contraction of the sheath and the formation of adhesions between its sides, at about the position of the head of the epidi- dymis. The lower portion invests the testicle (forming the tunica vaginalis propria testis), Avhile the upper portion lies in front of the spermatic cord, and constitutes the tunica vaginalis propria funiculi. In the normal state, the tunica vaginalis of the testicle continues tlirough life as a closed sac, Avhile the tunica vaginalis of the cord becomes obliterated and coverted into a delicate fibrous band. It not unfrequently happens, hoAvever, that the funicular portion of the vaginal process persists as a tube of small calibre, closed at both ends, or, more rarely, that either its ventral or testicular ori- fice, or both, remain patulous. The testicular orifice is, of course, that by Avhich the funicular portion communicates in foetal life with the testicular portion of the vaginal process of the peritoneum, Avhile the ventral orifice is that by Avhich it communicates Avith the general cavity of the peritoneum, and corresponds in position with the internal abdominal ring. From the above brief anatomical description, it can be readily understood that a patu- lous state of the vaginal process, or of its ventral orifice, Avould predispose the person in whom it existed to the occurrence of rupture. 4. A Relaxed and Elongated Condition of the Mesentery acts as a predis- posing cause of hernia. That the mesentery is actually elongated, in many cases of hernia, can scarcely admit of a doubt—for the bowel could not descend as low as it is observed to do in the scrotum, Avere its mesenteric attachments not abnormally relaxed—but Avhether this relaxation and elonga- tion be a cause or consequence of hernia, is a different question; that it is often a cause of rupture, is rendered probable, as pointed out by Birkett, by the facts that (1) persons Avith a hernial sac are more troubled by the descent of a hernia when out of health than at other times ; (2) persons of a relaxed frame are more apt than others to become subjects of hernia, as they advrance in life ; and (3) in middle-aged persons of either sex, affected Avith hernia, the abdominal viscera generally are less firmly held in place by their peri- toneal attachments, than in those Avho have no disposition to hernia. This STRUCTURE OF A HERNIA. 763 elongation of the mesentery may, as just mentioned, be due to a relaxed state of the fibrous tissues, acquired at any period of life, or may probably, in some cases at least, be of congenital origin. 5. The Gradual Stretching and Protrusion of the Parietal Peritoneum at Aveak parts of the abdominal Avail, as the result of frequently repeated muscular exertion, of coughing, of straining at stool, or in urinating, etc., may act as a predisposing cause of hernia, by leading to the ultimate develop- ment of a sac or pouch into Avhich the viscera may be received, this pouch then constituting the sac of the hernia. Immediate or Exciting Causes__In the majority of instances, probably, a hernia is sIoavIv developed, and may not attract the patient's at- tention until fully formed ; in other cases, hoAvever, the rupture occurs sud- denly, as the result of a fall, or of some violent muscular effort. Noaiexclature. Hernias are classified according to their (1) locality, as inguinal, femoral, scrotal, umbilical, etc.; (2) condition, as reducible, irreducible, strangulated, etc. ; (3) contents, as intestinal (enterocele), omental (epiplocele), vesical (cystoceie), etc. ; and (4) period of development, as congenital, infantile, etc. The latter mode of classification is, hoAvever, incorrect, as many cases of so-called congenital and infantile hernia do not occur until adult life. Structure of a Hernia. The hernia consists essentially of a sac and its contents, the tissues exter- nal to the sac being the skin, subcutaneous fascia, etc., of the part in Avhich the hernia occurs. In some instances the sac is Avholly or partially deficient, as in cascal and vesical hernias, certain congenital umbilical herniae, and in A'entral herniae resulting from penetrating Avounds. With these exceptions, every hernia has a sac (or peritoneal investment), that part Avhich communi- cates Avith the peritoneal cavity being the neck, and that Avhich surrounds the protruded viscera being the body of the sac. Varieties of the Hernial Sac__There are tAvo distinct varieties of the hernial sac, the congenital and the acquired. 1. The Congenital Sac consists of the patulous vaginal process of peri- toneum, or of its funicular portion, and is therefore only met with in those forms of oblique inguinal hernia Avhich are often, though improperly, termed congenital and infantile. It may exist through life as a pouch, communicat- ing Avith the peritoneal cavity, Avithout ever becoming the seat of an actual hernia. 2. The Acquired Sac is sIoavIv developed by the gradual stretching of a portion of the parietal peritoneum, as the result of frequently repeated pres- sure from within, exercised by the organs which ultimately form the contents of the hernia. This is the form of sac Avhich exists in the ordinary oblique and direct inguinal hernias, as Avell as in femoral hernia, and in those Avhich occur in other regions. The mode of development of the acquired hernial sac has been particularly studied by Cloquet and Demeaux, and is avcII described by Birkett. When the parietal peritoneum first protrudes through the abdominal Avail, the Avidest portion of the sac is that Avhich communicates with the peritoneal cavity, but in the fully formed sac, the neck is smaller than the body, the sac being puckered like the mouth of a purse, by the constriction of the fibrous or 764 HERNIA. muscular ring through which the hernia has escaped. In this stage of the hernial sac's development, which is called the period of formation, the neck of the sac itself exercises no constriction upon the protruded viscus, and the puckering which has been described disappears upon reduction of the hernia, or upon division of the ring of the abdominal wall through which the rup- ture has occurred. At a later stage, the period of organization, the puckered folds at the neck of the sac adhere together, Avhile at the same time the fat disappears from the adjacent subserous areolar tissue, this becoming converted into an indurated and Avascular ring which is said to contain a layer of con- tractile fibres. In this stage, the neck of the sac exercises an essential con- stricting power, and requires to be divided if the hernia becomes strangulated. The ultimate stage is the period of contraction; as soon as a hernia ceases to descend, the orifice of the sac manifests a disposition to contract, and may even become obliterated, thus accomplishing the cure of the disease—as is occasionally Avitnessed in the hernia,' of infants, and more rarely in those of adults. During this stage, the ring which surrounds the neck of the sac be- comes thicker, and of a fibrous or cartilaginous hardness. If the hernia protrude in this stage, strangulation is very apt to occur. The sac of a hernia is thus at first thin and translucent, but often at a later period becomes thick and indurated, and may even become the seat of calca- reous degeneration; in other instances, as in cases of large umbilical hernia, the sac may by distension become extremely attenuated. The aperture in the abdominal wall through Avhich a hernia has escaped, eventually assumes a more or less circular outline, and often becomes enlarged; it may become displaced by the Aveight of the protruding viscera, being usu- ally dragged downwards and towards the median line of the body; thus, in an oblique inguinal hernia of long standing, the internal may come to be placed directly behind the external abdominal ring. The superficial tissues fre- quently become thinned and stretched, but, if a truss have been employed for a long time, may be indurated and thickened from the pressure of the pad of the instrument. Contents of the Hernial Sac—Almost any of the viscera may be occasionally found in hernias, but the parts most usually protruded are the bowel and omentum. The small intestine, and particularly the ileum, is much more frequently involved in a hernia than the large intestine: only a portion of the calibre of the gut may enter the sac, or a large coil of boAvel Avith its mesenteric attachment. In some very large hernias, almost the whole of the small intestine may descend into the sac. When long protruded, the bowel becomes thickened and contracted, and of a grayish hue externally: its me- sentery at the same time becomes hypertrophied and vascular. When the sac of a hernia is habitually occupied by omentum, the latter tissue becomes indurated and thickened, and often matted together into a conical mass, the apex of Avhich corresponds to the neck of the sac. The omental veins become distended and varicose, and apertures or depressions often exist in the dense mass, into which a knuckle of intestine may slip, and become strangulated. When a hernial sac contains both bowel and omentum, the latter usually pro- trudes in front of, and may completely surround, the gut. Cysts sometimes exist in the protruded omentum, and may, in the operation of herniotomy, confuse the surgeon by their resemblance to knuckles of intestine. In addi- tion to the viscera Avhich are contained in the hernial sac, a certain amount of serous fluid ahvays exists in its interior: under ordinary circumstances the quantity is but small, but if the hernia become inflamed or strangulated, may be very much increased. Adhesions often exist in the sac of an old hernia, gluing together the contained viscera, or binding them to the wall of the sac SYMPTOMS OF HERNIA IN GENERAL. '65 itself; while recent, these adhesions are soft and easily separated, but incases of long standing become firm and form an impediment to reduction. Loose bodies, consisting apparently of detached appendices epiploicas, are occasion- ally found in the interior of a hernial sac. Hydrocele or Dropsy of a Hernial Sac is the name given to an unusual condition which consists in the accumulation of fluid in the bottom of a hernial sac, the communication of Avhich with the abdominal cavity is oc- cluded, either by obliteration of the orifice, or by the formation of adhesions betAveen the Avail of the sac and the viscera which occupy its upper portion. Cases of this form of disease, Avhich, rare in any situation, is particularly so in connection with femoral rupture, have been recorded by Pott, Pelletan, Boyer, LaAvrence, Curling, Erichsen, Langton, and W. F. Atlee, of this city. The treatment consists in evacuating the fluid by means of a trocar and canula, and, as advised by Langdon, if the effusion recurs, in the establish- ment of a seton. Fig. 418. -& Symptoms of Hernia ix Gexkral. The patient often experiences a sensation of weakness in the groin or other region in which a hernia is about to occur, before any protrusion takes place. There is also frequently a decided ful- ness in the part, wliich is most marked in the erect posture, or upon contracting the abdominal muscles. The hernia, if gradually developed, appears as a small tumor, not larger at first, perhaps, than the tip of the finger, which can be re- duced by pressure, and which disappears spontaneously when the recumbent pos- ture is assumed. In young children, the hernia is often of considerable size when first noticed, and the same is true of those cases of rupture which are sud- denly developed as the result of violent exertion ; in the latter cases, the forma- tion of the hernia is often attended with pain. A fully developed hernia forms a round or oval tumor, usually broader be- low than above (the neck of the hernia), increasing in size Avhen the patient stands up, holds his breath, or coughs, either subsiding spontaneously when the patient lies down, or being readily, re- duced within the abdomen by gentle pressure, and reappearing upon the re- sumption of the erect posture. When the patient coughs, a distinct impulse may be commonly perceived in the hernial tumor. The symptoms of hernia are somewhat modified by the nature of its contents. Intestinal Hernia or Enterocele. — When the hernia contains bowel only, the tumor is smooth, gurgles under pressure, and is often tympa- nitic and resonant when percussed. The hernia is often the seat of borboryg- mus or flatulent rumbling. The impulse on coughing is well marked, and the patient frequently complains of dyspeptic symptoms, and of an uncomfortable Scrotal hernia in a child ; a, position of left testis. (From a patient of Dr. C B. Nanc;ede.) 766 HERNIA. dragging feeling. Reduction is attended with gurgling, and with a peculiar, characteristic sensation, Avhich, when once felt, can scarcely be mistaken, and which is spoken of by some Avriters as the "slip" or "flop" of a hernia. Omental Hernia or Epiplocele__In these cases, the tumor is ir- regular and comparatively ill-defined, having a doughy feel, and Avith a less distinct impulse on coughing than in the form of the disease last described ; reduction is effected gradually, and Avithout the characteristic gurgling sensa- tion Avhich has been referred to. Omental hernia is said to be most frequent on the left side, and is chiefly seen in adults. Mixed Hernia or Entero-Epiplocele—In these cases the symp- toms of the intestinal and omental hernias are variously combined. Caeeal Hernia is of course confined to the riglit side, and is commonly irreducible, from that portion of caecum which is uncovered by peritoneum forming adhesions to the subjacent structures. Hernise of the Stomach or Bladder are of rare occurrence; the former ( Gastrocele) has been observed in the inguinal and umbilical regions, and in cases of diaphragmatic rupture ; there are no distinctive symptoms by which it can be certainly recognized during life. Hernia of the bladder ( Cystocele) is irreducible, and attended with difficult micturition ; urine may be made to flow by compressing the tumor. Hernia of the Ovary is occasionally met Avith, Hamilton having col- lected 13 cases, to which Balleray has added 5 others. Treatment of Reducible Hernia. The treatment of reducible hernia may be palliative, or may aim at effect- ing a radical cure. Palliative Treatment___This consists in preventing the descent of the hernia by the application of a suitable truss or bandage. In cases of um- bilical and ventral rupture, an elastic band and pad may be the best means of retention, but a truss is preferable for the ordinary forms of hernia. I do not purpose to enter into any discussion of the comparative merits of the many forms of truss which are offered by their respective inventors to the profession and the public, but shall merely mention what may be considered the requi- sites of a good truss. A Truss consists essentially of a pad and a spring: the pad should be firm, slightly convex upon the surface (except in particular cases), of an oval or elongated triangular shape, and sufficiently large to compress not only the aperture through Avhich the hernia escapes, but the Avhole canal through which it has passed to reach the surface. The pad may be of buckskin, firmly stuffed, of polished wood, or of such other material as may be found by expe- rience to produce least irritation of the skin, some patients in this respect differing from others. In certain cases, in Avhich the ring through which the hernia protrudes is very large, the ordinary convex, oval, or triangular pad may be advantageously replaced by one of a horseshoe or ring shape, as re- commended by Mr. .1. Wood, or by a pad containing a spiral spring as sug- gested by Mr. Holthouse. As a rule, the plate Avhich forms the back of the pad should be made of the same piece of metal as the spring, Avhile the bear- ing of the pad should be not directly inwards, but somewhat upwards as well, RADICAL CURE OF HERNIA. 767 the particular angle varying according to the shape of the patient's abdomen. The spring of a truss is made of metal (covered with buckskin or leather), and curved so as to pass around the patient's trunk, just above the rim of the pelvis ; it should not touch except at the point of counterpressure, which, in the ordinary single-pad truss, is at the patient's hip, on the opposite side to that of the rupture—and at this point the spring should be beaten thin, curved to fit the part, and suitably padded. The spring should be elastic, and should exercise just enough force to keep the hernia reduced, Avithout pressing so deeply as to cause absorption of the abdominal parietes. From the free end of the spring, a leather strap passes to the pad, thus completing the circle around the patient's pelvis, while, for additional security, another strap may pass from the body of the spring along the fold of the buttock and around the inside of the thigh, to be fastened to a button at the lower edge of the pad. In many cases, particularly in those of persons with fat and pendulous abdomens, it is difficult to keep a hernia reduced except by using a spring of such force as to produce great discomfort, beside incurring the risk of en- couraging the development of a rupture on the opposite side ; under such circumstances, it will be better to employ a double-pad truss, thus affording support to both sides of the abdomen. The points of counterpressure, Avhen such an instrument is used, are situated on either side of the spine. The double-pad truss is, of course, necessary in cases of double hernia. Before applying a truss, the hernia should be completely reduced, and the apparatus then adjusted Avhile the patient is in the recumbent posture; the truss may be left off at night, being removed after the patient is in bed and re-applied before he rises, but should be constantly Avorn at other times. Every one avIio is ruptured should be provided with at least two trusses, so that if one break, another may be immediately substituted; and it is well to have one furnished with a plain wooden pad, for use while bathing, etc. If the pad of a truss tend to produce chafing, as is apt to be the case in hot weather, the part should be frequently Avashed Avith alum and Avhiskey, or cologne water, and well dusted with ordinary toilet poAvder, or lycopodium. The necessity of constantly Avearing the truss, and of never permitting the descent of the hernia, cannot be too strongly insisted upon. The only circum- stance Avhich should be alloAved to prevent the use of the instrument, is the presence of an undescended testis in such a part of the inguinal canal as to render the pressure of the truss-pad unbearable ; and even such a case should not be abandoned, Avithout an attempt to effect the desired object by trying various forms of apparatus. As a test for the efficiency of a truss, Erichsen advises that the patient should be directed to cough, Avhile sitting on the edge of a chair, leaning for- Avards, and Avith the legs extended and Avidely separated ; if the hernia do not slip down behind the pad under these circumstances, the instrument may be considered satisfactory. Radical Cure of Hernia.—In those cases in Avhicli the vaginal pro- cess of the peritoneum constitutes the sac of a hernia (congenital sac), the application of a Avell-fitting truss will occasionally effect a cure (particularly if the patient be an infant), by inducing the formation of adhesions between the opposing sides of the canal, and thus imitating the process of nature in accomplishing the closure of the part. In the other forms of hernia, in which the sac is slowly developed (acquired sac), it may be possible to prevent the formation of the sac by the employment of a truss; but Avhen once formed, all that can usually be hoped for, in the use of the instrument, is to check the further enlargement of the sac by keeping the hernia constantly reduced. 768 HERNIA. though Dr. C. T. Hunter has recorded a case in which, by the patient's con- stantly pressing the testicle of the affected side against the inguinal rin^r. the gland eventually became fixed in that situation, and thus effected a cure. Castration, excision of the sac. ligation or scarification of its neck, and acu- puncturation, have at Aarious times been recommended and practised, in the hope of producing a radical cure of hernia, but are now matters chiefly of his- torical interest, though excision (Avith antiseptic precautions) has been recently revived by Pauly. The injection of the sac with the tincture of iodine, has been advantageously resorted to by J. Pancoast. as has the injection, outside of the sac. of an extract of white oak bark by Dr. G. Heaton. (jerdy's opera- tion, Avhich consisted in simply invaginating a portion of the sac and super- jacent integuments, by pushing them up with the finger into the canal through which the rupture descended, and holding them up with sutures, wliile adhe- sion was promoted by the application of liq. ammonias to remove the cuticle of the inAaginated part, has been reAived with various modifications and im- provements by Svme, Favrer, AVutzer, Wells, Davies. Armsby. Egea, Lan- genbeck, Agnew, and others ; Avhile J. Wood has devised another very ingeni- ous procedure, combining invagination with ligation of the neck of the sac. InAagination of the testicle with the sac is. according to Michel, an old Spanish mode of treatment. The subcutaneous employment of the silver-Avire suture has been recently recommended by Richardson, of New Orleans, and by Chis- holm, of Maryland. The more important operations for the radical cure of hernia Avill be described under the heads of the special forms of the disease for which they are adapted ; but it -will be convenient to refer, in this place, to the general question of the applicability of such modes of treatment. The objections to any operation for the radical cure of hernia, are (1) the risk by Avhich the procedure is necessarily attended, and (2) the probability of failure by the hernia recurring in spite of the operation. (1.) There is. in the first place, the risk of inflicting direct injury upon important vessels, the peritoneal cavity, or even the bowel itself. A skilful operator could doubtless avoid these accidents, yet the possibility of their occurrence should be borne in mind in estimating the dangers of the proced- ure. But eA-en if no such untOAvard event as has been referred to mars the progress of the operation, it is eAident that in every case there is necessarily a ri>k of the development of peritonitis ; for every operation aims to effect a cure by inducing a certain amount of inflammation in the neck of the sac. and it is impossible to be sure that this inflammation may not spread further than is intended. And, although the statistics of Aarious modes of operating sIioav that but few deaths have actually occurred from peritoneal inflamma- tion, in proportion to the number of cases in which the operations have been performed, yet. as justly remarked by Birkett, these facts only sIioav that peritonitis is not a necessary consequence of the procedure. (2.) If. however, the chance of a fatal termination is small, the probability of failure is comparatively great. Mr. Wood has pointed out that the main cause of failure, in most operations for the radical cure of hernia, lies in the neglect to include the posterior Avail of the canal in the part operated on. the rupture sooner or later redescending behind the seat of operation ; and hence a prominent feature in his oavii mode of procedure, consists in draAving for- Avard the posterior Avail of the canal, so as to induce its adhesion to the ante- rior ; yet of one hundred and eighty-eight cases referred to in his address to the British Medical Association, in 1 \ In the female i (fll) Int° the Canal °f Nuck' {-.) in tne lemaie. j (ft^ Inguino-labial. 2. Direct. II. Femoral or Crural. III. Pelvic. 1. Anterior. Obturator. !(1.) Perineal. (2.) Pudendal. (3.) Vaginal. 3. Posterior. Ischiatic. The pathology and treatment of each of these forms of hernia are now to be briefly considered. Diaphragmatic Herxia. In this rare form of hernia, some of the abdominal viscera protrude into the thoracic cavity. The protrusion may occur through one of the diaphrag- matic orifices which has undergone dilatation, through an aperture resulting from congenital defect of development, or, Avhich is most common, through a laceration or wound of the part. The affection is seldom recognized during life, the symptoms being necessarily of a very equivocal nature; even if strangu- lation should occur, the diagnosis from other forms of intestinal obstruction could rarely be made out, and the treatment, consequently, Avould be chiefly expectant. Epigastric Herxia. In this variety of the disease, the protrusion occurs in or near the linea alba, between the ensiform cartilage and the umbilicus. Reduction is usually easy. The treatment consists in the application of a pad and elastic bandage. If strangulation occur, and herniotomy be required, care must be takeu to divide the stricture by an incision made in the direction of the long axis of the body, and exactly in the median line, so as to a\roid wounding the epigas- tric artery. This variety of rupture may be properly considered as a form of Ventral hernia, though the latter term is here applied more particularly to similar hernias in the mesogastric region. . 50 786 SPECIAL HERNI.E. Ventral Hernia. This may occur in the linea alba or linear semilunares, or indeed in any part of the abdominal Avail. It may result from rupture of the abdominal muscles (p. 367), from Avounds, or from stretching of the fibrous tissue in the median line—due to over-exertion, to distension from pregnancy, etc., or to weakening of the part by the discharge of an abscess. The diagnosis can readily be made if the hernia be reducible, but under other circumstances the affection may be mistaken for a cold abscess, an enlarged lymphatic gland, or a cystic or fatty tumor, from any of Avhich, hoAvever, it may be distinguished by careful palpation and impiiry into the history of the case. The treatment consists in the application of a suitable truss or bandage. Strangulation rarely occurs in this form of hernia. For the radical cure of hernia of the linea alba, Simon, of Heidelberg, freshened the edges of the opening, and united them by deep and superficial sutures, relieving the tension of the parts by making incisions on either side. Umbilical Hernia. (Exomphalos, Omphalocele, Ruptured Navel.) In this variety of hernia, the protrusion occurs through, or in close prox- imity to, the umbilical ring or navel. Occasionally congenital, it is more commonly acquired, appearing usually during the early months of infancy, but sometimes not until adult life ; it is probable, hoAvever, that in many, if not most, of the latter cases, the umbilical ring has been patulous since birth, or at least never firmly closed. In congenital cases, the hernia has, it is said, been strangulated by the application of the ligature to the umbilical cord. In infancy both sexes are equally liable to this form of hernia, but in adult life it is much more common in women, owing to the influence of preg- nancy in distending and stretching the walls of the female abdomen. The sac of an umbilical hernia is ahvays of the acquired variety (see page 746). Symptoms—In infancy, the hernia appears as a smooth, tense, rounded tumor, varying in size from that of a marble to that of a small orange, easily reducible, and reappearing spontaneously when the child struggles or cries. In adult life, the hernia often attains a very large size, is irregular in shape, and, in parts at least, doughy to the touch ; it usually contains both boAvel and omentum, the latter being often indurated, hypertrophied, and adherent to the sac. The hernial tumor varies in shape in different cases, but most commonly tends to hang downwards in front of the abdomen ; in a remark- able case which was under my care some years ago, the tumor, Avhen the pa tient Avas in a sitting posture, rested on the chair between her thighs. The coverings of an umbilical hernia are in most cases Aery thin (consisting merely of skin, fascia, and sac), and are often closely connected together. The fascia sometimes presents perforations, through which a knuckle of in- testine may protrude and become strangulated. Umbilical hernia in the adult is usually irreducible, or at least not completely reducible, often be- comes incarcerated, and is not rarely subject to strangulation, this accident being comparatively infrequent in the case of children. In some instances, double and even triple umbilical hernias have been observed in the same individual. Treatment___In infants, it is usually possible to effect a cure by the use, for some months, of a compress of cork or metal, held in place by means LUMBAR HERNIA. 787 of a suitable bandage ; or, as suggested by Archambault, by the use of a plug of Avax, moulded to fit the umbilicus ; or, Avhich I prefer, by the simple appli- cation of a couple of broad strips of adhesive plaster, as advised by Fergusson. The strips should be reneAved from time to time as they become detached by washing. If the umbilical aperture be very large, and particularly in the case of adults (if the hernia is reducible), the ring pad devised by J. Wood may be advantageously employed. For irreducible umbilical hernia, a con- cave pad or bag-truss, held in place by an elastic bandage, will afford the best means of retention. Radical Cure—Various operations for the radical cure of umbilical hernia have been suggested and practised by Desault, Barwell, Heath, Lee, and other surgeons, the method Avhich has attained most favor being probably that recommended by J. Wood, of London. This operation consists in ap- proximating subcutaneously the tendinous margins of the aperture through which the protrusion has occurred, by means of pins bent at a right angle, which are introduced in opposite directions and then twisted together, or by means of Iavo or more wire sutures introduced Avith a curved needle, and secured OA'er a superimposed roll of lint. The operation is more likely to succeed in children than in adults, but, even in them, is believed by Mr. Wood to be of service, if not in obliterating, at least in diminishing the size of the hernial aperture, and thus facilitating subsequent retention Avith a truss.N Herniotomy.—It is very important, in the operation for strangulated umbilical hernia, to relieve the constriction Avithout opening the sac, particu- larly if this be of large size—its implication in the Avound being, under these circumstances, apt to be followed by a fatal result; hence, as the coverings of the hernia are commonly very thin, the surgeon should proceed Avith great caution in their division. The hernia being draAvn down and thus made tense, an incision two or three inches long is to be made over the neck of the tumor at the upper part, and usually in the median line ; the skin and fascia being divided, the finger-nail or director is slipped under the margin of the ring, which is then nicked in an upAvard direction. If the symptoms of strangulation persist, the hernial sac must be opened, and any internal source of constriction divided. The omentum, if closely adherent to the inner sur- face of the sac (as is often the case), should be left undisturbed, the gut being carefully returned, and the wound closed with sutures. The after-treatment consists in the application of a broad compress and bandage, and (if the sac have been opened) the adoption of means to combat the peritonitis which may be expected to folloAV. Fergusson advises, instead of the median incision above described, one at the side of the tumor's neck, as in Gay's method of operating for femoral hernia (see page 801). Demarquay also recommends a small lateral incis- ion, on the left side of the sac, but forbids any subsequent attempt at reduc- tion, believing it safer to leave the parts in situ, and to rely solely upon the division of the neck of the sac to relieve the strangulation. Lumbar Hernia. In this very rare form of hernia, which appears to have been first described by Petit, in 17H3, the protrusion occurs in the loin, between the crest of the ilium and the last rib. In two of six cases referred to by Dr. W. N. Camp- bell, of Ncav York (including one observed by himself), the hernia is said to have been of traumatic origin. A seventh case has been recently recorded by Cianciosi, an Italian surgeon. 788 SPECIAL HERNIiE. Inguinal Hernia. This is the most common A-ariety of rupture, inguinal constituting about two-thirds of the Avhole number of hernias observed in both sexes. In oblique inguinal hernia, the protruding vis- Fig. 423. cera pass through both the internal and external abdominal rings, tra- versing thus the Avhole length of the inguinal canal; in direct inguinal hernia, the viscera pass only through / ifikW^N^'j «^»-^yVii]l\ the external abdominal ring. The oblique variety is sometimes called external, because in it the neck of the hernial sac is placed to the outer side of the internal epigastric ar- tery, the direct inguinal hernia receiving the name of internal, be- cause in it the neck of the sac is to the inner side of the same vessel. An oblique inguinal hernia, in which the protrusion is still within the limits of the inguinal canal, is called a bubonocele, or an incomplete or interstitial hernia; while one in which the protrusion has passed the external ring is called a complete hernia, and when it occupies the scrotum, an oscheocele, or scrotal hernia. Inguinal hernia: on the right side oblique, on the left direct, a. The hernial sac. 6. The epigastric artery. I. Oblique Inguinal Hernia in the Male. Of this we may recognize five varieties, three of which are suddenly de- veloped, as the result, usually, of violent exertion, and in wliich a congenital defect allows the production of the hernia, while the other tAvo are gradually developed. The distinction is of importance, as the former offer a better prospect of radical cure, while, at the same time, if strangulated, they are less apt to yield to the taxis than the latter. 1. Hernia into the Vaginal Process of the Peritoneum—This is the variety ordinarily spoken of as congenital. As a matter of fact, Iioav- ever, the hernia, though most common in infancy, is occasionally not developed until late in life—it being not the disease, but the anatomical peculiarity which allows its occurrence, that is congenital. The vaginal process of peritoneum remaining patulous (pp. 702, 763), the hernia (which is suddenly developed) descends at once into the scrotum, where it lies in contact Avith and surrounds the testicle. In some cases, however, the hernia may descend into a patulous vaginal process, Avhile the testis itself is retained in or immediately outside of the inguinal canal, or even Avithin the abdominal cavity; in the former in- stances the hernia would, but in the latter instance would not be in contact with the gland. The sac, in this variety of hernia, is the vaginal process itself, its mouth corresponding with the position of the internal abdominal ring, and its neck occupying the inguinal canal, Avhich is not shortened by the approximation of the internal and external rings, as in the ordinary oblique inguinal hernia of sIoav formation. A sub-variety of the hernia into the vaginal process is the hour-glass-shaped hernia, in which a constriction or OBLIQUE INGUINAL HERNIA IN THE MALE. 789 narrowing of the hernial sac (vaginal process) exists at some point betAveen the position of the testis and that of the external abdominal ring. Fis. 424. Hernia into vaginal prjcess of peritoneum. (Pirrie.) Fig. 425. 2. Hernia into the Funicular Portion of the Vaginal Pro- cess___This variety of hernia (Avhich is sometimes called " infantile," in contradistinction to the last-mentioned, or so- called "• congenital" hernia), is of frequent occur- rence. It is suddenly developed, and, though common in infancy, often does not make its ap- pearance until adult life. The sac is the funi- cular portion of the Aaginal process of perito- neum (pp. 762, 763), and the hernia, when it reaches the scrotum, lies above and separate from the testis, which is inclosed in its OAvn proper tunic. I have shown, diagrammatically, the structure of this form of hernia in Fig. 425. 3. Inguino-Crural Hernia.—This is the name proposed by Holthouse for cases of sud- denly developed oblique inguinal hernia, in Avhich, owing to the non-descent of the testicle, or to other causes, the hernia, instead of passing down into the scrotum (or labium, in the case of a wo- man), protrudes outAvards along the folds of the groin, presenting someAvhat the appearance of a femoral hernia.1 Similar to these are the cases in Avhich prolongations of the hernial sac (vaginal process) extend in various directions within the abdominal walls, constituting the inter-parietal or inter-muscular herniae of English authors, and the uhernies en bissac" of French Surgeons. Hernia into funicular portion of vaginal process. 1 See a case reported by Prof. Parker, of New York, in Am. Med. Times, Sept. 1862, and Am. Journal of Med. Sciences, Oct. 1862, p. 568. 790 SPECIAL HERNIiE. / / / 4. Inguino-Scrotal Hernia of Slow Formation—This is the common form of oblique inguinal hernia in persons past the middle period of life ; the hernia " points" at the Fig. 426. internal abdominal ring, forming a small circumscribed SAvelling, Avhich is most prominent when the patient is erect, and Avhich transmits an impulse Avhen he coughs. As the hernia descends through the inguinal canal, it pushes before it the parietal layer of peritoneum, thus forming its own sac by a process of gradual distension. In this situation, it forms a someAvhat elongated tumor (Bubonocele), lying parallel to the line of Poupart's ligament, and usually in front of the spermatic cord. When the hernia makes its appearance at the external abdominal ring, it forms a tumor of a someAvhat globular shape, which, hoAvever, becomes more or less pyriform as the pro- trusion descends into the scrotum. Scrotal herniae often attain an enormous size, hanging perhaps as low as the knee ; in such cases the hernia is com- monly irreducible. In the descent of the hernia, the internal and external rings are approximated, thus shortening the inguinal canal, tlirough which, when the hernia is reduced, the finger may be readily passed (invaginating the coverings of the hernia) within the abdominal cavity. This is not usu- ally practicable in the suddenly developed herniae, in which the inguinal canal maintains its normal length. Common inguino-t crotal hern'a. (Pirrie.) Fie. 427. 5. Encysted Hernia__This is the " encysted hernia of the tunica vaginalis" of Cooper, and the "infantile hernia" of Hey, of Leeds. It is a hernia of slow formation, and is therefore to be dis- tinguished from the ordinary " infantile hernia" into the funicular portion of the vaginal process. The peculiarity of this form of hernia consists in the persistence of the testicular orifice of the funi- cular portion of the vaginal process of peritoneum, the ventral orifice being closed (p. 762); as a conse- quence of this congenital defect, the tunica vagi- nalis testis extends up to the external abdominal ring, and the hernia, forming its own sac from the parietal peritoneum, protrudes into the tunica vagi- nalis, which is therefore first cut into when an ope- ration is required in a case of this kind. This variety of hernia is very rare, and is seldom recog- nized before the parts are exposed in herniotomy. Coverings of Oblique Inguinal Hernia. —These are (1) the skin, (2) the superficial fascia, Encysted hernia. (Liston.) (3) the external spermatic or intercolumnar fascia, (4) the cremasteric fascia, containing fibres derived from the internal oblique muscle, (o) the fascia propria, internal spermatic, or infundibuliform fascia, corresponding to the fascia transversalis, and (6) the sac, which may consist of a dilatation of the parietal peritoneum, or of DIRECT INGUINAL HERNIA. 791 part or all of the vagin.il process. In the encysted hernia there is apparently a double sac, the true sac being surrounded by both layers of the tunica vagi- nalis testis ; hence, in laying open the sac of an encysted hernia, three layers of serous membrane are divided. Though the six coAerings above mentioned are properly described by sys- tematic Avriters, it is seldom in practice that they can be individually recog- nized, the third, fourth, and fifth being commonly blended together so as to be indistinguishable. Relations of Oblique Inguinal Hernia__The spermatic cord is almost invariably behind the hernia, its component parts being commonly together, but occasionally separated ; more rarely the various structures of the cord may be spread out in front of the hernia. The position of the tes- ticle corresponds with that of the cord, lying below and behind the hernia, or very rarely in front of it; the hernia and testis are in contact in the so-called congenital hernia (into the vaginal process) and in the inguino-crural variety, but in all others are separate. The epigastric artery lies to the inner side of and behind the neck of the hernia ; it is, in inguino-scrotal hernia? of long standing, somewhat deflected from its normal oblique course, by the shortening of the inguinal canal, and then passes upAvards and slightly inwards beneath the outer border of the rectus abdominis muscle. II. Oblique Inguinal Hernia in the Female. Of this Ave may recognize two \"arieties, one of sudden development, in Avhich the hernia descends into the canal of Nuck, this variety corresponding Avith the hernia into the vaginal process of the male (■'congenital" hernia), and one of gradual develpment, the ing ui no-labial, corresponding to the ordi- nary inguino-scrotal hernia of the male. AVhen, in a case of hernia into the canal of Nuck, the protrusion extends obliquely outAvards in the line of Pou- part's ligament, the hernia may be properly called inguino-crural. The coverings and relations of these hernias are tbe same as in the corresponding herniae of the male, substituting merely round ligament for spermatic cord, and labium pudendi for scrotum. Hernia into the Canal of Nuck is the commonest form of hernia met with in girls, and, Avith the exception of umbilical hernia, is the only form which occurs in female infants. It is in these cases, according to Kingdon, not unusual to find the ovary in contact Avith the hernia. Inguino-Labial Hernia, contrary to the commonly received notion, is almost as frequent in Avomen as femoral hernia. The symptoms are very much those of the inguino-scrotal hernia of the male, except that the tumor rarely attains so large a size, and is less pyriform in shape. The neck of the hernia is, besides, larger and narrower than in the corresponding hernia in the male. III. Direct Inguinal Hernia. This occurs in both sexes. The direct inguinal hernia is always gradually developed, except in the contingency of a traumatic laceration of the struc- tures immediately behind the external abdominal ring, Avhen a hernia may suddenly protrude. The hernia " points" behind the external abdominal ring, and escapes through the space known as Ilc-sclbach's triangle, usually pushing before itsel;', or separating the fibres of, the conjoined tendon, but 792 SPECIAL HERNIA. occasionally passing to the outer side of the latter. Leaving the external ring, the hernia reaches the upper portion of the scrotum, Avhere it forms a tumor which is more globular in form than that of an oblique inguinal hernia. The long axis of the sac, moreover, is parallel to the median line of the body, and its neck close to the outer border of the rectus muscle—not curving outAvards in the line of Poupart's ligament, as in the case of a hernia Avhich has traversed the entire length of the inguinal canal. Coverings of Direct Inguinal Hernia__These vary according to the particular part of the triangle of Hesselbach through Avhich the hernia protrudes. In the common form of direct inguinal hernia the coverings are (1) skin, (2) superficial fascia, (3) intercolumnar fascia, (4) fibres of the conjoined tendon, (5) transversalis fascia, and (6) the sac. In the compara- tively rare instances in Avhich the protrusion occurs to the outer side of the conjoined tendon, the latter does not furnish any part of the investments of the hernia, Avhich then carries with it a portion of the cremasteric fascia, as in the case of the oblique inguinal hernia. Relations.—The spermatic cord (or round ligament) passes almost inva- riably along the outer and posterior side1 of the hernial sac, while the epi- gastric artery also courses along the outer side of the sac, arching above the neck of the latter to reach the sheath of the rectus muscle. Anomalous Inguinal Herniae.—It occasionally, though very rarely, happens that an inguinal hernia escapes, not through the external abdominal ring, but through an abnormal opening in the aponeurosis of the external oblique muscle, close to the ring. In such a case the spermatic cord would not be in direct contact with the hernia. Diagnosis of Inguinal Hernia. From Femoral Hernia, an inguinal hernia maybe distinguished by observ- ing (1) that it invariably protrudes above the line of Poupart's ligament, and (2) that the external abdominal ring (through* Avhich an inguinal hernia escapes) lies to the inner side of the pubic spine. Hence, if the neck of the sac be found outside of this prominence, it may be inferred that the hernia is not inguinal. The Differential Diagnosis betAveen the various forms of inguinal hernia, may usually be made by investigating the history of the case, and by attention to the symptoms which have been described as characterizing the several varieties of the affection. In other instances, however, and par- ticularly in case of strangulation, the surgeon maybe unable to say positively even whether the hernia is oblique or direct. Inguinal Hernia which has not descended into the Scrotum is to be distinguished from abscess, hydrocele or hematocele of the cord, tumor of the cord, adenitis, and undescended testis. (1.) Abscess arising Avithin the pelvis and pointing in the course of the inguinal canal is reducible, and may transmit an impulse Avhen the patient coughs, but can be distinguished from hernia by its fluctuating character, and by the absence of gurgling in reduction. (2.) Hydrocele of the Cord may be distinguished by its elastic, semi-fluctu- ating character, its translucency if Ioav doAvn, the impossibility of complete 1 Todd met with a case in whicb tbe cord passed in front of the sac, and B. "Wills Richardson Avith one in whioh the cord passed on its inner side. DIAGNOSIS OF INGUINAL HERNIA. 793 reduction within the abdominal cavity, and the absence of gurgling. The same signs may, in the female, serve for the diagnosis, from hernia, of a serous cyst, which sometimes occupies the canal of Nuck (Hydrocele of the Round Ligament). (3.) Hematocele of the Cord may be recognized by the existence of fluc- tuation and ecchymosis, by the impossibility of complete reduction, and by the absence of gurgling. (4.) Tumors of the Cord have a well-defined outline, transmit no impulse on coughing, and are irreducible. (o.) Enlarged Lymphatic Glands are commonly situated below Poupart's ligament; but when a single gland is above, and inflamed, the case may be mistaken for one of strangulated hernia, the diagnosis perhaps being only cleared up by an exploratory incision. In a case of supposed hernia Avhich came some years ago under my care, I found the inguinal tumor to be glan- dular, and to be dependent upon cancer of the vagina Avhich had not been detected. (6.) An Undescended Testis occupying the inguinal canal may be distin- guished from hernia by the impossibility of reduction, the absence of gurgling, the peculiar sickening sensation caused by pressure, and the fact that there is no testicle in the scrotum of that side. The difficulty is greater Avhen the undescended testis is inflamed, but here (unless a strangulated hernia coexist) the diagnosis may be made by attention to the points already mentioned, and by noting the character of the vomiting, Avhich in the case of an inflamed testis is not persistent, and never stercoraceous. Scrotal Hernia is to be distinguished from hydrocele of the tunica vaginalis, hematocele, varicocele, and tumors of the testis. (1.) Hydrocele is to be distinguished by its translucency, its tense and semi-elastic character, its irreducibility, and the absence of impulse on cough- ing ; it begins at the bottom of the scrotum, instead of at the top, as is the case Avith hernia, and is distinctly circumscribed, the cord being readily per- ceptible above it. If a hydrocele of the cord coexist, the diagnosis is more difficult. Congenital hydrocele, in Avhich the communication between the tunica vaginalis and peritoneum persists, though reducible by pressure, may be distinguished by the absence of gurgling, and by the gradual manner in which the tumor reappears av hen the pressure is removed. Hernia and hydrocele may coexist, in Avhich case the hydrocele is usually in front, and each tumor presents its OAvn characteristic peculiarities. (2.) Hematocele may be distinguished by its history (of traumatic origin), its irreducibility, the absence of impulse and gurgling, and the distinctness with Avhich the cord may be felt above. (3.) Varicocele may be distinguished from hernia by making the patient lie down and by elevating the scrotum, when the tumor, if a varicocele, will disappear slowly and without gurgling; if now the surgeon press gently on the external abdominal ring, and direct the patient to rise, the tumor, if a varicocele, will be sloAvly reproduced, beginning at the bottom of the scrotum, but, if a hernia, will not reappear; if, on the other hand, moderately firm pressure be made upon the cord below the external ring, so as to take off the weight of the superincumbent column of blood, and thus prevent distension of the spermatic veins, the tumor, if a \aricocele, Avill not be reproduced, Avhereas a hernia will slip down alongside of the finger. (4.) Tumors of the Testis may be distinguished by their rounded shape and solid feel, by the absence of impulse or gurgling, by their irreducibility, and by the non-implication of the cord and inguinal canal. 794 SPECIAL HERNIAE. S Treatment op Inguinal Hernia. The Palliative Treatment of oblique inguinal hernia consists, Avhen the rupture is reducible, in the application of a truss, the pad of which should be of an elongated shape, and should press upon the Avhole extent of the inguinal canal and upon the internal abdominal ring. In applying a truss for hernia into the vaginal process, in a child, great care must be taken not to press injuriously upon the testis, if this have not fully descended. For direct inguinal hernia, a truss is required which shall support the abdominal parietes behind the external abdominal ring; a good instrument for the pur- pose is that with an " ovoid-ring pad," as employed by Mr. John Wood. For irreducible inguinal hernia of either form, a IioIIoav pad, or suspensory or bag-truss, is to be applied. Radical Cure___Of the numerous ingenious operations Avhich have been devised for the radical treatment of inguinal hernia, I shall describe but four, viz.: 1, Wutzer's; 2, Syme's and Fayrer's (Avhich are essentially the same); 3, Agnew's ; and 4, J. Wood's. A modification of Wood's method has been devised by Dr. Greensville Dowell, of Texas, who applies subcutaneous su- tures by means of what he calls a " shuttle-needle," and Avho reports GO at least temporary successes in a total of 68 operations. 1. Wutzer's Method consists in invaginating a plug of scrotum in the in- guinal canal, and endeaAroring to fix it there by exciting inflammation in the neck of the sac. The patient is placed in a supine posture, the rectum and bladder being empty, the affected part carefully shaved, and the hernia tho- roughly reduced. Invagination is effected by pushing up a cone of the scrotal tissues with the left forefinger, which is introduced Avithin the internal ring; an oiled, hollow, boxAvood cylinder (Fig. 428, C) is carefully introduced as the finger is withdrawn, so as to maintain invagination ; along the inner sur- rA c C X: c Wutzer's apparatus for radical cure of hernia. face of this cylinder, a flexible needle (A), gilt to prevent corrosion, is passed by means of a movable handle, and thrust through the scrotum, hernial sac, anterior wall of the inguinal canal, and tissues of the groin, the operation being completed by the application externally of a concave boxwood case or roof (B), the curve of which corresponds to that of the cylinder, and Avhich passes over the point of the needle and is held in place by means of a screw at the other end. Ike apparatus is kept in place for about a week, the in- vaginated plug being subsequently supported by a roll of lint and a spica bandage; the patient is kept in bed about three weeks, and should wear a light truss for several months afterwards. 2. Syme's Method is a modification of the above, and is thus described by its author : " Instead of a complicated machine for distending the invaginated integument, I employed a piece of bougie or gutta-percha, to one end of wliich was attached a strong double thread. The plug thus prepared and RADICAL CURE OF INGUINAL HERNIA. 795 smeared with cantharides ointment, av.is drawn into its place by the threads, Avhich, by means of a curved needle guided on the finger fairly within the ring, Avere passed, at the distance of rather more than an inch from each other, through all the textures to the surface, where they Avere tied firmly together on a piece of bougie, to prevent undue pressure on the skin." The plug is left in position ten days, and the patient kept in bed a fortnight longer. Prof. Fayrer's Method differs from Syme's, merely in the substitu- tion of an oiled wooden plug for that of gutta-percha; in the fact that the ligatures (Avhich are of silk), though introduced at different points, are brought out through the same aperture in the groin, Avhere they are tied over a piece of Avood or ivory ; and in the AvithdraAval of the plug in from two to six days. Thirty-eight cases operated on in this Avay by Fayrer gave twenty- four cures (the permanence of Avhich Avas, however, not ascertained), while twenty-five cases operated on by Wutzer's plan gave the smaller proportion of fourteen cures. 3. Agnew's Method—For this operation, a special instrument is required, which resembles a bivalve speculum, and consists of tAvo semi-cylindrical blades Avith handles, with two grooves on the inner or concave surface of each Fig. 429. blade, and a rod and screw to regulate the degree to Avhich the blades are separated. An incision 2-^- inches long is made over the scrotum, passing downwards from a point three-fourths of an inch below the external abdomi- nal ring; the subjacent tissues are . , . , . , ,. ,. , °. „ •' Agnew s instrument for the radical cure of separated from the skin of the. scrotum hernia. by the finger, introduced through the incision, and then invaginated, the " speculum" being made to replace the finger, as in Wutzer's operation. The blades of the instrument are then separated, and a long-handled needle, armed Avith a silver Avire, passed along one of the grooves of the loAver blade, thrust through the intervening struc- tures, and brought out on the surface of the body over the internal ring; the needle is then unthreaded and Avithdrawn, rethreaded with the other end of the wire, and passed along the second groove, to be brought out at nearly the same point as before. Both ends of the wire are then drawn tight and firmly twisted together. A short needle is next armed with silk or wire, and passed across the inguinal canal betAveen the blades of the speculum at three points, near the summit, at the middle, and just above the external ring; these sutures are tied over a roll of lint, the speculum removed, and the operation completed by the application of a compress and bandage. The sutures are remoA-ed on the eighth day, and the patient is kept in bed, in all, for about three weeks, and subsequently furnished Avith a light truss. " With reference to my own operation," says Prof. Agnew, " the success obtained has not been sufficiently uniform to justify me in speaking of it in any other way than with distrust." 4. Wood's Method—-The most important feature of Mr. AVood's various operations consists, as has been already mentioned, in applying sutures in such a Avay as to effect compression and closure of the tendinous sides of the hernial canal in its whole length. The instruments required are, (1) a «trongly-curved needle, eyed near the point, and mounted in a firm handle ; (2) a knife someAvhat resembling a tenotome ; (3) a strong, hempen thread, or silvered copper Avire ; and (4) a compress, which, if the thread be used, is to be made of boxAvood, glass, or porcelain. 796 SPECIAL HERNI.E. (1.) Operation with Thread—The patient being anaesthetized, and the rupture thoroughly reduced, a small scrotal incision is made over or beloAV the fundus of the hernial sac, and the skin and fascia separated over an area tAvo or more inches in diameter, by means of the knife introduced flatwise. The knees of the patient are then brought together, and elevated so as to relax the structures of the groin, and the detached fascia invaginated with the forefinger, which is pushed Avell up into the inguinal canal, Avith the nail directed backwards. The finger being hooked forwards, so as to raise the loAver border of the internal oblique muscle, and with it the conjoined tendon, the unarmed needle, Avell oiled, is passed up on the pubic side of the finger, pushed deeply through the tendon at its most salient part, made to traverse the internal pillar of the superficial ring obliquely upwards and inwards, and finally brought through the skin, Avhich is first drawn inwards and upwards as much as its deep attachments will alloAv. One end of the thread is then passed through the eye of the needle, wliich is quickly withdrawn, leaving the other end of the thread in the puncture. The finger is next placed be- hind the external pillar of the superficial ring, close to Poupart's ligament, opposite the internal hernial opening, in the groove between the spermatic cord and the ligament. The finger is again raised, stretching the aponeu- rosis, and the needle (which is now armed) passed betAveen the point of the finger and Poupart's ligament, pushed through the latter, and brought out at the same opening as before; a loop of the thread is this time left in the punc- ture, and the needle carrying the free end again withdrawn. The finger is now placed on the inner side of the spermatic cord, just above the pubic spine, and pressed firmly upon the conjoined tendon, pushing this backwards and the cord outwards, so as to feel the border of the rectus tendon. Into the tendinous layer of the triangular aponeurosis covering this part of the rectus, the needle is then deeply thrust, turned obliquely towards the surface, and a third time brought out tlirough the original puncture, Avhich now con- tains both ends of the thread and an intermediate loop; tAvo portions of thread thus cross the hernial canal, invaginated fascia, and sac, closely embracing but not including the spermatic cord, and joining together the front and back Avails of the canal. The compress is placed obliquely over the canal, the free ends of thread and the loop crossed and firmly draAvn in opposite direc- tions, and the Avhole then secured by passing one end of the thread through the loop and tying it back to the other end in a " bow-knot." The operation is completed by the application of pads of lint and a spica bandage. The knot is untied and the compress removed from the third to the seventh day, the threads being allowed to remain as setons as long as may be deemed necessary. (2.) Operation with Wire—The preliminary steps are the same as Avhen the thread is used, but in passing the needle for the second time it is un- armed, and withdrawn armed with the other end of the Avire, thus leaving a loop above and bringing both free extremities out at the scrotal incision below: the hernial sac and the fascia covering it opposite the scrotal aperture are then pinched up Avith the finger and thumb, and the cord slipped back as in the operation for varicocele, when the needle is passed (entering and emerging through the scrotal Avound) from Avithout inAvards and a little upAvards, immediately in front of the spermatic cord; it is now armed with one of the ends of wire (either will answer the purpose) and Avithdrawn; the next step is to straighten and draAv doAvn the ends of wire until the loop is near the skin, Avhere it is held while the ends are tAvisted together with three or four turns, the inclosed sac and fascia being thus tAvisted and held betAveen the ends of wire. The loop is now drawn up\Arards, so as to effect, complete invagination of the twisted sac and scrotal fascia, and in its turn twisted HERNIOTOMY FOR INGUINAL HERNIA. 797 Fig. 430. doAvn into the groin puncture; the ends of the Avire are then cut off about three inches from the surface and bent into a hook wliich is carried up- wards to meet the loop, both being locked together over a compress of lint, and the Avhole covered with a spica bandage. The wire may be un- tAvisted about the eighth or tenth day, and re- moved about the fourteenth. (3.) Operation with Pins___For small rup- tures in children, particularly for ruptures into the vaginal process, Mr. Wood resorts to the use of pins bent at a right angle ; these are passed in opposite directions, one through the conjoined tendon and internal pillar, and the other through the external pillar of the ring, the hernial sac being transfixed by both pins, which are then tAvisted together. The pins are withdrawn from the second to the tenth day. The statistics of the operations for the radical cure of inguinal hernia performed by Mr. Wood himself, have already been given (page 768) ; 30 cases operated on by one or other of his methods, which are recorded in the Reports of the Boston City Hospital, gave 8 recoveries, 3 " fair results," 2 deaths, and 17 failures. Taxis for Inguinal Hernia—In employing the taxis, in a case of inguinal hernia, the pressure must be applied strictly in the direction of the Fig. 431. Wood's operation for cure of hernia. Incision for strangulated inguinal hernia. (Fergusson.) inguinal canal, i. e., obliquely upwards and outwards. It must, however, be remembered that, in a case of inguino-scrotal hernia of long-standing, the direction of the canal itself becomes changed, by the approximation of the abdominal rings. Herniotomy—An incision of from two to four inches in length is made in the direction of the long axis of the tumor (Fig. 431), so that the position of the external ring will be a little above the middle of the wound : the va- rious coverings of the hernia are then carefully divided, until the director or tip of the finger can be insinuated beneath the edge of the ring, when, if this be found to exercise any constriction, it is to be incised in an upward direc- 798 SPECIAL HERNLE. tion, in a line parallel to the linea alba. The taxis may be then gently employed, when it will occasionally happen that reduction can be effected without further trouble, but if such is not the case, the internal ring is to be explored and similarly dealt with: in the majority of instances, hoAvever, the stricture is in the neck of the sac itself, and an opening must then be made of sufficient size to allow the introduction of the finger, Avhich is passed up to the seat of obstruction, a hernia-knife folloAving and nicking the stricture in the vAray described at page 781. It is a Avell-established rule that the incision in this part of the operation should be made directly upAvards, in a line parallel to the linea alba, so that Avhether the rupture be of the oblique or direct variety (and this cannot ahvays be determined beforehand), the epigastric artery may escape injury. Femoral or Cimral Hernia. (Merocele.) In this form of hernia, which is more common in Avomen than in men (in the proportion, according to Croft, of nearly five to one), the protrusion takes place beneath Poupart's ligament, and almost invariably to the inner side of the femoral vein. Descending through the femoral ring, the hernia pushes before it the parietal layer of peritoneum (thus forming its own sac), Avith the Fig. 432. 1, Femoral hernia; 2, femoral vein; 3, femoral artery, giving off, 4, common trunk of epigastric and obturator arteries, and 5, epigastric artery ; 6, spermatic cord. (Erichsen.) dense layer of areolar tissue which normally closes the ring and is knoAvn as the septum crurale; passing downwards along the crural canal, in the inner compartment of the sheath of the femoral vessels, the hernia changes its course upon arriving at the saphenous opening, and, turning forwards, pushes before it the cribriform fascia, and curves upAvards on to the falciform process of the fascia lata and lower portion of the external oblique tendon, lying at this point beneath the superficial fascia and skin. Varieties.—Several varieties of femoral hernia are described by system- atic writers. Thus, when the rupture is still within the crural canal it is DIAGNOSIS OF FEMORAL HERNIA. 799 called incomplete, being complete Avhen it has passed the saphenous opening. Another division is founded upon the relations of the sac to the internal epi- gastric and obliterated umbilical arteries, the common form, in which the mouth of the sac lies betAveen these vessels, being called middle crural hernia, and the rare varieties in which it lies to the outer side of the epigastric, or to the inner side of the umbilical artery, being called, respectively, external and internal crural hernia. LeGendre has described four rare varieties, to which Birkett has added a fifth : these are, (1) the pectineal crural, or hernia of Cloquet, in Avhich, after passing the femoral ring, the hernia turns within and behind the femoral vessels, resting on the pectineus muscle ; (2) the hernia through Gimbernat's ligament, or hernia of Laugier, the anatomical peculiar- ities of Avhich are sufficiently expressed by its name; (3) the hernia with a diverticulum through the cribriform fascia, or hernia of Hesselbach, in Avhich the hernia protrudes through several openings in the cribriform fascia, getting thus a lobukted appearance ; (4) the hernia with diverticulum through the superficial fascia, or hernia of Cooper, Avhich, mutatis mutandis, is similar to that last mentioned ; and (5) the hernia external to the femoral vessels, or hernia of Partridge. Coverings—The coverings of an ordinary complete femoral hernia are (1) skin, (2) superficial fascia, (3) cribriform fascia, (4) crural sheath, (5) septum crurale, and (6) sac. The septum crurale and adjacent portion of the crural sheath are commonly matted together, constituting the fascia propria of Cooper. The coverings of an incomplete femoral hernia are the same, substituting the falciform process of the fascia lata for the cribriform fascia. Relations—The femoral vein lies close to the outer side of the hernia, and separated from it merely by a septum of the crural sheath, the epigastric artery is above and to its outer side, Avhile the spermatic cord or round liga- ment passes almost immediately above it on the inner side. The obturator artery, when, as not unfrequently happens, it arises from the external iliac, common femoral, or epigastric, instead of from the internal iliac artery (as in the normal condition), usually descends on the outer side of the crural ring to reach the obturator foramen, but occasionally skirts along the free border of Gimbernat's ligament, when it would almost completely encircle the neck of the hernial sac. In the rare cases in which the hernia escapes externally to the femoral vessels, the circumflex ilii artery would lie to the outer side of the sac. Diagnosis—Femoral hernia seldom attains a large size, appearing usu- ally as a firm, tense, rounded tumor, on the inner side of the femoral vessels, and invariably originating below Poupart's ligament—though it frequently passes above that structure, as it curves upwards after emerging from the saphenous opening. When of large size, the appearances are somewhat dif- ferent, the tumor then being often soft and doughy, even though strangulated. The diagnosis of crural from inguinal hernia, can always be made by observ- ing the relations of the neck of the hernia to Poupart's ligament and the spine of the pubes, as pointed out at page 792. Obturator hernia can be dis- tinguished by noting its deep situation and the freedom of the femoral ring. Enlarged lymphatic glands may be mistaken for crural hernia, but can usu- ually be distinguished by observing that there is more than one tumor, and that there is no impulse on coughing, and by attention to the history and progress of the case. As, however, a strangulated femoral hernia may exist behind an enlarged gland, in any case of doubt an exploratory incision should 800 SPECIAL HERNIA. be made. The same course may be necessary if symptoms of strangulation occur in a case in which a fatty or cystic growth occupies the region of the femoral ring. For the diagnosis of crural hernia from psoas abscess, see page G44. A dilated and varicose condition of the saphena vein may be distin- guished by the absence of gurgling on reduction, and by the return of the tumor when the patient stands up, even though pressure be made at the crural ring. Treatment of Femoral Hernia__The Palliative Treatment consists in the application of a well-fitting truss, Avhich, in ordinary cases, should be furnished Avith a small and convex pad, made to press just below Poupart's ligament and a little to the outside of the pubic spine, in the line of the crural canal. If, hoAvever, as is sometimes the case, the whole crural arch be much relaxed, a large and rather flat pad is preferable, in order to press Poupart's ligament against the body of the pubes, and thus approximate the walls of the canal. A hollow-pad or bag-truss must be employed if the hernia is irreducible. Radical Cure__Mr. Wood has described an operation in which wire is used in the same manner as in his second method of treating inguinal hernia, and by which " that part of the tendinous crural arch Avhich overrides the neck of the sac is drawn backwards and dowmvards, and becomes adherent to the pubic portion of the fascia lata." Cheever, of Boston, has recorded one case in which this plan was resorted to without any permanent benefit, but no extended statistics of the operation have, I believe, as yet been published. Taxis—In applying the taxis in a case of femoral hernia, the thigh of the affected side should be strongly flexed, rotated imvards, and carried Avell across the opposite limb, so as to relax the crural arch. Pressure is to be made in accordance with the direction of the descent of the hernia, viz., first doAvnwards, so as to clear the falciform process, then backwards, and finally upAArards in the line of the crural canal. The taxis is less likely to succeed in femoral than in inguinal hernia, and the proportion of cases requiring herni- otomy is therefore greater. Moreover, there is less time for delay, as stran- gulation in crural rupture is commonly of the acute variety (see p. 776). Herniotomy.—The external incision may vary according to the fancy of the operator, some surgeons preferring a single longitudinal incision, others one which is oblique and parallel to Poupart's ligament, while still others combine both, thus, I** ""'j , or make a slightly curved cut over the pubic side of the neck of the tumor, reaching one inch above and one or two below the crural arch. The superficial coverings having been divided, the con- densed layer formed by the septum crurale and crural sheath (fascia propria) is cautiously opened, so as to expose without wounding the sac. The finger is then passed up below the fascia propria, and the nail, or the extremity of a grooved director, insinuated under the sharp edges of Gimbernat's ligament and the falciform process, at their point of junction (Hey's ligament), the hernia-knife being then introduced and made to cut upwards and inwards for a space not exceeding two lines. If reduction cannot now be effected, any constricting fibres of the fascia propria which may have been left are to be carefully severed, Avhen, if the hernia be still irreducible, the sac must be opened, and the stricture sought for and divided, Avith the precautions de- scribed on a previous page. It is sometimes possible to relieve the strangu- TREATMENT OF FEMORAL HERNIA. 801 lation by nicking Gimbernat's and Ilev's ligament outside of the fiiscia propria. In the majority of instances, however, the stricture is in this structure itself, requiring it to be laid open in the manner above described. The fascia pro- pria, Avhen much thickened and congested, may be mistaken for the hernial sac, or for a mass of omentum. It has not, hoAvever, the arborescent arrange- ment of vessels wliich characterizes the former, and is more rounded and uni- Fig. 433. Incision for strangulated femoral hernia. (Fergusson.) form in appearance than the latter. The direction in Avhich the stricture is to be divided, Avhether the sac be opened or not, is invariably upwards and inu-ards. An outAvard incision might Avound the femoral vein, one upAvards and outwards the epigastric artery, and one directly upAvards the spermatic cord, Avhile an imvard incision Avould divide Gimbernat's ligament only, and therefore probably fail to relieve the constriction. The only possible risk, in the incision upwards and imvards, is of wounding the obturator artery, in the rare cases in Avhicli this vessel Avinds around the neck of the sac {page 799). This danger may be obviated by slightly blunting the edge of the hernia- knife, Avhich will then push the vessel before it, Avhile it will still be sharp enough to divide the fibrous bands Avhich impede reduction. Wyeth advises that the point of the knife should be kept firmly pressed against the pubis during this step of the operation, as, if the cutting edge does not pass beyond the ligament, the artery cannot be Avounded. As already mentioned, a very limited incision is sufficient. Should the obturator artery be accidentally wounded, hemorrhage from either end must be arrested by torsion, or, if this fail, by the application of a ligature. Herniotomy by Gay's Method___An incision of about an inch in length is to be made on the inner side of the tumor, near the neck of the sac, and the various tissues cautiously divided until a concealed bistoury can be introduced fktAvise between the neck of the sac and the inner margin of the crural ring. The edge of the knife is then turned tOAvards the pubis, Avhen, by projecting the blade, the stricture is readily divided. The small lateral incision Avhich is practised in this mode of operating, Avas highly commended by the late Sir William Fergusson, avIio declared that he rarely employed any other. This distinguished surgeon, hoAvever, apparently completed the operation with the ordinary hernia-knife, instead of Avith the bistouri cache,, as originally advised by Gay. 51 802 SPECIAL HERNIA. Obturator Hernia. In this rare form of hernia, which Avas first described by Garengeot, the protrusion takes place through the obturator foramen, forming in some cases a well-marked tumor in Scarpa's triangle, though, in other instances, not even the slightest fulness of the part has been perceptible. The affection is com- moner in women than in men, and the hernial sac (which is one of gradual development) is ahvays small, not unfrequently containing a portion only of the calibre of the bowel. Obturator hernia is occasionally complicated by the coexistence of femoral or inguinal hernia, and, in a case recorded by Hil- ton, the sac of an obturator hernia was found on either side of the body. The position occupied by an obturator hernia is in Scarpa's triangle, behind and someAvhat to the inner side of the femoral vessels, and to the outer side of the adductor longus tendon ; the hernial tumor is covered by the pectineus muscle. Zoja, an Italian surgeon, has recorded a case of obturator cystocele. Diagnosis___When the protrusion is perceptible, the case may be diag- nosticated from one of femoral rupture by observing the position of the tumor in relation to the femoral artery and body of the pubis—these structures lying behind the tumor in the case of a crural, but in front of it in the case of an obturator hernia. When no swelling is observable, the symptoms of strangu- lation being at the same time present, the diagnosis of obturator hernia may be made, according to Birkett, by attending to the folloAving particulars : (1) there is often a history of colicky pains previously felt in the pelvic region, sometimes relie\ed Avith an accompanying sensation of something having slipped back into the abdomen ; (2) the evidences of strangulation may have been preceded by a sudden and violent pain at the inner and upper part of the thigh ; (3) cramp in the abdominal muscles, rather than pain within the abdomen, may be complained of, obviously due to reflected irritation from the cutaneous filaments of the obturator nerve ; (4) pain in the course of the distribution of the obturator nerve—a very significant symptom, the value of Avhich was first pointed out by Howship—may be induced or increased by rotating the thigh outwards, and thus putting the obturator muscles on the stretch ; (.">) pain may be elicited by making pressure over the external out- let of the obturator canal, comparing the effect on either side of the body ; and (6) pain may be elicited by pressing on the pelvic outlet of the canal with the finger introduced into the vagina or rectum. Treatment—If the hernial tumor be perceptible, an attempt may be made to effect reduction by means of the taxis ; but if this fail, or if there be reason to suspect the existence of strangulated obturator hernia, though no swelling can be recognized, an exploratory operation should at once be resorted to. A longitudinal incision about three inches in extent may be made, be- ginning a little above Poupart's ligament, and passing doAvnwards on the inner side of the femoral vessels. The pectineus muscle being divided, and the fibres of the obturator separated Avith the director or handle of the knife, the sac of the hernia, if there be one, Avill be exposed. The taxis should now be tried again, Avhen, if still unsuccessful, the sac should be opened, and the stricture cautiously divided in an upward direction. Birkett has collected twenty-five recorded cases of strangulated obturator hernia, in fourteen of which the nature of the affection was not discovered until after the patient's death, Avhile in one the symptoms disappeared spontaneously without treat- ment. Of the ten cases recognized during life and submitted to treatment, four recovered and six died. The taxis Avas employed in two cases, Avith one recovery; and herniotomy in six cases, with three recoveries. In one case ISCHIATIC OR SCIATIC HERNIA. 803 (Hilton's)1 the diagnosis was not made until after the performance of laparo- tomy (the patient dying), and in another, in Avhich the integuments were becoming gangrenous when the case was first seen, the patient died the day after the establishment of a fecal fistula. Perineal Hernia. In this form of rupture, the protrusion occupies the perineum, and is placed, usually, betAveen the rectum and prostate in the male, and between the rectum and vagina in the female, but, occasionally, on one or other side of the anus. Perineal hernia, Avhich is more common in women than in men, is readily reducible, and may be kept Avithin the pelvic cavity by the use of a pad and T bandage. Pudendal or Labial Hernia. In this variety, the hernia occupies one of the labia majora, descending betAveen the vagina and the ramus of the ischium. Pudendal hernia is to be diagnosticated from ingui no-labial and from femoral rupture, and from cysts of the labium and of the canal of Nuck, the so-called hydrocele of that part. From ingui no-labial hernia, it may be distinguished by the parallelism of its axis to that of the vagina, by the non-implication of the inguinal canal, by its rounded rather than pyriform shape, and by its position alongside of the ramus of the ischium instead of over the body of the pubis; from femoral hernia, by the position of the neck of the hernial sac as regards the ramus of the ischium, this bone lying externally in the case of pudendaUand internally in the case of crural rupture ; and from cystic growths, by their irreducibility, their tense and resisting character, their gradual increase in size, and, in many instances, the possibility of completely isolating them Avith the fingers. The treatment consists in the introduction of a suitable pessary, or in the application of an elastic bandage. Should strangulation occur and herniotomy be required, the stricture should be divided in an inward direction. Vaginal Hernia. The protrusion occupies either the anterior or posterior wall of the vagina, and may produce discomfort by compressing either the rectum or urethra. The treatment consists in the use of a suitable pessary or elastic bandage, and in the employment of the catheter, if there is any difficulty in evacuating the contents of the bladder. . Ischiatic or Sciatic Hernia. The hernia protrudes through the sciatic notch, usually beloAV but some- times above the pyriformis muscle, and projects beneath the gluteus maximus. The treatment consists in the application of a pad and elastic bandage ; should herniotomy be required, the stricture should be divided, as recommended by Sir Astley Cooper, in a forAvard direction. An interesting example of this rare form of hernia has been recently reported by Crossle, of Dublin. 1 A second case of laparotomy (fatal) for obturator bernia has since been recorded by Coulson. 804 DISEASES OF INTESTINAL CANAL. CHAPTER XLII. DISEASES OF INTESTINAL CANAL. Intestinal Obstruction. Obstruction to the passage of fecal matter along the intestinal canal may be due to various causes, some of which produce acute symptoms and often terminate life in the course of a feAV days, while others act comparatively slowly—the obstruction in these cases not unfrequently yielding spontaneously, and, even when proving fatal, not doing so for a considerable period ; hence the customary division of cases of intestinal obstruction into two classes, the acute and chronic, a division which is convenient for purposes of study, and Avill therefore be retained, though in practice eases will often be met Avith which are on the border line between the two varieties, the acute forms of obstruction sometimes, as Avell remarked by Pollock, subsiding into the chronic, while, on the other hand, the chronic cases may at any moment become acute. Fie. 434. Acute Intestinal Obstruction__The most frequent causes of this form of obstruction are (1) congenitcd malformations; (2) the impaction of foreign bodies, gall-stones, etc.; (3) invagi- nation or intussusception—the upper seg- ment of bowel commonly slipping within the grasp of the lower, like the finger of a glove when it is taken from the hand—though occasionally the loAver segment is invagi- nated into the upper, constituting retrograde intussusception; (4) twisting of the boAvel upon itself—volvulus—commonly connected Avith abnormal elongation of the mesenteric attachment of the affected gut; and (5) in- ternal strangulation, due to the bindingdoAvn of the bowel by a diverticulum, or by a band of organized lymph, to the protrusion of the gut through an aperture in the mesentery or omentum, etc. Symptoms of acute obstruc- tion may also occur in the course of inflam- matory affections of the abdomen, such as peritonitis or typhlitis, or (as already men- tioned) in cases of chronic obstruction, espe- cially from cancerous disease of the boAvel. Spasm, Avithout organic change, is considered by some authors to be capable of producing acute obstruction ; but though the possibility Internal strangulation by a diver- °f SUch an event may not be denied, its OC- ticuium. (Pirrie.) currence must be extremely rare.1 1 Strangulated hernia, which is perhaps the most frequent cause of acute intestinal obstruction, is treated of in Chap. XL., and is therefore omitted here. INTESTINAL OBSTRUCTION. 805 Symptoms of Acute Obstruction__These are usually Avell marked; the patient commonly experiences intense pain, often referred to a particular spot, accompanied Avith great vital depression, and occasionally absolute syn- cope. Vomiting, at first of the gastric and subsequently of the intestinal con- tents, and complete constipation, quickly supervene, the abdomen at the same time becoming tender, swollen, and tympanitic, and the interference with normal peristalsis causing the boAvels to roll over each other with loud borbo- rygmns and gurgling; the motions of the intestine, if the abdominal parietes be thin, may be felt or even seen externally, and may sometimes be observed to cease suddenly at some particular point which corresponds to the seat of obstruction. Unless relief be speedily obtained, death ensues—either from simple exhaustion, or more commonly from peritonitis, gangrene, or both— the duration of the case rarely exceeding a Aveek or ten days ; in cases of intussusception, the iiiA'aginated portion of gut is occasionally separated by sloughing, and discharged per anum, the continuity of the boAvel being main- tained by previously formed adhesions, and spontaneous recovery thus fol- lowing. Chronic Obstruction__The most common causes of this A^ariety of obstruction are (I) fecal accumulations; (2) stricture of the bowel, often of a malignant character; (3) inflammatory changes in the bowel, resulting from injury; (4) chronic peritonitis (often .tuberculous), or abdominal abscesses; and (5) abdominal tumors of various kinds, wliich may compress and thus obstruct the adjacent portions of intestine. Symptoms.—In the case of chronic obstruction, constipation is the most prominent symptom; there is seldom any acute pain, and comparatively slight constitutional disturbance, while the vomiting is not constant and does not assume a stercoraceous character until much later than in cases of the acute variety. Abdominal distension, though ultimately Avell marked, is slowly developed, and life may be prolonged for six weeks or more, recovery even being sometimes obtained after the persistence of complete obstruction for this period of time. Statistics of Intestinal Obstruction__The statistics of intestinal obstruction were particularly investigated by the late Dr. W. Brinton, avIio found, from an analysis of 12,000 post-mortem examinations taken promiscu- ously, that, excluding hernia, intestinal obstruction caused death in one out of 280 cases. Of the fatal cases of obstructed bowel, about 43 per cent. Avere due to the existence of intussusception ; 31^- per cent, to internal stran- gulation (by bands, etc.); 17-g- per cent, to strictures, or to tumors implicating the intestinal wall; and 8 per cent, to tAvisting of the gut upon itself. The locality of the lesion was (in the case of intussusception) the junction of ilium and cecum in 56 per cent., the ilium alone in 28 per cent., the jejunum in 4 per cent., and the colon in 12 per cent, of the Avhole number of instances. In obstruction from internal strangulation, (by bands, etc.), the part affected was the small intestine in 95 per cent, of all cases ; Avhile, on the other hand, strictures and twistings involved the large intestine in 88 per cent, of all cases. The sexes are almost equally liable to most of the causes of intestinal obstruction, but impacted gall-stones are four times as common in Avomen as in men, Avhile, on the other hand, according to Leichten- stern, intussusception is nearly twice as common in the male as in the female. Diagnosis.—It is of the utmost importance, in undertaking the treat- ment of a case of intestinal obstruction, to ascertain (1) whether it belongs 806 DISEASES OF INTESTINAL CANAL. to the acute or to the chronic variety, and (2) to Avhat cause the obstruction is due. From Dr. Brinton's statistics, quoted above, it will be seen that of acute (fatal) cases rather more than half (43 to 394^) are due to intussuscep- tion, while of the remainder, about four-fifths are due to internal strangula- tion ; and as the treatment of these conditions is not the same, their diag- nosis becomes a matter of great interest. Intussusception is by far the most frequent cause of obstruction met Avith among infants and young children, and is sometimes traceable to the dis- turbance created by polypi of the bowel, by intestinal worms, or even by masses of undigested food ; it is especially characterized by a constant desire to go to stool, and by the discharge from the rectum of mucus, with liquid or coagulated blood. The perpetual desire to defecate is considered by Pollock almost pathognomonic of invagination. Stercoraceous vomiting is not so uniformly present in this as in other varieties of actute obstruction. In many cases, if the abdominal wall be thin, an elongated tumor, the shape of which has been compared to that of a saus;T.ge, may be distinctly felt by pal- liation, usually at the left side, and, in children at least, the invaginated gut may often be felt by the introduction of the finger into the rectum. Internal Strangulation is most common in the periods of adolescence and early adult or middle life. Its most characteristic symptom is the occurrence of intense prostration or syncope. Twisting of the Bowel is usually an affection of advanced life, and com- monly involves the sigmoid flexure of the colon, its next most frequent seat being in the neighborhood of the ileo-ca'cal valve. True knotting of the bowel has been observed in at least three cases, recorded by Parker, Gruber, and M. W. Taylor. In obstruction from twisting, the abdomen is, according to Erichsen, unevenly distended, one side being flattened while the other is tympanitic. Strictures or Tumors (causing chronic obstruction) affect the lower bowel much more commonly than the upper, and the diagnosis can usually be made by inquiring into the history of the case, and by an examination per anum. The history of the case will likewise serve for the purpose of diagnosis, should acute symptoms suddenly supervene under these circumstances. In order to determine what part of the intestinal canal is the seat of ob- struction, it is to be borne in mind that Avhen the symptoms are acute, the lesion (unless the case be one of tAvisting of the gut) is usually situated in the upper bowel, while chronic obstruction commonly involves the large in- testine. Obstruction below the descending colon can generally be recognized by careful exploration of the rectum. The period at Avhich stercoraceous vomiting occurs is earlier in proportion to the greater proximity of the seat of obstruction to the pylorus; moreover, the higher .the point at Avhich peri- stalsis is arrested, the less, as a rule (according to Hilton, Bird, and Barlow), is the amount of urine secreted. Finally, careful palpation of the abdomen may, if the parietes be thin, serve to point out more or less exactly the point at which the bowel is obstructed. Treatment of Intestinal Obstruction. Certain -indications are common to all cases of intestinal obstruction.1 Bearing in mind thatthe most desperate cases sometimes terminate in spon- taneous recovery, the surgeon should in the first place endeavor to obviate 1 It is perhaps scarcely necessary to say that in every case of intestinal obstruction, the surgeon should make a careful examination of all the localities in which hernia is apt to occur. TREATMENT OF INTESTINAL OBSTRUCTION. 807 the tendency to death by relieving pain, diminishing peristaltic action, pre- venting distension, and maintaining the patient's strength. The first and second objects are best accomplished by the free administration of opium (Avhich may be advantageously combined with belladonna), and preferably in the solid form. From half a grain to a grain of the Extraction opii of the U. S. Pharmacopoeia, may be given every three or four hours, or at such in- tervals as may be thought proper. The third and fourth objects are to be accomplished by the administration of concentrated food in small quantities and at frequent intervals. It is obviously desirable that, in order to prevent distension, the bulk of food, and especially of liquid, introduced into the stomach, should be as small as possible, and for the same reason the exhibi- tion of purgatives by the mouth should be strictly interdicted. Large and repeated enemata of warm Avater, or, which Head prefers, warm oil,1 ad- ministered through a long tube, are, on the other hand, of the greatest value, serving in different cases to effect disintegration of fecal accumulations, to alter the position of the bowel and thus car.se the disappearance of a tAvist, or even possibly to relieve intussusception by pushing up the invaginated gut: the last-mentioned result could, however, only be attained in very recent cases, on account of the rapid formation of adhesions betAveen the tAvo portions of intestine Avhich are involved. Inflation of the large intestine u-ith air, introduced through the rectum by means of a long tube and stomach-pump, has occasionally proved successful in relieving the obstruction Avhen all other measures have failed, and should certainly, I think, be resorted to in such cases. The application of electricity has also proved successful in cases recorded by Finny, Giommi, and others. The administration of calomel, in combination with opium, might be proper in case peritonitis should be developed at an early period ; but under other circumstances should be avoided, as tending by its cathartic action to increase the distension of the bowel. External manipulation by gently rubbing and kneading the abdo- men (abdominal taxis), has occasionally proved of service, and may be aided, as may the administration of enemata, by placing the patient upon the knees and elboAvs, or, in the case of an infant, by complete inversion. The special treatment of congenital malformations of the anus or rectum, of stricture or tumor involving the large intestine, and of abdominal abscess or tumor, compressing, though not directly implicating the bowel—any of Avhich conditions may lead to intestinal obstruction—will be considered in future pages. But, supposing that the case is one of acute obstruction, re- sulting from either intussusception, internal strangulation, tAvisting, stricture of the small intestine, or the impaction of a foreign body, and that the course of treatment which has been recommended has been tried and failed, Avhat is to be done ? There is no time for delay, for these cases as a rule soon termi- nate fatally, and if any operation is to be done, it should not be postponed until the patient is at the point of death. Laparotomy, or, as it is more commonly though less accurately called, Gastrotomy.2 the laying open of the abdominal cavity in order to search for and if possible remove the source of obstruction, has been resorted to in these cases, and is, I think, justifiable under certain circumstances. If, hoAvever, the case be one of intussusception (and this is, as has been seen, the cause 1 Cases have been recorded by Libur and Jate, in which cures Avere effected by the successive injections of solutions of bicarbonate of sodium and of tartaric acid. Murray, of Newcastle-on-Tyne, and others, recommend enemata of ox-gall. 2 It is better, I think, to reserve the term gastrotomy for the operation of opening the stomach to remove a foreign body (page 374), designating the operation of abdominal sec/ion, in general, by the word laparotomy (from Xairap*, the soft part of the body below the ribs). 808 DISEASES OF INTESTINAL CANAL. of obstruction in the majority of acute cases), the surgeon will, in my judg- ment, usually best consult the interests of his patient by declining operative interference. My reasons for this opinion are, that (1) the tender age of many of the subjects of invagination renders them peculiarly ill adapted to support so grave an operation ; (2) the operation, which is always one of a very serious nature, is particularly so in these cases, on account of the fre- quent existence of peritonitis as a complication ; (3) the attempt to dislodge the invaginated bowel is very apt to fail; and (4) there is a fair probability of spontaneous recovery after sloughing of the invaginated gut. The latter point may be illustrated by Leichtenstern's statistics, which show that of 557 cases of which the termination is known, sloughing occurred in 149, of Avhich 88 ended in recovery and 61 (41 per cent.) in death, while of the 408 in Avhich sloughing did not occur, only 63 terminated favorably and 345 (K5 per cent.) in death. The only cases of intussusception in Avhich laparotomy seems to me to be justifiable are the rare instances in Avhich the symptoms are those of obstruction merely, and not of strangulation. The operation has, I believe, been employed in 31 cases, 10 of Avhich terminated successfully. The earliest age at which the operation has been successful is six months (Sands). In cases of acute obstruction due to causes other than intussusception, there can be no doubt, I think, that laparotomy is justifiable, should other measures fail to give relief in the course of two or at most three days. There is, under such circumstances, no reasonable prospect of spontaneous recovery, and the only hope of cure in a case of persistent internal strangulation, which, next to invagination, is by far the most common lesion found in cases of acute obstruction, is in the employment of operative measures before the occurrence of general peritonitis or gangrene. Even in these cases, hoAvever, it may be well, before resorting to the knife, to try, as advised by Brinton, the effect of one or more tobacco enemata. Laparotomy is thus performed : The patient, thoroughly etherized, is placed in the recumbent posture, his buttocks being brought to the foot of the operating table, and the contents of his bladder evacuated by catheterization; the temperature of the room should be previously raised to at least 70° Fahr. The surgeon may cut doAvn directly upon the seat of obstruction, if the point at which this exists has been accurately determined, but should, under other circumstances, make his incision strictly in the median line, the wound ex- tending from an inch beloAV the umbilicus, longitudinally downwards for about four inches. The dissection is cautiously carried down to the peritoneum, in which membrane a small opening is then made, and enlarged as much as may be necessary with a probe-pointed bistoury introduced upon the finger as a director. Search is next to be made for the seat of obstruction, by carefully tracing doAvmvards that portion of the boAvel Avhich is found distended. The source of strangulation having been discovered, the constriction is to be re- lieved, by the division or separation of bands or organized adhesions, or by AvithdraAving the strangulated gut from any pocket or fissure in which it may have been caught. If it should be found that the case is one of volvulus, the bowel may be carefully untwisted and replaced in its normal position. If the obstruction be due to the impaction of a foreign body or a gall-stone, the gut may be opened and the offending substance removed, the case being subse- quently treated as one of wounded intestine (see page 372). If a stricture of the intestine be found (very rare except in the lower bowel, Avhen a different operation would be indicated), the best that can be done is to lay open the gut above the stricture, and attach the margins of the aperture thus made to the edges of the external Avound, in hope that the patient may recover Avith OPERATIONS FOR CHRONIC OBSTRUCTION. 809 Cases. Recovered. Died. 10 3 7 14 5 9 31 10 21 5 4 1 2 2 44 *9 35 1 1 10 3 "i 6 2 4 a fecal fistula. The same course should be pursued if the case be found to be one of intussusception, and if the firmness of the adhesions should prevent the relief of the invagination. Unless it be designed to attempt the establishment of a fecal fistula, the external avouikI should be immediately closed, upon the completion of the operation ; the after-treatment consists in the adoption of means to combat the peritonitis which may he expected to arise. The statistics of laparotomy for intestinal obstruction have been investigated by several Avriters, including Adelmann, Whitall, Sands, and myself. I have collected in all 123 cases, of Avhich only 35 appear to have ended favorably. Operation for Volvulus ........ Strangulation continuing after herniotomy or taxis Invagination ....... Foreign bodies, impacted feces, etc. Prolapsus of small intestine through rupture of rectum ........ Strangulation by bands, adhesions, or diverticula Obstruction from rctroverted uterus Tumors, strictures, ulcers, etc. .... Internal hernia and " ileus" .... Aggregate.....123 37 86 Enterotomy for Acute Obstruction__The operation which has just been described, is that which I Avould ordinarily recommend in cases of acute intestinal obstruction in Avhich interference is deemed necessary. Other surgeons, however, including Air. Maunder, prefer a resort to Enterotomy, making an incision in the right iliac region, and opening the first coil of intestine Avhich presents itself, so as to establish a fecal fistula. This opera- tion involves much less interference Avith the peritoneal cavity than laparotomy, and may therefore be preferred in some cases as a palliative or euthanasial measure, but it could not be expected to afford permanent relief in cases of internal strangulation, Avhile in cases of intussusception, no operation should, as a rule, be performed, for the reasons already mentioned. Puncture of the Bowel with a delicate trocar or aspirator is recommended by Gross, Demarquay, and Wagstaffe, as a means of affording relief by alloAv- ing the escape of gas from the distended bowel. This procedure is, however, not free from risk, death directly traceable to the operation having folloAved in three out of ten cases recorded by Frantzel, of Berlin. Operations for Chronic Obstruction; Colotomy__In most in- stances, the cause of the obstruction in chronic cases can be detected by careful rectal exploration, when very simple treatment Avill often suffice to give relief; thus, if an accumulation of hardened and impacted feces be found in the loAver boAvel, repeated enemata must be employed, so asi to soften and disintegrate the mass, removal being, if necessary, aided by the use of the finger, or, Avhich is certainly more agreeable to the operator, a lithotomy scoop, or the handle of a teaspoon. In cases of obstruction dependent on uterine or ovarian disease, the surgeon should address his treatment to the organs primarily implicated. The cases of chronic obstruction demanding operative relief are chiefly those dependent on stricture of the rectum, Avhether malignant or otherwise, and the operation employed in these cases consists in the establish- ment of an artificial anus by opening the colon (colotomy), the part of the gut usually selected for this procedure being the sigmoid flexure. The operation of colotomy may also be occasionally required in certain cases of malformation 810 DISEASES OF INTESTINAL CANAL. of the loAver boAvel, of ulceration or cancerous disease of the rectum (even if unattended by obstruction), and of recto-vaginal or recto-vesical fistula. Colotomy may be performed by opening the sigmoid flexure in the left iliac region (as originally suggested by Littre, in 1710) ; the cecum in the right iliac region (Pillore, 1776); the sigmoid flexure in the left lumbar region (Callisen, 1796) ; the transverse colon in the umbilical region (Fine, 1797) ; or, finally, the cecum in the right lumbar region. Callisen's or Amussat's Operation___The operation, which is generally resorted to at the present day, and Avhich is certainly the best in cases of chronic obstruction from stricture, etc., Avas suggested by Callisen and subse- quently improved by Amussat, and consists in opening the colon in the left lumbar region—Left Lumbar Colotomy; the folloAving directions for its per- formance are given by Allingham, and are founded upon the experience derived from more than fifty dissections, and from a large number of opera- tions performed by that surgeon. Ana'sthesia having been induced, the patient is fixed in the prone position with a slight inclination tOAArards the right side, a hard pillow being placed under the left side so as to render the loin tense and prominent. To determine the exact position of the colon, a point on the crest of the ilium, midAvay betAveen the anterior superior and posterior superior spinous processes, is marked with iodine paint, the colon in Fig. 435. Kesult of lumbar colotomy, showing line of incision. (Bryant.) the normal condition being ahvays situated half an inch behind the point thus marked. The surgeon then, standing in front of the patient, makes an incision of at least four inches, midway betAveen the last rib and the crest of the ilium, the centre of the wound corresponding exactly with the point which has been marked. The wound may be transverse, as recommended by Amussat, or, wliich is better, oblique, doAvnwards and forwards in the course of the ribs, as advised by Bryant. The various tissues are carefully divided to the full extent of the external Avound, until the lumbar fascia and edge of the quadratus lumborum muscle have been reached; the former being cut through, the colon usually presents itself, and may commonly be recognized, even if undistended, by the appearance of one of its longitudinal bands. Care must be taken not to open the peritoneum, which is sometimes inflated Avith gas, and simulates the appearance of the boAvel. The operation is completed by introducing Avith a curved needle strong silken sutures, by means of which the gut is drawn to the surface, Avhen it is incised in the direction of its long axis, to the extent of about an inch ; the margins of the intestinal aperture LUMBAR COLOTOMY. 811 are then stitched to the edges of the external wound, the sutures being retained until they begin to cut their way through by ulceration. The great advantage of this operation over Little's, is in the fact that the abdominal cavity is not opened, the colon being approached on that side which is uncovered by peritoneum ; the operation is comparatively easv when the bowel is distended with feces, but under opposite circumstances (as when performed for stricture Avithout obstruction) may be attended Avith con- siderable difficulty; it is a good plan in such a case to distend the gut Avith air before beginning the operation, so as, if possible, to render the position of the colon more apparent. Some inconvenience is usually at first experienced from prolapse of the boAvel through the artificial anus, but, as the tissues con- tract, the tendency to protrusion diminishes, and it may be ultimately neces- sary to adopt means to prevent the orifice from closing. To avoid the escape of fecal matter at incoiiA-enient times, the patient .should wear an obturator of ivory or other suitable material, attached to a gutta-percha plate, and held in position with a truss or bandage. If the disease for which the operation is performed be situated above the sigmoid flexure (which may commonly be ascertained by noting the quantity of fluid Avhich can be injected),1 the cecum should be opened in the right lumbar region by a similar procedure to that Avhich has been described. Littre's Operation is a more simple procedure than Amussat's, particularly in children. It consists in making an incision from two to three inches in length, parallel to and a little above the line of Poupart's ligament, and mid- way betAveen the anterior superior spinous process of the ilium and the spine of the pubis. The various tissues, including the peritoneum, are cautiously divided upon a grooved director, Avhen the colon is draAvn forwards and opened as in Amussat's method. This operation is usually performed on the left side, opening the sigmoid flexure, but may also be practised on the right side, opening the cecum. With regard to the statistics of these operations, it may be mentioned that Mr. Hawkins, from an analysis of all the cases Avhich he Avas able to collect up to February, 1852, came to the conclusion that the proportion of recove- ries after Amussat's operation was decidedly greater than after Littre's. Mr. Hawkins's tables contain 17 cases in which the peritoneum Avas opened, with 7 recoveries and 10 deaths, and 31 in which the peritoneum was not opened, Avith 17 recoveries and 14 deaths. Of 75 terminated cases of lumbar coloto- my, tabulated by Dr. Mason, of New York, 53 ended in recovery, and only 22 in death. Mr. Curling's experience in lumbar colotomy is perhaps as large as that of any other living surgeon; of 21 cases reported by himself and his colleagues, 14 Avere successful, Avhile 7 terminated fatally—though in some of these great relief wras temporarily afforded. Mr. Allingham's experience has been equally satisfactory; of 10 terminated cases reported by this surgeon up to 1870, 6 are fairly regarded as successful, great relief Avas afforded in 3 more, and death resulted from the operation in only 1 instance. When colotomy is performed for malignant disease of the rectum, perma- nent recovery cannot, of course, be anticipated, but, even as a means of affording temporary comfort, the operation should, in my judgment, be unhesitatingly resorted to in suitable cases. I would advise its performance (provided there were no special contra-indications) in any case of chronic obstruction from disease of the loAver bowel, in which no benefit had resulted from a fair trial of judicious medical treatment. 1 Mr. T. P. Teale recommends laparotomy as an exploratory operation to ascertain on which side the colon should be opened, a preliminary measure which seems to me as dangerous as it is unnecessary. 812 DISEASES OF INTESTINAL CANAL. Malformations of the Axus and Rectum. The surgeon is not unfrequently called upon to attempt the relief of con- genital malformations of the lower bowel, which, unless remedied by operation, Avill inevitably lead to fatal intestinal obstruction. Partial Occlusion of the Anus.—In this condition the anus, though not entirely occluded, yet presents so minute an orifice as not to permit the free escape of feces. The diagnosis of this from the more serious conditions Avhich will be presently described, can be made by careful inspection, Avhich Avill reveal a passage admitting the introduction of a probe. The treatment consists in enlarging the orifice by making radiating incisions with a probe- pointed knife, dilatation being subsequently maintained by the occasional use of a bougie. Complete Occlusion of the Anus__In this variety of malformation the anus is closed by a membrane of greater or less thickness, through which the meconium may be seen, and wliich bulges Avhen the child struggles or cries. The treatment consists in making a crucial incision, excising the flaps thus formed, and bringing the skin and mucous membrane together with fine stitches—a bougie being passed from time to time to maintain the opening in a patulous condition. Imperforate Anus__Here the anus is completely absent, its normal position being occupied by a dense fibro-cellular mass, from a quarter of an inch to an inch in thickness, behind which the rectum terminates in a blind pouch. The treatment consists in making an incision of about an inch in Fig. 436. Imperforate anus. (Ashton.) length, forAvards from the coccyx, in the direction of the raphe of the peri- neum. The wound is then cautiously deepened, in the median line, following the curve of the sacrum until the gut is reached, when a free opening is to be made, and the meconium evacuated. The mucous lining of the rectum is then to be drawn downwards (if possible) to the external wound, and attached to the skin with sutures. The use of bougies is subsequently required to maintain dilatation. MALFORMATIONS OF THE ANUS AND RECTUM. 813 Occlusion of the Rectum.—The anus is Avell formed, and the nature of the case is, therefore, probably not suspected until after the development of symptoms of intestinal obstruction, Avhen the diagnosis may be readily made by the introduction of the finger or a probe, the instrument coming in contact with a bulging membranous septum, from half an inch to an inch above the anal orifice. The treatment consists in making a small incision to evacuate the meconium, the wound being subsequently dilated Avith dressing- forceps or enlarged with a concealed bistoury. The use of the bougie must be continued daily for some months. If the operation is attended with much bleeding, plugging of the rectum should be resorted to. Imperforate Rectum—In this condition the Avhole rectum is Avant- ing, the anus being usually likeAvise imperforate. The colon terminates in a dilated pouch, in the iliac fossa, or opposite the promontory of the Fig. 437. sacrum. The diagnosis of this condition from that of imperforate anus, is ahvays difficult, and often impossible. It may in some cases be facilitated by careful palpation of the abdomen, or (as suggested by Holmes) by introducing a sound into the bladder (or vagina, if the patient be a female), Avhen, if the instrument impinge directly on the posterior Avail of the pelvis, it may be inferred that the rectum is to- tally absent. In the treatment of these cases the surgeon has four operations to choose from, viz., (1) puncture with an aspirator, over the needle of which a small canula may be afterAA'ards pushed in and the passage thus gradually dilated, as advised by Grimes, of Liver- pool, (2) cautious dissection up- Avards from the perineum (as re- commended for imperforate anus), (3) Littre's operation of opening the colon in the iliac region, and (4) lumbar colotomy by the meth- od of Callisen and Amussat. In case of failure to reach the gut by means of the aspirator, the perineal operation should be chosen, unless it is evident that the bowel cannot be reached in this direction. It is performed in the manner already described, great care being taken not to Avound the bladder, vagina, peritoneum, or iliac vessels. If the gut can be reached, its mucous lining should, if possible, be draAvn doAvmvards and attached to the edges of the external wound—as otherwise, apart from the danger attending the passage of the meconium over a raAv surface, the artificial canal will be apt to contract into a narrow and troublesome sinus. Verneuil recommends that the coccyx itself should be excised in these cases, as a preliminary to searching for the boAvel; he has himself adopted this plan in several cases with a successful result. If, however, it be evident that no attempt to reach the bowel from the Imperforate rectum. 814 DISEASES OF INTESTINAL CANAL. perineum can succeed, or if the attempt have been made and have failed, the only remaining course of treatment is to open the colon by one or other of the methods already described. I cannot subscribe to the doctrine that it is more merciful to abandon a child to certain death, than to strive to saAe his life by the formation of an artificial anus ; on the contrary, it is in my judg- ment the surgeon's duty, in these cases, to urge the performance of this operation, on the same principles as those which guide him to recommend tracheotomy in a case of occlusion of the larynx, or amputation in one of hopeless disorganization of a limb. With regard to the particular mode of opening the colon in these cases, some difference of opinion exists. Amussat's operation in the left lumbar region is usually preferred, but is less apt to succeed in these cases than in those of chronic obstruction in adults, on account of the frequent existence in infants of a long meso-colon, Avhich, by allowing the bowel to float, as it were, may render it impossible to complete the operation without opening the peri- toneum ; hence Erichsen is disposed to think that it may be better in these cases to open the caecum on the right side, instead of the descending colon on the left. Mr. Holmes, whose opinion on all subjects relating to the surgery of childhood is of the greatest value, gives a decided preference to Littre's operation, because (1) the operation is easier, the abdominal wall in the infant being thin, while the fat and other tissues of the loin are very deep ; (2) the colon often cannot be reached from the loin without opening the peritoneum, and (3) the descending colon, in cases of imperforate rectum, is often so short that it might not be reached at all by Amussat's operation, unless the incision were made so high as to endanger the kidney ; hence Mr. Holmes recom- mends colotomy from the left groin, and similar advice is given by Mr. Cur- ling. Finally, Huguier advises that the colon should be opened by an incision in the iliac region of the right side. Upon the whole, I think that the Aveight of evidence is in favor of Littre's operation, and it is that Avhich I should recommend in any ease in which it was found impossible to reach the bowel from the perineum. Congenital Malformations with Abnormal Openings in Other Parts___The several varieties of malformation Avhich have been described, may be complicated by the existence of an abnormal communica- tion betAveen the gut and other parts; thus the bowel may open into the bladder or urethra, or into the vagina, according to the sex of the infant, or upon the surface of the body, sometimes at a considerable distance from the natural position of the anus. The treatment of such cases consists in restoring the natural passage (if possible), when the abnormal opening will usually heal of itself, or, if not, may be closed at some future time by a plastic operation. When the gut opens into the vagina, the treatment may be facilitated by introducing a director tlirough the fistulous orifice, and carrying it downwards tOAvards the perineum ; its point may then be cut down upon, and the skin and mucous membrane stitched together in the way already described. Should the bowel commu- nicate with the bladder or urethra, the case may be one of greater difficulty; if, in such a case, the natural passage cannot be restored, a free perineal inci- sion should be made, as in the operation of lithotomy, laying open the neck of the bladder or membranous portion of the urethra, whichever may be in- volved, so as to afford a direct outlet for the meconium and feces. If the gut open on the surface of the body, the question of operath'e interference turns on the position of the abnormal opening; if this be in a situation in which no particular inconvenience Avould result from the deformity (as immediately in front of the coccyx), or, on the other hand, in such a locality as to render it STRICTURE AND TUMORS OF RECTUM AND ANUS. 815 probable that a great part of the large intestine is absent (as in the iliac or umbilical region), the safest plan will be to decline an operation, merely dilating the abnormal aperture so as to prevent fecal accumulation ; if, how- ever, the gut open in the anterior part of the perineum, or in the scrotum the rectum will be found at a short distance beneath the integument, and may be readily reached by an incision in the ordinary position of the anus. In a case recorded by Miss Susan Dimock, in which, after the operation, fecal incontinence continued, the normal and abnormal openings were found to be both within the limits of the sphincter, and a cure was effected by simply dividing the tissues by which they were separated. _ Before operating in any of the more complicated cases of rectal malforma- tion, it may be well, if the symptoms of the case are not urgent, to wait a day in order to allow the gut to become distended, as it will then be more easily reached than if it be in a flaccid condition. Stricture axd Tumors of the Rectum axd Axis. Any part of the large intestine may be the seat of stricture, but it is by tar most commonly met with an inch or two above the anus, or just below the junction of the rectum and Fig. 438. sigmoid flexure of the colon. Three forms of rectal stricture may be described, viz., the sim- ple, the warty, and the ma- lignant. Simple or Fibrous Stricture—The constriction (wliich appears to be due to the presence of an adventitious structure of a fibrous character) is usually seated in the sub- mucous areolar tissue, but more rarely in the muscular coat, or even in the mucous lining of the boAvel. The extent of the stricture varies from a few lines to an inch or more, the whole calibre of the gut being com- monly inATolved, though not unfrequently the induration and thickening are most marked on one side. The causes of this form of stricture are chiefly inflammation or ulceration of the part, Avhether arising from chronic dysentery, from wounds, from the irritation caused by fecal accumulations or foreign bodies, or from the contact of gonorrhoeal or leucorrhoeal dis- charges. In other instances, stricture of the rectum may fol- low the cicatrization of a chancroid, or may occur as a syphilitic lesion, almost invariably, in this case, as a secondary or tertiary phenomenon. The fibrous stricture appears to be more common in women than in men. Fibrous stricture of the rectum. (Ashton. 810 DISEASES OF INTESTINAL CANAL. Symptoms___The symptoms of stricture of the rectum are difficult and painful defecation (the feces being flattened and ribbon-like, or passed in the form of scybala, mingled Avith mucus and perhaps blood), folloAved by various dyspeptic phenomena, and ultimately by the evidences of intestinal obstruc- tion. Abscesses not unfrequently form in the areolar tissue around the gut, and communinate with the boAvel either above or below the stricture, opening into the vagina, in the perineum, or in the gluteal region, and giving rise to intractable fistuhe, Avhich contribute much to the discomfort and exhaustion of the patient. In other cases, the formation of fistulas is due to the escape of fecal matter through ulcerations of the boAvel above the seat of stricture. The more solid portions of the feces are detained above the stricture, the gut at this point becoming dilated into the form of a pouch ; Avhile the more liquid portions mingled with mucus or muco-pus find their Avay tlirough the con- tracted part, leading the patient not unfrequently to complain of diarrhoea. When intestinal obstruction occurs, its symptoms may be gradually deve- loped, or may be suddenly manifested owing to the complete occlusion of the gut by the lodgement of a fish-bone or other foreign body. Diagnosis.—The diagnosis of stricture of the rectum, Avhen the seat of constriction is Avithin three or four inches of the anus, can usually be readily made by digital examination, the finger being Avell oiled, and passed with the utmost gentleness. When the stricture is at a higher point, it may often be brought Avithin reach by directing the patient to bear doAvn, or by making the examination Avhile he is in the upright posture, or, as advised by Simon, the Avhole hand may be introduced, Avhile the patient is in a state of anaes- thesia, and exploration thus carried as high as the sigmoid flexure. The last-mentioned mode of exploration is, hoAvever, as pointed out by Dittel, Weir, and Dandridge, not free from risk, and the latter surgeon has collected four cases, including one of his oavii, in which lacerations of the bowel Avere thus produced. Fatal peritonitis from rupture of a splenic cyst has folloAved the same procedure in the hands of Dr. Briddon. The introduction of a bougie is not of much value for diagnostic purposes, as it is apt to catch in some of the folds of the rectum, or to strike the promontory of the sacrum, and thus lead to error. In making a digital examination, the surgeon should bear in mind that the rectum may be compressed by objects external to itself, as an enlarged prostate, a retroverted uterus, A'arious forms of tumor, enlarged lymphatic glands, abscesses, etc. Treatment—The treatment of rectal stricture is both general and local. The general treatment consists in maintaining the state of the patient's health, in keeping the bowels in a soluble condition by regulation of the diet and the administration of mild laxatives or emollient enemata, and in relieving pain by the use of opium, particularly in the form of suppositories. Iodide of potassium would be indicated in a case of syphilitic origin. The local treat- ment consists in endeavoring to restore the part to its normal calibre by the cautious employment of oiled bougies of gradually increasing sizes ; and in obstinate cases, especially if of traumatic origin, by making slight radiating incisions Avith a blunt-pointed bistoury. Rectal bougies are ordinarily best made of India-rubber, and should invariably be used with the greatest cau- tion, lest laceration, or even perforation, of the boAvel ensue. A bougie, of such a size as to be firmly grasped by the stricture, should be chosen, and may be introduced every third or fourth day, being left in for fifteen or twenty minutes on each occasion. After its Avithdrawal an opium suppository should be inserted, if possible above the stricture. If incisions are required, the knife should be introduced, guided and guarded by the left forefinger, the stricture being simply notched at several points, though Whitehead, Lente, and Beane prefer free incisions in the median line, posteriorly in the case of MALIGNANT STRICTURE. 817 a male, and both posteriorly and anteriorly in that of a female. A bougie may then be passed, and followed in a few minutes by an opium suppository, the patient being kept at rest for a day or Iavo subsequently. In the after- treatment. Whitehead employs an India-rubber bag (such as that used by Bushe in cases of rectal hemorrhage), distending it Avith Avarm water after its introduction; a similar apparatus is employed by Wales. Various ingenious modes of effecting rapid dilatation have been proposed by surgeons, but are, I believe, more dangerous, and not more satisfactory, than the use of the simple bougie, which, though it may perhaps never accomplish an absolute cure of rectal stricture, affords in many instances very decided relief. Verneuil has introduced an operation, under the name of linear rectotomy, wliich consists in freely dividing the stricture together with the lower part of the rectum, including the sphincter. The section is effected Avith the ecraseur (the chain of the instrument being introduced through a fistula, if there be one extend- ing aboA-e the stricture), and the division is made by preference at the poste- rior part of the gut and in the median line ; the wound should not extend more than ten centimetres (about four inches) above the anus, for fear of Avounding the peri- Fi7), or, if necessary, by opening the colon, either in the left or riglit loin, according to the seat of constriction. Warty Stricture.—A peculiar form of rectal stricture, Avhich might be appropriately called warty, has been described by Brodie, Curling, II. Lee, and others, in Avhich numer- ous excrescences, resembling condylomata, oc- cupy the margin of the anus and the interior of the gut, beloAV the seat of stricture. These cases are believed by Gosselin to be of syphi- litic origin. The profuse muco-purulent dis- charge, Avhich is the most, annoying complica- tion of this form of stricture, may be some- Avhat controlled by the use of astringent injec- tions and the application of a solution of nitrate of silver. Malignant Stricture__In this form of stricture, the obstruction is due to a cancerous (usually scirrhous or encephaloid) growth, Avhich may originate as an independent tumor, or as an infiltration in the tissues of the bowel. 52 Malignant stricture of the rectum. (Ashton.) 818 DISEASES OF INTESTINAL CANAL. The symptoms do not at first materially differ from those of simple stricture, though the diagnosis can be made by digital examination, the induration of the malignant growth being of an irregular and nodulated character. When ulceration occurs, the act of defecation is commonly attended with great pain and a burning sensation, extending to the loins and thighs, the discharges containing a considerable quantity of pus and blood. Digital examination at this time reveals a soft, fungous mass, and the finger is Avithdrawn smeared with blood. As the cancerous tumor groAvs, it frequently involves neighbor- ing parts, as the vagina or bladder, giving rise, perhaps, to vesi co-rectal or vagino-rectal fistula, and thus rendering the patient additionally miserable. By compressing the iliac veins, the tumor causes oedema of the lower extre- mities. Death may ensue from gradual exhaustion, at the end, perhaps, of three or four years, or at an earlier period from the occurrence of intestinal obstruction. The treatment must be merely palliative, any attempts to excise or tear aAvay the malignant growth being (in my judgment) totally unjustifiable, and usually leading to a speedy death from peritonitis or hemorrhage. Fain is to bd alleviated by the free use of anodynes (by suppository or otherwise), and fecal accumulation to be prevented by the occasional use of laxatives. Emol- lient enemata may sometimes afford relief, but great care must be taken, in their employment, not to inflict injury on the bowel. Bougies may be cau- tiously employed before ulceration has begun, but at a later period could only be productive of mischief. Linear rectotomyis recommended by Verneuil, but I confess, seems to me not a very promising mode of treatment, and I must say the same of Volkmann's proposal to remove the growth with a circular portion of the rectum, and stitch together the divided portions of the bowel. Finally, lumbar colotomy may be properly resorted to, either to relieve obstruction or to obviate the suffering caused by the passage of feces over the ulcerated surface. Malignant Disease of the Anus__This, aa hen primary, is com- monly ot an epitheliomatous character, though the anus may become second- arily involved in cases of cancer of the rectum. Epithelioma of the anus, if recognized at an early period, may occasionally be excised Avith advantage, the diseased part being held up by tAvo tenacula, Avhich are then freely dis- sected out, as advised by H. Lee ; but in a more advanced stage of the affec- tion, palliative treatment is alone justifiable. Here, as in cancer of the rec- tum, great comfort may be occasionally afforded by a resort to lumbar colotomy. Extirpation of the lower end of the rectum has been practised by Verneuil, Billroth, Koeberle, Levis, Agnew, Briddon, Holmes, J. R. Wood, Keyes, and other surgeons ; in some instances with at least temporary advantage, but in a large proportion of cases Avith a fatal result. The most important point in the operation appears to be to bring the resected gut down and attach it to the surrounding integument by means of sutures. Non-malignant Tumors of the Rectum__These are commonly of a fibrous, libro-cellular, or adenoid character, occasionally sessile, but more often pedunculated, constituting the affection knoAvn as polypus of the rectum. Rectal polypus is most common in children (though rare at any age), and may, unless the examination is made with care, be mistaken tor a hemor- rhoidal tumor, or for a prolapse of the mucous coat of the bowel. The polypus often protrudes through the anus at the time of defecation, and is frequently attended with hemorrhage ; it may exist as a complication of the painful ulcer or fissure of the rectum. The treatment consists in the application of a RECTAL FISTUb.33. 819 firm ligature, so as to strangulate the growth, Avhich may then be cut off be- Ioav the point of ligation, or, which is safer, may be pushed above the sphinc- ter, an opium suppository being then administered to prevent straining and to relieve pain. The strangulated mass becomes detached, and is passed at stool in the course of a feAV days. Excision, Avithout previous ligation, should be avoided on account of the risk of hemorrhage. Sessile growths may be treated in the same way (the base being transfixed by a double ligature and tied in two halves), or may be more speedily re- moved by means of the ecraseur. A vascular tumor of a papillary or villous character has been described as occurring in the rectum by Quain, 11. Smith, Allingham, and other Avriters. It is usually attended with constant, and sometimes with profuse, hemorrhage, Avhich gradually exhausts the patient. Repeated applications of strong nitric acid effected a cure in the case observed by Mr. Smith, but in most instances the ligature would probably be a surer mode of treatment. A dermoid cyst in the rectum has been met with in one instance recorded by Danzel. Rectal Fistul.e. The rectum may communicate Avith the bladder or urethra in the male, and Avith the vagina in the female. Recto-Vesical and Recto-Urethral Fistulae may depend upon congenital malformation, or may be caused by ulceration, usually of a malig- nant character, or by wounds accidentally inflicted, as in the operation of lithotomy. Recto-urethral fistula may also be due to the careless use of a bougie, or to the bursting of a prostatic abscess. The symptoms are suffi- ciently evident; urine escapes into the gut, and by flowing over the nates produces excoriation ; while if the opening be large, fecal matter may enter the bladder, giving rise to cystitis and vesical tenesmus. When the fistula is due to the ulceration of a malignant growth, little can be done in the way of treatment, beyond the adoption of mere palliative measures, lumbar colotomy being justifiable Avhen the feces escape into the bladder. In other cases, hoAvever, an attempt may be made to close the fistula, if small, by occasion- ally touching the part Avith nitrate of sih*er or with the galvanic cautery, Avhile if more extensive, a plastic operation may be tried, the fistula being exposed by means of a duck-billed speculum, and its edges pared and brought together in a transverse direction ; the bladder should be subsequently kept empty by the frequent use of a gum-elastic catheter, and the bowels locked up by means of opium suppositories. The patients in these cases should be taught, before the operation, to introduce the catheter for themselves, so that there may be no occasion for urine to flow over the Avound until cicatrization is completed. Advantage may be sometimes derived from keeping the pa- tient in the prone position, and in one instance Sir H. Thompson succeeded in effecting a cure by this alone. As a last resort, a large staff may be introduced into the urethra, and the sphincter ani divided upon this so as to lay the parts freely open ; the patient should then be placed in the prone position, and a catheter retained in the bladder Avhile the wound is alloAved to heal by granulation. Recto-Vaginal Fistula may depend upon congenital deformity, or upon abscess or ulceration affecting the recto-vaginal septum, sometimes in connection Avith rectal stricture ; but its most frequent cause probably is injury received during parturition. The treatment consists in cauterization (if the fistula be small), or in the closure of the opening by means of a plastic 820 DISEASES OF INTESTINAL CANAL. operation, which is thus performed : The contents of the rectum and bladder having been evacuated, the patient is thoroughly etherized and secured in the lithotomy position ; the fistula is next exposed by draAving upAvards the an- terior Avail of the vagina with a duck-billed speculum, and the edges obliquely pared—the vaginal mucous membrane being dissected off in an extent of four lines around the aperture ; a sufficient number of deep and superficial sutures are then introduced to bring the freshened edges of the fistula accurately together in a transverse direction. Copeland, BroAvn, and Erichsen advise that the sphincter ani should be divided, so as to prevent the contraction of this part from interfering with the healing process. The sutures may be of silk, or (Avhich is better) of silver, or flexible iron wire ; if of silk, they should be removed about the sixth day, but if of metal, may be allowed to remain several days longer. The bowels should be locked up Avith opium for nearly a fortnight. Other modes of treatment consist in laying open the recto-vaginal septum beloAV the fistula by incision, the parts being allowed to heal by granulation, or in introducing a ligature Avhich is daily tightened until it cuts its way through. The late J. R. Barton, of this city, and, more recently, Taylor, of New York, have recommended simple division of the sphincter ani, as in the treatment of fistula in ano; this mode of treat- ment is also applicable to cases in Avhich the gut communicates by a fistulous track with one of the labia majora, constituting Recto-labial Fistula. AVhen recto-vaginal fistula folloAvs upon stricture of the rectum, this must be fully dilated before any operation upon the fistula is attempted. Entero-Vaginal Fistula, in which the small intestine opens into the vagina, its communication with the lower bowel being interrupted, is a rare condition Avhich obviously does not admit of operative relief. Fistula ix Axo. This common and distressing affection consists in an abnormal communica- tion between the rectum and some point on the external surface, usually in the space betAveen the anus and the tuberosity of the ischium. Causes__Fistula in ano may originate in ulceration and perforation of the mucous membrane of the gut, as the result of the irritation produced by fecal accumulations (as in rectal stricture), or by foreign bodies, such as fish- bones or grape-seeds; it may also be traceable to an abscess which occurs externally to the bowel, in the ischio-rectal fossa, and is caused by injuries, such as bloAVS or kicks upon the anus, or by exposure to cold, as from sitting upon Avet grass or stones, or Avhich arises from suppuration around the prostate, or in a lymphatic gland. Varieties.—Three forms are recognized by systematic writers, Adz., (1) the complete fistula, in Avhich there are two openings, one in the gut, and one on the surface of the body ; (2) the incomplete external fistula, in wliich there is no inner opening, though the fistulous track can usually be traced to just beneath the mucous membrane ; and (3) the incomplete internal fistula, in which the sinus communicates Avith the gut, but not with the external surface. The second and third varieties are also spoken of as blind fistule. Symptoms—The position of the external orifice is usually marked by a prominent }>apihk or granulation, while the internal opening can be felt by the finger in the rectum, or may be seen by the aid of the rectal speculum (Fig. 440). There is a discharge of thin pus from the fistula, producing FISTULA IN ANO. 821 excoriation of the surrounding parts, which are commonly thickened and indurated. The fistula sometimes runs a pretty straight course, but is often tortuous and bent upon itself, being superficial from the external orifice to the margin of the sphincter, and then passing up deeply alongside the bowel. There may be several sinuses Fig. 440. opening externally, but all communicating with the same principal track; or there may be tAvo or more inde- pendent fistiike in the same case. Occasionally a slight form of fistula is met with, which opens at the margin of the anus within the position of the sphincter; but in the true " fistula in ano," the external orifice is an inch or more distant from the anus, Avhile the track of the fis- tula passes through or more frequently quite outside of the sphincter. Diagnosis.—This can readily be made by intro- ducing a probe through the external opening, while the finger is placed in the rectum ; the track of the fistula can thus be traced Avith a little trouble to its internal opening, which will almost invariably be found just above the internal sphincter, though a sinus may extend some distance further up the bowel. If there be no internal opening, the probe can be felt in the same locality, imme- diately beneath the mucous lining of the gut. In cases of blind internal fistula \ a bent probe may be introduced tlirough the inner opening (which may be brought into view by the aid of the speculum) and carried downwards in the direction of the fistulous track; in these cases, too, pressure on the external surface will cause an escape of pus into the bowel. It must be remembered that every sinus in the neighborhood of the anus is not necessarily a fistula in ano; it may, for instance, be connected Avith caries or necrosis of the tuber ischii; may depend upon the presence of a tuft of hair, as in curious cases recorded by J. M. Warren and J. J. Lamadrid; or may communicate with an abscess, Avhich may arise within the pelvis, or may proceed from the hip-joint. Treatment—The formation of a fistula in ano may sometimes be pre- vented by the dilatation Avith bougies of any rectal stricture that may exist, and by the prompt treatment of inflammation or abscess in the ischio-rectal space. If the surgeon be called in before suppuration has actually occurred, the formation of an ischio-rectal abscess may perhaps be arrested by the assiduous use of poultices or Avarm fomentations, but if matter be present, it should be at once evacuated by a sufficiently free and deep incision, Avhen the part may possibly heal Avithout forming a communication Avith the gut. The treatment of fistula in ano may consist (1) in the employment of stimulating applications, such as nitrate of silver or the tincture of iodine ; (2) in the use of a ligature, tied so as to strangulate the tissues intervening betAveen the fistula and the surface of the body, and tightened everv few days until it cuts its Avay through by ulceration ; and (.'!) in incision, or the " operation for fistula." The first and second methods are chiefly applicable to those cases in Avhich, from the constitutional condition of the patient, or from his fear of the knife, any cutting operation is contra-indicated. The use of an elastic ligature is recommended by Dittel, Courty, and Allingham, and the latter has devised an ingenious instrument to facilitate its introduction. There is some difference of opinion among surgeons as to the propriety of operating for fistula in ano in the case of phthisical patients, many Avriters 822 DISEASES OF INTESTINAL CANAL. deprecating interference under these circumstances, on the ground that the fistula acts a useful part as a source of revulsion or counter-irritation, Avhile others advise the operation, in the belief that every additional drain upon the system must be injurious. It seems to me that this question should be decided, in each individual case, according to the stage and extent of the constitutional affection, and the degree of annoyance caused by the local dis- ease. In a case of advanced phthisis, unless the discomfort produced by the fistula Avere unusually great, it Avould doubtless be more prudent to decline an operation—but under other circumstances, a different course may be proper. The mere existence of tubercle is not in itself a contra-indication, and there is in many instances reason to hope that by curing the local affection, the progress of the constitutional disease may be retarded, if not completely arrested. When fistula in ano is dependent upon stricture of the rectum, no operation for the relief of the fistula should be performed until the stricture has been properly dilated, and if the stricture be of a malignant character, the opera- tion is positively contra-indicated. The Operation for Fistula in Ano consists in dividing the sphincter, Avith the tissues between the external orifice of the fistula and the anus. It is not necessary to give ether in this operation, unless the patient particularly desire it, but there is no objection to its use, and it should ahvays be em- ployed if there are several external openings, rendering the operation unusually complicated and tedious. The rectum having been emptied by an enema, the patient is placed on the side corresponding to that of the fistula, with his buttocks at the edge of the bed or table, and held apart by an assistant. If there be several sinuses communicating with one fistula, tliese should be laid open on a grooved director; but in the majority of instances there is but a single external opening. Through this the surgeon introduces his director, slightly bent at the extremity, and passes it up in the track of tbe fistula until it projects through the internal opening into the gut, where it can be felt by the forefinger1 inserted into the rectum. The internal opening of the fistula will almost invariably be found just above the sphincter ani, even though the fistula itself extend some distance further along the bowel; if, however, no opening be found here, one should be made by thrusting the director through the rectal mucous membrane, it being quite unnecessary and not very safe to extend the incision higher up. The point of the director being felt in the rectum, is to be hooked doAvn by the finger and brought out through the anus, thus raising the sphincter and other parts to be divided upon the groove of the instrument, Avhich is then cut loose by a few strokes with a sharp scalpel. The Avhole surface of the Avound should then be wiped with the solid stick of nitrate of silver, or caustic potassa, so as to check oozing, and, by making a superficial eschar, prevent premature adhesion of the edges. A strip of oiled lint is finally laid in the Avound, Avhich is allowed to heal by granulation, a probe being occasionally passed between its edges to prevent their uniting superficially and thus reproducing the fistula. The patient should be kept in bed for a few days after the operation, the boAvels being locked up by opium for about forty-eight hours, AA-hen a full dose of castor oil may be administered. I have never met with trouble- some hemorrhage either during or after this operation, but if it should occur (as it may, if the incision be carried too high, from Avound of the hemor- rhoidal vessels), it must be controlled by compression or by styptics, or, if a bleeding vessel can be found, by the application of a ligature. 1 In making digital examinations of either rectum or vagina, tbe finger sbould be well oiled, and the depressions around tbe nail filled with soap, or simple cerate, so as to prevent the adhesion of any oIFensive substance. FISSURES AND ULCERS OF THE ANUS. 823 If the fistula be of the blind internal variety, an external opening may be made by cutting upon the point of a director introduced from Avithin, the subsequent steps of the operation being conducted in the way already described. Other modes of operating are frequently resorted to, but the principle is the same in all. Gross and Allingham, after passing the director, cut from Avithin outAvards with a curved bistoury introduced along the groove of the instrument, Avhile many other surgeons, and perhaps the majority, employ a probe-pointed bistoury, and dispense Avith the director altogether. Brodie, and more recently W. Cooke, have preferred to divide the sphincter Avith scissors, while Hewson and others use the " syringotome," or, as Syme not inaptly called it, tbe "' probe-razor." If there should be more than one fistula, there would be reason to fear that a multiple division of the sphincter might entail subsequent fecal inconti- nence. Hence, in such a ease, the elastic ligature might be used in preference to the knife, or the knife might be used on one side and the ligature on the other. Felix, of Brussels, employs a ligature draAvn rapidly backAvards and forAvards so as to cut its way through, in the manner of the hemp-saw recom- mended for uterine polypi by McClintock, of Dublin. Fissures axd Ulceus of the Axes. Several distinct affections are often included under these names. 1. Fissures, Chaps, or Cracks, may exist in the thin skin around the anus, Avithout at all implicating the mucous membrane. These may fol- Ioav upon herpetic or eczematous eruptions of the part, or may be produced by the acridity of the intestinal discharges, want of cleanliness, etc. In their worst form, these fissures or chaps constitute the rhagades often seen in pros- titutes, and therefore commonly supposed to be of syphilitic origin, though it is probable that, in many instances, they are due rather to the irritating con- tact of vaginal discharges, and to a neglect of ablutions. Though these fis- sures are productive of a great deal of annoyance by the itching and smarting which they occasion, they are not attended by the intense burning pain Avhich characterizes the affection which will next be described, and though they may, like it, cause suffering during the act of defecation, this suffering is of comparatiA'ely brief duration. The treatment consists in the enforcement of scrupulous cleanliness, and in the application of stimulating and slightly as- tringent washes or ointments, with attention to the state of the boAvels and the administration of arsenic or other alteratives, as indicated by the general condition of the patient. Among the most useful local applications are solu- tions of nitrate of silver (gr. v-x to f'oj) or borax, the oxide of zinc or tar ointments of tbe U. S. Pharmacopeia, and the citrine ointment diluted to an eighth of its officinal strength. If mucous patches or vegetations exist, they must be treated as directed in previous chapters (pp. 44.1, 4oH, 500). 2. The True Fissure of the Anus, or, as it should, in many in- stances, rather be called, the Painful Ulcer of the Anus, is a small ulcer situated at or within the margin of the anus, and in the grasp, as it AArere, of the sphincter. It appears, when at the margin of the anus, as a linear ulcer or fissure (Avhence its name), but, when Avithin the gut, may be seen by dilating the sphincter with the speculum to be of an elongated oval shape, rarely exceeding half an inch in length by a quarter of an inch in breadth. The fissure is not unfrequently concealed by a small reddish pile or fold of 824 DISEASES OF INTESTINAL CANAL. skin, while the painful ulcer may be complicated by the existence of a rectal polypus. Symptoms__The symptoms of this affection are sufficiently characteristic. The patient experiences an intense burning pain, beginning at the time of or shortly after the act of defecation, and continuing without alleviation for several hours subsequently. The severity of the pain induces the patient to postpone going to stool as long as possible, thus causing an artificial costjve- ness which only aggraAates his condition. The feces themselves may be streaked with blood or pus on the side corresponding to the seat of the ulcer. There is ahvays a spasmodic contraction of the sphincter ani, attended with tenesmus, and often with a discharge of slimy mucus, and there is frequently great sympathetic disturbance of the urinary apparatus, or of the uterus, oc- casioning an error in diagnosis by directing attention to these organs. The true nature of the case may, however, always be detected by digital or ocular examination, aided, if necessary, by anaesthesia and the use of the speculum. The fissure or ulcer may occupy any part of the circumference of the anus, but is commonly found posteriorly. This is essentially an affection of adult life, though Houghton, of Dudley, has seen a Avell-marked case in a child one year old. Treatment__In slight cases, a cure may sometimes be effected by the ap- plication of chloral, iodoform, or nitrate of silver, and by the use of anodyne and astringent lotions, ointments, or suppositories, but in the majority of in- stances, at least in adults, a trifling operation will be necessary. Boyer, who first accurately described this affection, divided the whole sphincter, thus effectually putting the part at rest and allowing the ulcer to heal; but this procedure is now known to be unnecessarily severe, and the practice of modern surgeons is simply to divide the floor of the ulcer and the muscular fibres immediately beneath it. The rectum being emptied by an enema, the surgeon introduces upon his left forefinger, Avhich serves as a director, a straight, narrow, probe-pointed knife, and, beginning above the upper margin of the ulcer, cuts quickly dowmvards, fairly dividing in a longitudinal direction the whole ulcerated surface tlirough its centre. In some cases it may be more convenient to expose the ulcer by means of a fenestrated speculum, the in- cision being made through the aperture of the instrument. The patient may be etherized for this little operation, if thought necessary, but chloroform should not be used, as death has, according to Ducamp, followed its employ- ment several times in these cases. The after-treatment consists in the appli- cation of a little oiled lint and the introduction of an opium suppository. Recamier, and more recently Van Buren, of XeAv York, have recommended, instead of the incision of the ulcer, forcible dilatation or partial rupture of the sphincter, accomplished by introducing both thumbs, or both forefingers, back to back into the rectum, and then Avidely separating them. I do not know that this procedure is any less painful than the incision, Avhile it is, I think, less certain to effect a permanent, cure. 3. Chronic Ulcer of the Rectum__Extensive ulceration of the rectum, above the sphincter, may result from dysentery, from the irritation caused by foreign bodies or hardened feces, or from the incautious use of bougies or enema-tubes. The symptoms are pain, not, however, usually very severe, with a muco-purulent discharge. The ulcers may be felt by digital examination, or seen by the aid of the speculum. The treatment consists in the employment of anodyne and astringent lotions or suppositories, with attention to the state of the digestive functions. Advantage may be some- times derived from the internal use of the confection of black pepper, Avhich has acquired a reputation under the name of Ward's paste. HEMORRHOIDS. 825 4. Tuberculous Ulcer of the Anus__Under this name MM. Mar- tineau and Fereol have described an affection resembling that met with by Trelat in the tongue (see p. 724). They recommend the topical use of a weak solution of chloral. Hemorrhoids. Hemorrhoids, or piles, are tumors met Avith at or within the verge of the anus, consisting essentially of a hypertrophy and infiltration of the mucous or muco-cutaneous and subjacent areolar tissues, Avith a varicose dilatation of branches of the hemorrhoidal veins ; in some instances rupture of a vein occurs, Avith extravasation of blood into the subcutaneous tissues, while in other cases there appears to be a neAv development of arterial capillaries, the pile being then of a vascular, spongy, and almost erectile character, and its mucous covering having an ulcerated, granular, or somewhat villous appear- ance. Piles are classified according to their situation, into external and internal, and, according to the presence or absence of hemorrhage, into open or bleed- ing, and blind piles. The ordinary bleeding pile is that form of internal hemorrhoid in which the arterial element predominates, and is sometimes called from its shape the globular pile, in contradistinction to the longitudinal or fleshy pile, which is rarely attended by hemorrhage. Causes of Hemorrhoids__Any circumstance which impedes the re- turning current from the hemorrhoidal plexus of veins, or Avhich encourages a flow of blood to the rectum, tends to promote the formation of piles; hence a sedentary life, luxurious habits, occupations which require much standing (as that of a barber), disorders of the alimentary canal, or of the liver, the presence of abdominal tumors, the pregnant state, constipation, the straining due to urethral stricture or prostatic enlargement, inordinate sexual indul- gence, etc., may all act as causes of hemorrhoids. Piles may occur at any age, but are most common during the periods of adolescence and later adult life. They occur with about equal frequency in either sex. The first step in the formation of a pile, either external or internal, is dilatation of a hem- orrhoidal vein, soon followed, if the disease persists, by hypertrophy and infiltration of the superincumbent tissues ; Avhen the pile is unirritated or indolent, it may appear to consist merely of a fold of skin or mucous mem- brane and areolar tissue, but Avhen from any cause the hemorrhoid is inflamed, it becomes SAvollen and tense, and is evidently filled with fiuid or coagulated blood. After a succession of such attacks, the pile forms a distinct tumor, sometimes of considerable size, which, even in its indolent state, gives a good deal of annoyance by its bulk and the sensation of Aveight which it occasions. External Piles___In the indolent state these appear as small tumors or radiating folds, occupying the verge of the anus external to the sphincter, and covered Avith the thin integument of the part. They give rise to a feel- ing of heat and fulness about the anus, particularly after defecation, and may be attended with some itching, but do not usually cause a great deal of incon- venience. When inflamed, however, they become excessively painful, the pain radiating in various directions and being much aggravated by exercise, or even by the assumption of the erect posture ; they are often accompanied by an intolerable itching and burning, witli violent tenesmus, depriving the patient of sleep, and for the time being rendering life almost a burden. If examined in this condition—which constitutes an "attack of the piles"— 826 DISEASES OF INTESTINAL CANAL. Fig. 441. the hemorrhoidal tumors will be found tense and SAvollen, extending up within the grasp of the sphincter, and thus becoming partially covered with mucous membrane (extero-internal piles). Their color, which in the uninflamed state was nearly that of the surrounding integument, is iioav of a deep purplish-red hue. The hemorrhoidal tumor occasionally suppurates, but more commonly returns gradually to its previous indolent state, becoming, however, larger and more indurated Avith each successive attack of inflammation. When piles are large and numerous, the skin betAveen them may undergo macera- tion, giving rise to a sero-purulent discharge wliich sometimes produces troublesome excoriation. External piles are rarely attended by bleeding, but Syme and others have recorded cases of profuse rectal hemorrhage, in which no internal piles could be found, and in which entire relief was afforded by the removal of the pendulous flaps of skin Avhich surrounded the anus. The diagnosis of external piles is made with little difficulty; the only affections Avith which they are liable to be confounded are vegetations and mucous patches, but these can be distinguished by observing that they are not like piles solely confined to the anal region. External hemorrhoids often coexist with the painful ulcer of the anus, or with fistula in ano. Internal Piles___These are situated entirely within the sphincter, and are therefore covered Avith mucous membrane. As already mentioned, there are tAvo principal varieties, the longitudinal or fleshy pile, which in structure corresponds pretty closely with the external hemorrhoid, except that the venous element is more prominent, and the globular, vascular, or granular pile, which is characterized by the development of a con- geries of arterial capillaries. The former va- riety has a broad base, is firm and elastic to the touch, and of a reddish-brown color; the latter may be either sessile or pedunculated, is at first of a bluish hue (resembling a varicose vein), but ultimately assumes its characteristic red color, and villous or straAvberry-like appear- ance. Internal piles may exist just within the sphincter, or an inch or two higher up; occa- sionally the hemorrhoidal tumors form a double circle, one above the other. The symptoms of internal piles are similar to those of external hemorrhoids, but there is more distress, from the tumors frequently protruding during defe- cation and being caught or grasped by the sphincter, thus causing great pain and tenesmus. The frequent protrusion of the piles ultimately leads to general prolapse of the mucous coat of the rectum, while the constant irritation of the part gives rise to a discharge of thin mucus, which excoriates the skin around the anus, and is often sufficiently abundant to soil the patient's clothes. Bleeding from the Rectum, or the Hemorrhoidal Flux, is a most charac- teristic symptom of internal piles ; it may accompany either form of the dis- ease, though by far most common in connection Avith that, in which there are isolated tumors Avith a granular, strawberry-like surface. In most instances, blood of an arterial hue appears to issue directly from the surface of the pile, but occasionally there is general oozing from the congested mucous mem- Protruding hemorrhoids. (Ashton.) TREATMENT OF HEMORRHOIDS. 827 brane. or a copious stream may be poured from an ulcerated opening in a dilated Aein. The amount of blood varies, in different cases, from a feAV drops to many ounces—enough in some instances to produce excessive and even fatal anaemia and exhaustion. The bleeding may be continuous, or in- termittent—recurring sometimes at regular intervals. The occurrence of the hemorrhoidal flux is not unfrequently preceded for some days by an increase of the ordinary symptoms of piles, constituting what the older Avriters called the Hemorrhoidal Effort: in these cases, the loss of blood seems often to act beneficially both by giving local relief and by acting as a deriA'ative, and per- haps preventing serious visceral congestions. The hemorrhoidal flux some- times alternates vicariously with the menstrual Aoav. The pain in a severe case of internal piles is not limited to the rectum, but radiates to the loins, sacrum, hips, and thighs, and marked sympathetic irritation is frequently developed in the urino-genitary organs. Internal like external piles, may become inflamed, and ultimately subside into an indolent condition, persist- ing as hard and incompressible tumors containing clotted blood ; the clot occasionally undergoes a calcareous change and becomes coiiA"erted into a phlebofite or vein-stone. In other instances, the piles protrude and are stran- gulated by the sphincter, eventually sloughing off, and thus undergoing a spontaneous cure. Internal hemorrhoids are to be diagnosticated from prolapsus, and from polypus of the rectum : in complete prolapse of the rectum (a very rare affection in adults), the smooth character of the mucous membrane and the cylindrical form of the protrusion will enable the surgeon to make the diag- nosis, Avhile the common form of prolapse, in which the mucous membrane alone is implicated, may usually be distinguished from piles by its annular form, and by the absence of distinct tumors. The tAvo affections, however, often coexist in the same patient. Rectal polypus may be recognized by its being solitary and of comparatively large size. The diagnosis of bleeding piles from other sources of intestinal hemorrhage may be made by observing that the blood in the hemorrhoidal flux is bright, liquid, and spread over, rather than mingled Avith, the feces, Avhereas blood entering the bowel at a higher point Avill be dark, partially clotted, and mingled more or less inti- mately with the other contents of the intestinal canal. Internal hemorrhoids sometimes exist in cases of fistula in ano, and may prove a troublesome com- plication in the treatment of that affection, by protruding in the wound after the operation. Treatment of Hemorrhoids. Constitutional Treatment__This consists in endeavoring to improve the general health, by the administration of nutritious food and tonics if the patient be of relaxed or debilitated frame, or by regulating the diet and par- tially cutting off the supply of animal food under opposite circumstances : highly seasoned dishes and alcoholic stimulants should be particularly avoided. Any habits that predispose to the disease should be given up, and the patient should daily take moderate but not fatiguing exercise in the open air. If any special cause of the affection can be detected (as urethral stricture), this must of course be appropriately treated. In every case the bowels should be kept in a soluble condition by the administration of mild laxatives, such as castor oil, the compound rhubarb pill, copaiba, the confection of black pepper or senna, the mineral Avaters of Saratoga or Kissingen, etc. Glycerine is recom- mended by G. B. PoAvell, D. Young, and others. Enemata of cold or tepid Avater, as most agreeable to the patient, are sometimes of service. 828 DISEASES OF INTESTINAL CANAL. Local Treatment.—The local treatment may be palliative or radical: the former will, in many instances, suffice to give very great comfort to the patient, and may in mild cases even effect a permanent cure ; it is often the only plan Avhich is applicable in the latter stages of pregnancy, or in extreme old age. The radical cure, or that by operation, should, howe\er, usually be advised whenever the hemorrhoidal tumors have become permanent, leading to more or less constant inconvenience and suffering, and particularly in cases of bleeding piles, in which the amount of blood lost tends to render the patient anaemic. If, on the other hand, the hemorrhoidal flux be slight and not productive of much annoyance, it may, in some instances, be wiser not to interfere, for, as already mentioned, there is reason to believe that the loss of blood in these cases sometimes acts beneficially as a derivative. The Palliative Treatment consists in the topical use of various astringents and anodynes, and in the practice of frequent ablutions, so as to insure perfect cleanliness. Sponging with cold Avater, or the employment of the cold douche, should be resorted to night and morning, and after each fecal evacuation. For internal piles, Aveak astringent injections (as of alum, or of the Tinct. ferri chloridi, ten drops to the ounce) may be applied, and are par- ticularly useful in cases complicated with prolapsus. Enemata of the fluid extract of ergot (f'3ss to f^** of water) are highly recommended in these cases by Dr. Semple, of Virginia, and Drs. Orr and Conner, of Cincinnati, Avhile Langenbeck advises the injection of ergotin beneath the rectal mucous mem- brane. Enemata of bismuth (in the form of the liquor bismuthi) are recom- mended by Dr. Cleland. Whenever the piles protrude, they should be care- fully replaced. In other cases great comfort may be derived from the use of opium combined with acetate of lead or tannic acid, in the form of supposi- tories. The same or similar remedies may be used for external piles, in the form of ointments. A good combination is one containing equal parts of the gall and stramonium ointments of the U. S. Pharmacopoeia. To relieve the itching which attends either form of piles, the best remedy, according to my experience, is the Ung. hydrargyri nitratis, diluted in the proportion of one part to seven. When piles become inflamed, the patient should be put to bed and the part constantly fomented or poulticed, wliile the boivels are moved Avith mild laxatives. Leeches may sometimes be applied around, but not over the hemorrhoidal tumors, and if a pile be tense and evidently filled with coagulated blood, a puncture may be made Avith a lancet or sharp bistoury, and the clot turned out. An ice-Jjag may be substituted for the Avarm applications, if more agreeable to the patient. Forcible dilatation of the sphincter ani is recommended by Verneuil, Fontan, and Cristofori. As a rule, no operative treatment should be instituted while the piles are in a state of inflammation, though, as the operation can be rendered painless by anaesthesia, it need not be postponed if there be any reason to the contrary. The Radical or Operative Treatment of Hemorrhoids may consist in excision, ligation, torsion, the application of caustics or the cautery, or the injection of coagulating fluids. 1. Excision is chiefly adapted to the treatment of external piles. For the removal of these, it is sufficient to seize each pile Avith broad-bladed ring- forceps (Fig. 442), and cut it off with scissors curved upon the flat, treating in the same Avay any loose folds of skin that may exist around the anus. If the piles be altogether external (covered with skin only), there is no risk of troublesome hemorrhage, and any bleeding that may occur can be readily controlled by pressure or torsion. If, however, as is often the case, the piles OPERATIVE TREATMENT OF HEMORRHOIDS. 829 be partly covered Avith mucous membrane (extero-internal), the hemorrhage may be quite profuse, and it is then much better to use the ligature in the way wliich Avill be presently described, notching first with the scissors the cutaneous surface of the hemorrhoidal tumor, and applying the ligature in the Fig. 442. Ring-forceps for piles. groove thus made. Care must be taken, in the excision of external piles, not to remove too much skin, lest the contraction Avhich occurs in the healing process should result in the formation of a troublesome anal stricture. In order to render excision a safe mode of treatment for internal piles, a plan Avhich originated Avith Cusack, of Dublin, may be employed. In this, Avhich is called the Operation by Clamp and Cautery, the base of the hemor- rhoidal tumor is closely compressed betAveen the blades of clamp-forceps, and, the pile being then cut off Avith scissors, bleeding is prevented by applying to the stump or pedicle strong nitric acid or the hot iron. Instruments for this operation have been devised by H. Lee, Wood, and others, the best, probably, being that introduced by II. Smith, of King's College Hospital. The blades of this apparatus (Fig. 413) fit accurately together with a tongue and groove, Fig. 443. Smith's clamp for piles. and the compression of the pedicle is effected by means of a screAv wliich unites the handles. Plates of* ivory are fixed to the outer surfaces and edges of the blades, so as to prevent the heat of the cautery-iron from reaching the surrounding parts. This operation, Avhich Mr. Smith also employs in cases of prolapse of the rectum, is said to be attended Avith very little pain, and to be followed by quicker convalescence than the operation of ligation. 2. Ligation is the method usually employed for the treatment of internal piles, and is that which I myself am in the habit of adopting. The patient should take a dose of castor oil the night before, and have his lower bowel thoroughly Avashed out by means of an enema on the morning of the opera- tion. Though it is not absolutely necessary, it is usually better for him to be 830 DISEASES OF INTESTINAL CANAL. Fig. 444. etherized. If the piles do not protrude, they may be made to do so by administering a warm Avater enema, which Avill bring them doAvn as it is ejected from the rectum. The patient being placed on his side and turned slightly over on his belly, while the nates are widely separated by an assistant, the surgeon seizes each tumor with the ring- forceps and transfixes its base Avith a double ligature, in- troduced by means of a naevus-needle, or, Avhich is better for the purpose, the needle known as Bushe's (fig. 444). The needle being detached, the pile is effectually strangu- lated by tying the ligatures on either side. The ends of the ligatures are then cut short, Avhen the bulk of the strangulated pile may be lessened by cutting off its summit at a safe distance from the point of ligation. If, however, the hemorrhoid arise from some distance up the rectum, it is safer not to use the scissors, but to push the whole strangulated mass above the sphincter. When all the internal piles have been thus ligated, and any external ones that may exist excised, an opium suppository should be placed in the rectum, and the patient returned to bed, Avith cold Avater dressing constantly applied to the anus. The boAvels should be kept locked up for four or five days, after which a free evacuation may be secured by the ad- ministration of castor oil. The ligatures become detached usually Avithin a Aveek, leaving small granulating surfaces, Avhich soon heal under the occasional application of nitrate of silver. The operation is sometimes followed by stran- gury, or even by retention of urine, requiring the admin- istration of a Avarm bath, or possibly the use of the catheter. In cases of internal piles complicated "with prolapsus, the ecraseur may be occasionally used Avith advantage, as it produces more contraction than the ligature. The instru- ment should be very slowly worked, as otherwise its em- ployment is apt to be followed by hemorrhage. Dr. ]Sktt has employed with success a form of clamp Avhich he calls a recti-linear ecraseur, to compress the base of the pile, then removing the instrument and applying a ligature in the groove wliich it has left. The ligation of piles is not entirely free from danger, being, in some cases, folloAved by erysipelas, pyaemia, phlebitis, or tetanus. I have, fortunately, never as yet seen a fatal result from the operation in my own practice, though I nearly lost one case from erysipelas. In tAvo cases, hoAvever, Avhich oc- curred in the Avards of my colleagues, a feAV years ago, tetanus ensued, Avith a fatal termination. Bushe's needle and needle carrier. 3. Torsion is recommended by Allingham for small and particularly for single hemorrhoids, situated near the median line ; the base of the pile is grasped Avith a clamp applied in a longitudinal direction, and the strangulated mass then seized with broad forceps and sloAvly tAvisted off. This mode of treatment is said to be almost painless, but, I confess, seems to me less safe, and therefore less desirable, than the application of a ligature. The same may be said of the operation with tooth-edged scissors suggested by Richard- son, of Dublin. PROLAPSUS OF THE RECTUM. 831 4. The Application of Caustic is particularly suited for those piles in Avhich the arterial element is predominant, and which may be recognized by their granular or straAvberry-like appearance. This mode of treatment, which Avas introduced by Houston, of Dublin, is now chiefly advocated by H. Lee, Fergusson, and H. Smith ; it is more apt to succeed Avhen the piles are sessile than when they are pedunculated. The caustic used is strong nitric acid, Avhich is conveniently applied Avith a piece of Avood or a glass brush tlirough a fenestrated glass speculum ; as soon as the pile is Avell coated Avith the acid, it should be Aviped Avith a piece of lint dipped in oil, or in a paste of prepared chalk and water. A thin slough is formed, the detachment of which leaves a healthy granulating surface Avhich soon heals. The great advantage of this mode of treatment is, according to II. Smith, that it does not require the patient to keep the house after the operation. If the acid be carefully applied, so as not to touch the skin, it causes very little pain ; but its use is not absolutely free from risk, one case referred to by Erichsen hav- ing terminated fatally from erysipelas. 5. Puncture of the pile with the conical tip of Paquelin's Gas Cautery is recommended by H. A. Reeves. 6. The injection of the Tincture of Chloride of Iron has been successfully resorted to, in the treatment of internal piles, by Colles, of Dub- lin. The instrument used is the ordinary hypodermic syringe, and about 20 minims of the tincture are injected into each- hemorrhoid. The operation is said to be painless, but I should fear Avould expose the patient to the risk of embolism. Carbolic acid has been employed in the same Avay by Dr. J. H. Pooley. Prolapses of the Rectum. This occurs under tAvo forms—the partial and the complete. In partial prolapsus of the rectum, the mucous membrane of the gut is alone involved in the protrusion, though the submucous areolar tissue is commonly thickened and elongated. In complete prolapsus, all the tissues of the gut are involved, the bowel being actually invaginated, and protruding sometimes to the extent of several inches. Causes___The causes of prolapse of the rectum are, (1) a relaxed and weakened state of the tissues in general, such as is met with in feeble chil- dren or in debilitated adults; (2) chronic irritation of the rectal mucous membrane, such as results from dysentery or from the presence of internal piles ; and (3) reflected irritation dependent upon diseases of other organs, such as urethral stricture, prostatic enlargement, vesical calculus, or exstrophy of the bladder. Symptoms___The protrusion occurs, at first, only after defecation, and perhaps only when the bowels are unduly relaxed ; but as the disease pro- gresses, the prolapse becomes more constant, coming down when the patient stands or Avalks, and being Avith difficulty kept in place. In the partial form of prolapse the mucous membrane forms a red or purplish ring, somewhat elongated in shape, and continuous with the mucous coating of the sphincter; in the complete prolapse the gut is invaginated through the sphincter, betAveen which and the protruded boAvel a distinct groove may ahvays be recognized. The complete prolapse forms an elongated cylindrical tumor, of the ordinary color of mucous membrane, presenting a smooth and even surface in the 832 DISEASES OF INTESTINAL CANAL. child, but being usually someAvhat convoluted and rugose in the adult. AYhen the protrusion is clown, there is a sensation of Avekht and draco-in", Avith some pain (not, however, very intense), and sympathetic vesical disturbance. In a case of recent, prolapsus of either form, strangulation may occur, leading Fig. 445. Fig. 440. Partial prolapsus of rectum. (Bryant.) Section of complete prolapsus of rectum. (Druitt.) perhaps to sloughing, and possibly spontaneous cure ; but in cases of long standing the sphincter is commonly much relaxed, facilitating both the de- scent and the reduction of the protrusion. Diagnosis.—The diagnosis of prolapsus of the rectum is usually made Avithout difficulty; the complete form of the affection can, indeed, scarcely be mistaken for anything else, Avhile partial prolapse is only likely to be con- founded with internal piles, with wliich it is very often complicated, but from which it may be distinguished by the annular character of the protru- sion, and by the absence of distinct tumors. Mr. Stocks has reported a case in Avhich an ovarian cyst protruded through the anus, and Avas at first mis- taken for prolapsus of the rectum. Treatment___The first step in the treatment of prolapse of the rectum is to effect reduction ; this may usually be readily effected by placing the patient on his side, and gently but firmly compressing and pushing up the gut with the hand, protected Avith a soft cloth dipped in oil. If the sphincter be much dilated, both hands may be required—one to fix the part, Avhile compression is made Avith the other. When strangulation occurs, reduction may be, if necessary, facilitated by incising the mucous membrane, if the prolapse be of the partial variety, or by dividing the sphincter, if complete invagination have occurred. After reduction, the part may be supported with a pad and bandage. In order to prevent a recurrence of the prolapse, the bowels should be kept in a soluble condition by the administration of lax- atives, such as were recommended for piles. The descent of the gut while at stool should be prevented by avoiding straining, and by having the bowels moved Avhile in the recumbent position, or even Avhile standing—protrusion being less apt to occur in either of these than in the ordinary sitting posture. With children a kneeling posture is preferable, and the nurse may, as advised by MacCormac and H. Smith, be directed to draw the skin of the anus forci- bly to one side during the act of defecation, so as to cause contraction of the sphincter, and thus prevent the gut from protruding. In mild cases, a cure INFLAMMATION OF THE RECTAL POUCHES. 833 may often be obtained by attention to these points, and by the local use of bismuth or other astringents in the form of injections or suppositories. Hy- podermic injections of strychnia are advised by Lorigiola and W. H. Thom- son, and of ergotine by Langenbeck and Henoch. The daily use of the cold douche is highly recommended by Saint Germain. If the prolapse be due to sympathetic irritation from stricture, calculus, etc., these affections must, of course, be properly treated, when the rectal complication Avill com- monly subside of itself. Operative Treatment—In cases of extensive and inveterate pro- lapsus, especially in adults, something more may be required. Excision of the muco-cutaneous folds around the anus, ligation of two or more folds of mucous membrane, tbe application of caustics, and the operation by clamp and cautery, are the chief modes of treatment. 1. Excision is effected simply by cutting off Avith curved scissors the radi- ating flaps of integument around the anal orifice, the subsequent contraction often sufficing to effect a cure ; if the incision involve the mucous membrane, a stitch or tAvo should be inserted so as to guard against hemorrhage. 2. Ligation is effected by seizing Avith ring-forceps a portion of the pro- lapsed mucous membrane, and tying it firmly Avith a single ligature : it is usually sufficient to apply one ligature on either side, but more may be re- quired if the prolapse be extensive. The parts should then be carefully returned through the sphincter, and an opium suppository introduced. 3. Caustic, the strong nitric acid being the best, may be applied, through a fenestrated speculum, as directed in the case of piles, or to the protruded gut, before reduction, as advised by Allingham. 4. The Clamp and Cautery method is perhaps the best mode of treatment. Longitudinal folds of mucous membrane are to be seized Avith Smith's clamp and cut off Avith scissors, Fig. 447. the pedicle being then seared Avith a hot iron. 5. Excision of a V-shaped Segment of the sphinc- ter on one or both sides has been occasionally prac- tised, but is a severe mode of treatment, and may be followed by fecal incontinence. Finally, in cases in which operative interference is not deemed advisable, great comfort may be af- forded by the adaptation of a well-fitting anal truss or supporter, such as shown in Fig. 447. Anal truss. Ixflammation of the Rectal Pouches. The pouches or lacunae of the rectum are sometimes much enlarged, chiefly in old people, becoming distended Avith fecal matter, and as a consequence inflamed or ulcerated, and causing intense itching, and often severe pain, un- accompanied, however, by spasm of the sphincter. This affection Avas first described by Physick, under the name of Encysted Rectum, and is called by Gross, Sacciform Disease of the Anus. The diagnosis is readily made by exploring the rectum with a blunt hook or a probe bent at its end. The treatment consists in drawing down successively each pouch that is affected, and excising the mucous fold at its base with curved scissors. Neuralgia op the Anus. This usually occurs as a symptom of some local lesion (as painful ulcer of the rectum), but may exist independently. The treatment in such cases is 53 834 DISEASES OF THE ABDOMINAL ORGANS. very unsatisfactory; the free use of quinia and the local application of bella- donna are perhaps the best remedies. Pruritus or Itching of the Anus. This is probably ahvays symptomatic, but occasions so much distress as to be worthy of special mention. It may be due to hemorrhoids, to the presence of intestinal parasites, to papular or other eruptions in the neighborhood of the anus, or to uterine displacement. The treatment consists in the removal of the cause, if this can be ascertained, in attention to the state of the boAvels, in the use of frequent ablutions, and in the employment (somewhat empiri- cally, it must be confessed) of various av ashes or ointments. The dilute cit- rine ointment is, perhaps, the best remedy for itching piles, while for the pruritus dependent on cutaneous eruptions of the part, the tar and iodide of sulphur ointments of the U. S. Pharmacopoeia will often be found useful. Curling speaks highly of an ointment containing chloroform and oxide of zinc, and of a Avash of sulphuret of potassium and lime-water (Sjkoviij). Chlori- nated lotions or weak solutions of hydrocyanic acid may also be employed, or a Aveak solution of carbolic acid (gr. v-fsj). Arsenic is often of service as an internal remedy, and may be conveniently given in the form of arsenious acid, combined in a pill Avitli iron and quinia. CHAPTER XLIII. DISEASES OF THE ABDOMINAL ORGANS, AND VARIOUS OPERATIONS ON THE ABDOMEN. Paracentesis Abdominis. Paracentesis abdominis, or " the operation of tapping," is not unfre- quently required in cases of ascites and ovarian dropsy. The circumstances Avhich in any particular case indicate or contra-indicate this operation, are discussed in Avorks on the Practice of Medicine or on the Diseases Peculiar to Women, and it will, therefore, only be necessary to describe in these pages the manual procedure itself. The bladder having been emptied, the patient sits on the edge of the bed, or lies on either side, a broad four-tailed flannel bandage being laid over the upper part of the abdomen, and the ends crossed behind, and firmly held by an assistant. The surgeon makes a short incision in the median line about an inch and a half below the umbilicus, dividing the superficial structures, and then with a quick motion thrusts in a full-sized trocar and canula ; the trocar being withdrawn, the fluid is allowed to escape, and is collected in suitable basins or pails. While the flow continues, the bandage should be continually tightened, so as to compress the abdomen and prevent the occurrence of syn- cope. Should the canula become clogged, it may be freed from obstruction by introducing a director or flexible catheter. When all the fluid has been evacuated, the canula is withdraAvn and the wound closed with a broad adhe- sive strip, the abdomen being supported with a firm compress and bandage. The steps of the operation as above described may be occasionally varied; thus, if the abdominal parietes be tense and thin, the trocar may be thrust in at once, without a preliminary incision, the instrument being hindered from OVARIAN TUMORS. 835 penetrating too far by the operator's finger placed about half an inch from the point, Avhile the canula may, if preferred, be provided Avith a stopcock and flexible tube, as in the operation of paracentesis thoracis. The puncture in the median line is to be adopted in cases of ascites, and indeed in every Fig. 448. Tapping the abdomen. (Fergusson.) instance, unless the unilateral character of the swelling should indicate the choice of another locality, Avhen the puncture may be made in the corre- sponding linea semilunaris. When, as usually happens, the operation has to be repeated, the second puncture should be make a few lines above or beloAV the cicatrix of the first. The operation of tapping is rarely attended by any unpleasant results ; it may occasionally, hoAvever, be followed by the development of a Ioav form of peritonitis, and, in cases of dropsy from malignant disease, the wound of puncture may become the seat of secondary deposits. It might seem unnecessary to caution the surgeon against mistaking preg- nancy for abdominal or ovarian dropsy, but for the fact that tapping has occasionally been incautiously employed under such circumstances, with an unfortunate result that can be readily imagined. Ovarian Tumors. I do not purpose entering into any prolonged discussion of the symptoms, diagnosis, and therapeutics of ovarian disease, for these subjects belong more to the special domain of Gynaecology than to that of Surgery ; it will be sufficient to enumerate the principal affections with which ovarian tumors are likely to be confounded, and to describe briefly the various operative pro- cedures which are employed in their treatment.1 Diagnosis.—Fecal Accumulations in the cagcum or other parts of the large intestine have been mistaken for ovarian tumors ; the diagnosis may commonly be made by digital examination per vaginam, the fecal tumor imparting a characteristic doughy sensation to the touch. Pregnancy, either normal or extra-uterine, is usually attended with such obvious symptoms as to prevent the possibility of mistake, and in any case of doubt, a brief delay will serve to clear up the diagnosis. Fibro-muscular Tumors of the Uterus can usually be distinguished from 1 In the following pages I have drawn freely from Prof. T. Gaillard Thomas's excel- lent " Practical Treatise on the Diseases of Women." 836 DISEASES OF THE ABDOMINAL ORGANS. ovarian groAvths, by observing that in cases of the former there is commonly uterine hemorrhage and leucorrhoea; the uterine sound or probe enters fur- ther than in the normal state; the tumor, wliich is often multiple, is usually hard, and by vaginal exploration is found to be irregular in outline and con- Fig. 449. Sims's uterine probe, smallest size. tinuous with the uterus : and, finally, if the uterus be moved by means of the sound, the tumor moves Avith it. On the other hand, in a case of ovarian tumor, there is neither menorrhagia nor leucorrhoea; the uterine sound enters only to the normal distance; the tumor, aa hich is usually solitary, often fluc- tuates, and is smooth and not continuous with the uterus ; and, finally, the uterus can be moved without the tumor moving with it. It is to be noted, with regard to the last diagnostic point, that it is the uterus and not the tumor AArhich must be movable ; for the upper part of a solid uterine growth may be movable, while its base is so tightly wedged in the superior strait of the pelvis, that no motion can be communicated to the mass through the uterine sound. Ascites can commonly be distinguished by the character of the tumefac- tion, which in abdominal dropsy is uniform, but in ovarian disease is localized at first to one or other iliac fossa; by the flattening of the abdomen, in the recumbent posture, owing to the ascitic fluid gravitating to the sides of the peritoneal cavity ; by the change in the line of dulness upon variation in the patient's position ; by the resonance anteriorly when the patient lies on her back, OAving to the intestines floating upAvard ; by the prominence of the recto-vesical pouch, in which fluctuation can be detected by the finger intro- duced into the vagina; by the presence of a distinct Avave when the patient rolls in bed ; and by the coexistence of signs of disease of the heart, liver, or kidney, the skin being often harsh and jaundiced, and the feet (edematous at an early period of the affection. In dropsy from disease of the ovary, on the other hand, beside the local character of the SAvelling in the early stages, it is found that, OAving to the fact of the fluid being contained in a tense cyst, there is no flattening of the abdomen nor anterior resonance in the supine posture ; little or no variation in the line of dulness ; no prominence of Doug- las's cul-de-sac; no abdominal wave Avhen the patient rolls in bed; and no evidence (except by a coincidence) of disease of other viscera. Finally, in a doubtful case, the diagnosis may be made by examining the fluid Avithdrawn by tapping, which, if the disease be ovarian, will probably be found to con- tain altered blood-cells, epithelial scales, masses of granular matter, oil globules, and crystals of cholestearine. Hughes Bennett, and, more recently, Dr. Drysdale, of this city, have described cell-forms which they believe to be peculiar to ovarian fluids, but their vieAvs have not been universally ac- cepted by pathologists. Foulis and KnoAvsley Thornton have described cer- TREATMENT OF OVARIAN TUMORS. 837 tain groups of cells as being peculiar to the fluid from malignant growths of the ovary or peritoneum. Cystic Disease of the Broad Ligament so closely resembles that of the OA-ary, that a diagnosis is frequently impossible, though if the fluid removed by tapping Avere found to be non-albuminous and like that of ascites, there would be strong reason for believing that the ovary Avas not implicated. The fluid from Fibro-cystic Tumors of the Uterus is, according to Atlee and other authorities, remarkably free from morphological elements, while it coagulates spontaneously and completely. Drysdale describes a peculiar cell Avhich he believes to be characteristic of this form of tumor. Other abnormal conditions may be occasionally mistaken for ovarian tumors, such as hydatids, uterine distension from retention of the menstrual secretion, accumulation of fat in the omentum or abdominal walls, partial contractions of the recti muscles, hydronephrosis, and cysts of the kidney or spleen. Though the diagnosis of ovarian tumors can, in most instances, be made with tolerable certainty, by careful and repeated examination, yet cases occa- sionally occur which completely baffle the most cautious observer, and it has repeatedly happened that the operation of ovariotomy has been undertaken in cases in which no ovarian tumor could be found, the morbid growth being perhaps connected with the uterus, kidney, spleen, or omentum ; or more rarely there being no tumor at all (see Phantom Tumor, p. 479). The diffi- culty, and in some cases impossibility, of making a correct diagnosis, is one of the strongest arguments against tbe propriety of ovariotomy; and yet the operation should not on this account be considered unjustifiable, more than should the ligation of arteries for aneurism, on the ground that deligation has been occasionally performed Avhen no aneurism existed. Treatment__Solid tumors of the ovary do not, as a rule, call for ope- rative interference, and the same may be said of those tumors Avhich contain both solid and fluid elements, with the exception of the fibro-cystic tumor, or cystic sarcoma, which may occasionally be properly removed by ovariotomy. Hence the remarks which follow are to be understood as applying to the treat- ment of cysts of the ovary, which are of much commoner occurrence than the other forms of tumor. The question whether or not a tumor of the ovary be cystic, can usually though not invariably be decided by noting the presence or absence of fluctuation, upon external, and especially upon vaginal palpa- tion. In any case of doubt, an exploratory puncture with a small trocar should be resorted to. There may be a single cyst, or the tumor may be multilocular; in the latter case the secondary cysts may sometimes be recog- nized by palpation, and the contained fluid is usually darker and more viscid than that of a cyst which is unilocular; single cysts, moreover, rarely attain a. very large size; the distinction is of importance as regards the prognosis of the case, single cysts being occasionally curable by milder measures than ova- riotomy, and offering a better prospect of recovery after that operation, than multilocular growths. Another point which is usually considered of great importance as regards the prognosis of ovariotomy, is the presence or absence of adhesions; these may sometimes be detected by careful palpation and aus- cultation, but, on the other hand, may exist without giving any evidence of their presence ; it is probable, however, that, as remarked by Spencer Wells, the prognosis after operation is more influenced by the age and general con- dition of the patient than by the size and condition of the tumor. According to this writer, the prognosis is more favorable in patients under tAventy or over sixty years of age, than in those at an intermediate period of life. The exist- ence of pelvic adhesions is more to be dreaded than that of adhesions to the 838 DISEASES OF THE ABDOMINAL ORGANS. omentum or abdominal parietes. The occurrence of suppuration in an ova- rian cyst is, according to T. Keith, an indication for immediate ovariotomy, and this surgeon reports twelve cases operated on under these circumstances with ten recoveries. The surgical procedures resorted to in the treatment of ovarian cysts, are tapping, drainage, incision, partial excision, injection of iodine, galvano- puneture, and ovariotomy. 1. Tapping, the mode of performing which has already been described, is chiefly resorted to as an aid to diagnosis, or Avith a vieAV to palliation, rather than radical cure. It has been conclusively shown by Spencer Wells, whose experience in cases of ovarian disease is probably greater than that of any other living surgeon, that the prospect of recovery after ovariotomy is not lessened by the fact of the patient having been previously tapped once or oftener; and hence there need be no hesitation in employing this simple ope- ration, either to assist the diagnosis in a doubtful case, or as a means of affording temporary relief before resorting to graver measures. Special care must be taken to prevent the escape of the cystic contents into the peritoneal cavity (an occurrence which might be followed by peritonitis), by using Thomson's " siphon trocar," an aspirator, or some similar instrument. Though Fig. 450. 0§ Siphon trocar. in the large majority of instances tapping acts only as a palliative, it has occasionally been followed by permanent recovery; an additional argument in favor of the practice which has been recommended. Tapping through the vagina or rectum is occasionally preferred to the ordinary operation through the abdominal parietes. 2. Drainage is effected by enlarging the puncture made in parietal or vaginal paracentesis, and introducing a tube which is fixed so as to alloAv the escape of fluid, and, if necessary, the Avashing out of the cyst with simple or medicated injections. This mode of treatment is chiefly adapted to cases of unilocular cyst, in which ovariotomy is contra-indicated by the extent of adhesions. 3. Incision consists in laying open the tumor through the abdominal wall or vagina; this plan, which may be considered a modification of that last mentioned, is best adapted for the treatment of firmly adherent multilocular cysts, which do not admit of ovariotomy on the one hand, nor of simple drain- age on the other. Bernutz advises incision as preferable to ovariotomy in cases of suppurating dermoid cyst. 4. Partial Excision consists in cutting away a small portion of the anterior wall of the cyst, and allowing the contents to escape into the peri- toneal cavity; this mode of treatment is more applicable to cases of cystic disease of the broad ligament than to those in Avhich the ovary is involved (see p. 837). OVARIOTOMY. 839 5. Injection of Iodine for the cure of ovarian cysts, appears to haA*e been first successfully employed by Dr. Alison, of Indiana, in 1816, but was not brought prominently before the profession until some years afterwards, through the writings of Boinet and other European surgeons. The formula recommended by Boinet is 100 parts each of tincture of iodine and Avater, with 4 parts of iodide of potassium. The operation consists in introducing through the canula (after tapping) a flexible catheter, by means of Avhich from four to ten ounces of the solution are injected, the liquid being Avith- draAvn again after ten or fifteen minutes ; the catheter is retained as long as may be thought necessary, the injections, the strength of which is gradually increased, being occasionally repeated. This mode of treatment should, according to Peaslee, be reserved for cases of unilocular cyst, Avith clear, serous contents, in Avhich simple tapping has been previously employed at least once; by so limiting its application, Dr. Peaslee believes that the mor- tality of the operation Avould be reduced to one in ten, and the proportion of cures increased to one in three. 6. Galvanopuncture is recommended by Semeleder, Avho reports three recoveries by this mode of treatment. 7. Ovariotomy, or the formal extirpation of a diseased ovary, was sug- gested by Wm. Hunter and recommended by John Bell; but the first surgeon who actually resorted to the operation Avas McDoAvell, of Kentucky, who per- formed the first OAariotomy in the year IXoi). This case was successful, the patient surviving thirty-two years. McDowell repeated tbe operation about a dozen times, with varying success, and his example Avas followed by a feAV surgeons both at home and abroad, but for many years the feeling of the pro- fession at large was that ovariotomy was an unjustifiable procedure, and it is within a comparatively short period only that this operation has been generally accepted as a legitimate resource of surgery. Among those Avho have acquired most distinction as ovariotomists may be particularly mentioned Bird, Clay, Baker Brown, Tyler Smith, Wells, Bryant, and Keith, among British sur- geons ; AV. L. and J. L. Atlee, Kimball, Dunlap, Peaslee, and Thomas, in our OAvn country, and Koeberle, in France. The operation is not usually a very difficult one, but is always one of great gravity, the mortality in the hands of the most skilful ovariotomists averag- ing from 24 to 30 per cent.1 This is in itself no valid objection to the opera- tion, for the death-rate is less than that of many other operations which are universally recognized as legitimate ; but it is surely sufficient to render the surgeon very cautious in his prognosis, and to induce him to neglect no means of satisfying himself both as to the accuracy of his diagnosis, and as to the applicability of the operation to the particular case Avith Avhich he has to deal. As Spencer Wells justly remarks, " it is seldom that a surgeon is called upon to perform ovariotomy in order to saA'e a patient from imminent death. . . . There is generally as much time for discussion as in the parallel case of litho- tomy in the male adult. And in both cases, the responsibility of operating, with the full knoAvledge that if the patient be not saved by the operation he or she is killed by it, must be fairly faced." This responsibility, moreover, is one which the surgeon has no riglit to throw upon the patient; every AAroman knoAvs that, after an operation like ovariotomy, she may die or she may get well, and it is to the superior knowledge and wide experience of the surgeon that she looks for advice as to Avhether the operation is or is not desirable in her particular case. The ultimate decision in this, as in eAery other case, 1 Spencer Wells has published records of 900 cases, of which 221 proved fatal. 840 DISEASES OF THE ABDOMINAL ORGANS. must of course rest with the patient, but the surgeon should honestly and plainly express his opinion, whether it be favorable or unfavorable ; and if, after a full and careful consideration of all the circumstances of the case, he is brought to the conclusion that the operation is, upon the whole, not advisa- ble, he should, in my judgment, simply decline to operate. The Operation of Ovariotomy may be performed as follows : The patient's bowels should have been emptied by the administration of a dose of castor oil a day or two previously, and by means of an enema on the morning appointed for the operation. The temperature of the room should be at least 70° Fahr., and the table well covered with blankets ; the patient should be thoroughly anaesthetized, and at the last moment the contents of the bladder should be evacuated by means of the catheter. The first incision is made to correspond as nearly as possible to the position of the linea alba, and may reach from about an inch or an inch and a half below the umbilicus to Avithin two inches of the pubes, though, in many in- stances, a smaller Avound may be sufficient. Wells's statistics, however, go to sIioav that provided that the incision does not extend abo\'e the umbilicus, its exact length in inches does not affect the result of the operation. The dissection is cautiously continued until the peritoneum is reached, when, all hemorrhage having been checked, this membrane is opened by picking it up with forceps, making a small cut, and then introducing the left forefinger, upon which as a director the wound is enlarged to the full extent of the ex- ternal incision. A small quantity of serum noAv usually makes its escape, Avhen the cyst wall probably presents itself immediately below the wound ; should a fold of omentum or a loop of intestine intervene, these should be carefully lifted off and put to one side. The surgeon then proceeds to investigate the extent of adhesions, if there be any, by introducing first two or three fingers dipped in lukewarm " arti- ficial serum," then a curved steel sound dipped in tbe same, so as to sweep around the base of the tumor, and finally, if necessary, the whole hand. The " artificial serum," the use of which was suggested by Dr. Peaslee, consists of half an ounce of table-salt, six drachms of white of egg, and tAvo quarts of Avater. If the adhesions be extensive, or if the tumor be noAv ascertained to be chiefly or entirely solid, it may be necessary to carry the incision above the umbilicus—this being done by a curve to the left side, so as to avoid wounding the round ligament of the liver. Should the adhesions be found so firm and extensive as to forbid the hope of removing the tumor, the surgeon may attempt the treatment by drainage, incision, partial excision, or injection of iodine, according to the character of the cyst—Avhether single or multilo- cular—and the nature of its contents, Avhich may be ascertained by making an exploratory puncture with a small trocar. (See pp. 8-'!7, 838.) If the adhesions be less firm and extensive, those Avhich are accessible may be care- fully separated by the fingers, thus completing Avhat may be called the second stage of the operation. The third stage consists in turning the patient on her side, and then lessen- ing the size of the tumor by tapping the cyst, or the principal cysts, if there be more than one—good instruments for tbe purpose being the winged trocar and canula of Spencer Wells, or the ingenious hollow trocars devised by Dr. Mears and Dr. Hodge, of this city, and Dr. Fitch, of Ncav Brunswick (Fig. 451). The fluid may be conveyed away through a flexible tube, Avhile the cyst-wall is held forwards Avith vulsellum forceps, and compression of the abdomen kept up by the hands of an assistant. The sac having been suffi- ciently reduced in size, is now gently drawn out through the external Avound, any remaining adhesions being severed by the hand, by a small cautery iron (or the galvanic cautery), by an ecraseur, or by scissors, according to the OVARIOTOMY. 841 peculiar circumstances of the case. If any hemorrhage occur, it may be controlled by torsion, by styptics, by the cautery, or by the ligature; in the latter case, silver Avire should be used, or, which would perhaps answer equally well, the antiseptic ligature of Prof. Lister. If the adhesions be in- separable, it may be necessary to leave a portion of the cyst-wall, Avhich J. L. Atlee advises should then be secured with the clamp, the abdominal wound being carefully closed below the instrument. Fig. 451. Fitch's trocar and canula. The next step is to secure the pedicle of the tumor, so as to prevent hemor- rhage. This may be done by means of the ligature or the clamp; by di- viding the pedicle with the ecraseur or the actual cautery; by applying torsion to each individual vessel as it is cut across ; or by enucleating1 the tumor in the ingenious Avay recommended by Miner, of Buffalo, so as to avoid hemorrhage by tearing across the vessels at their peripheral terminations. If sufficiently long, the pedicle should be fixed between the lips of the Avound, but if too short for this, it must be returned into the abdominal cavity; or it may be " pocketed" in the deeper part of the incision (as suggested by Storer, of Boston), the external Avound being accurately closed above it. When the stump is to be fixed in the external wound, the use of the clamp is probably the best method of securing the pedicle. Several varieties of clamp have Fig. 452. Atlee's clamp. been employed, those devised by Wells, Koeberle, Atlee, and DaAvson, being perhaps the best. When the stump is so short as to render its restoration to the abdominal cavity necessary, a different plan must be adopted; here the surgeon may choose between slow division of the pedicle and the application of torsion to each separate vessel, the use of the actual cautery, and the em- 1 Miner's method of enucleation has also been applied to uterine tumors by Spiegel- berg, and by Moore, of Rochester; the former surgeon, after enucleation, closes the peritoneum over the uterus by the introduction of sutures, while tbe latter brings the pedicle out and fixes it in the abdominal wound in the ordinary way. 842 DISEASES OF THE ABDOMINAL ORGANS. ployment of the ligature. Torsion has not been resorted to sufficiently often to allow a positive opinion as to its merits. If the ligature be employed, the pedicle is transfixed and tied in tAvo parts, when the ends may be brought out at the lower end of the Avound (Clay's method), or may be cut short and dropped into the peritoneal cavity, as advised by Tyler Smith and Peaslee ; if the short cut ligature be used, it should be of silver Avire, as advised by Sims, or rendered antiseptic in the way recommended by Prof. Lister. Hayes, of Dublin, recommends the use of a catgut ligature applied subperi- toneally, so as to close the vessels without endangering the vitality of the stump. If the cautery be used (as Avas done by Baker Brown), the surrounding parts may be protected by the use of the clamp-shield devised by Prof. Storer. The pedicle being secured, and the tumor removed, the surgeon examines the other ovary (excising it also, if it be diseased), and then, having cleansed the peritoneum by careful sponging, closes the wound Avith large harelip pins, or with deep and superficial sutures, and applies water-dressing or oiled lint, supporting the Avhole abdomen Avith a broad flannel bandage. The sutures should be made of silver or flexible iron wire, and the deep set should pass through the whole thickness of the abdominal wall, including the peritoneum. Sims recommends that, unless the antiseptic method be used, a puncture should be made from the vagina, through the recto-uterine fold of the perito- neum (Douglas's cul-de-sac), and a drainage tube introduced; or, if enuclea- tion have been practised, two drainage tubes, one into the cavity of the pelvis, and one between the folds of the pedicle:1 these drainage tubes may, if thought proper, be brought out at the lower part of the abdominal wound, so as to facilitate the use of disinfecting injections, if these should become neces- sary. Sims's plan has been successfully followed by other surgeons, including Hahn and Spiegelberg, but is thought unadvisable by Spencer Wells, who reserves puncture and drainage for exceptional cases. The after-treatment consists in adopting means to prevent the occurrence of peritonitis, Avhich is the cause of death in about one-fourth of the fatal cases. The patient should be kept perfectly quiet and tranquil, and fed upon liquid diet for ten days or a fortnight after the operation. A Sims's catheter should be retained in the bladder during the first four or five days, and the Fig. 453. Sims's sigmoid catheter. bowels locked up by the moderate use of opium for about two weeks. If there be much tympanitic distension, a simple enema may be given on the eighth or ninth day. The chief sources of danger, beside shock and nervous prostration, are secondary hemorrhage, peritonitis, and septic poisoning; the latter is, indeed, according to Sims, the principal cause of death after the operation. Hemorrhage must be arrested by exposing or opening the wound, and securing the bleeding vessel in the pedicle, and peritonitis is to be treated in the Avay described in previous chapters. Koeberle applies an ice-bag on either side of the incision, as a prophylactic against both of these complica- tions. Wells and Thornton apply cold to the head by Petigand's coil, as a 1 Dr. A. Dunlap, of Ohio, recommends that the pedicle itself should be inverted through the vagina. CESAREAN SECTION. 843 means of reducing the temperature of the body. Should symptoms of septic poisoning supervene, the lower part of the incision should be opened suffi- ciently to allow the introduction of an elastic catheter, through which disin- fectant solutions may be injected, and the peritoneal cavity washed out, as recommended by Dr. Peaslee. This surgeon reports several successful cases, in one of which no less than 135 injections Avere made in the course of 78 days. The best disinfectants for the purpose are probably the Liq. sodoe chlorinatis and carbolic acid, either being, of course, very much diluted. Quinia should, at the same time, be freely gi\-en internally. The sutures may be removed, a feAV at a time, from the fifth to the tenth day. Vaginal Ovariotomy, or the removal of an ovarian tumor tlirough the posterior Avail of the vagina, an operation which has been practised by Thomas, Wing, Davis, Gilmore, and Goodell, may occasionally be preferred to the ordinary operation, but is manifestly suited only to cases in wliich the tumor is small, and free from adhesions. Rectal Ovariotomy—Mr. A. W. Stocks, an English surgeon, has recorded a remarkable case, in which an ovarian cyst protruded through the rectum, and was successfully removed through an incision in the anterior wall of that organ. Normal Ovariotomy; Oophorotomy; Battey's Operation__ These names have been applied to an operation introduced by Dr. Battey, of Georgia, and since repeated by several surgeons, including Sims, Peaslee, Thomas, Sabine, Trenholme, Engelmann, Frew, and Goodell; it consists in the removal of one or both ovaries, even when not obviously diseased, as a means of hastening the menopause, when that may seem desirable. The glands are removed either by abdominal section or through the posterior wall of the vagina, as in Thomas's operation of ATaginal ovariotomy. Engelmann has analyzed 36 terminated cases, and finds that 8 patients were cured, 8 improved, 9 not benefited, or made worse, Avhile 11 died—a record Avhich seems to me hardly to justify a repetition of the operation, unless in very ex- ceptional instances. Double Ovariotomy was first performed by Dr. J. L. Atlee, of Lan- caster, Pa., in 1843, and has been since repeated by several surgeons, among Avhom may be particularly mentioned Dr. Peaslee, who reported his third case in 1864. The operation is attended with but little greater difficulty and risk than that of removing a single ovary, but has the necessary disadvantage of rendering the patient sterile. Extirpation of both Ovaries and of the Uterus has been not unfrequently performed, but usually with a fatal result (see Chapter XLVII.). In the light of past experience, the repetition of the operation cannot be re- commended, though it is, of course, possible that wider observation may, at some future time, compel the rendition of a more favorable verdict with regard to this operation, as it has already done with regard to the simpler procedure of ovariotomy. Cesarean Section, etc. The Cesarean section may be performed with the hope of saving the child alone (in case of sudden death occurring to a woman far advanced in preg- nancy), or with the hope of saving both mother and child, in cases of extreme 844 DISEASES OF THE ABDOMINAL ORGANS. deformity of the pelvis, etc. The operation consists in opening the abdo- minal cavity in the median line (as in ovariotomy), incising the Avomb, rup- turing the membranes, and extracting with the least possible delay both child and placenta. Bleeding is then to be arrested, the peritoneal cavity cleansed by sponging, and the uterine wound and that of the abdominal parietes sepa- rately closed with sutures. Some difference of opinion pre\"ails as to whether sutures should or should not be applied to the uterus; if it be determined to use them (as seems to me judicious), the material should be silver or iron wire, or strong silk or thread ; if, on the other hand, uterine sutures are to be dispensed witb, a drainage tube may be properly introduced (as adAised by Depaul), one end coming out by the abdominal Avound, and the other by the vagina. The after-treatment is directed to the prevention of peritonitis. When performed during the first 24 hours of labor, the statistics of the ope- ration are more satisfactory than might be anticipated, 24 American cases referred to by Harris, of this city, having resulted in the preservation of 18 mothers and 21 children. The same Avriter has collected, in all, 108 cases from American sources, giving a total mortality of 58 mothers. Porro, Spaeth, and Muller have reported successful cases of Cksarean section sup- plemented by extirpation of the uterus. The Caesarean section has been occasionally repeated on the same patient, in successive pregnancies, from two to seven times. Laparotomy for rupture of the pregnant uterus is often spoken of as a variety of Cesarean section, but is, according to Harris, a much less serious operation. The steps of the procedure are the same as in the former case, except that the incision of the AA'omb is not required. Laparotomy may be called for in cases of extra-uterine pregnancy. The abdominal cavity ha\Ting been opened, the sac containing the foetus is care- fully incised, and the foetus removed. Koeberle, Lawson Tait, and Harris advise that the placenta should be left in situ, the peritoneal cavity being carefully closed Avhile the abnormal sac is left open. The placenta is ulti- mately discharged piece-meal, Avhen the sac, which must be frequently washed out by syringing, gradually becomes obliterated. Laparo-elytrotomy, or opening the vagina through the abdominal wall above Poupart's ligament (an operation devised by Ritgen, Physick, and Baudelocque), is recommended by Thomas and Skene, as a substitute for Caesarean section. Nephrotomy for Renal Calculus (Litho-Nephrotomy). Calculous concretions have been not unfrequently extracted from the kidney or ureter, in cases in Avhich the existence of an abscess1 or urinary fistula has served as an indication for the proceeding, but the first formal nephrotomy for the removal of renal calculus appears to have been performed by an Italian surgeon, named Marchetti, in the latter part of the seventeenth cen- tury. Several concretions were extracted, and the patient recovered with a renal fistula. The revival of this operation has been recently advocated by T. Smith (in a paper in the Medico-Chirurgical Transactions, vol. lib), Avho recommends a longitudinal incision along the outer border of the erector spina? muscle, extending dowmvards four inches from the lower margin of the last rib. The incision is cautiously deepened until the finger can be placed upon the hilus of the kidney, when, if thought proper, this organ can be laid open. This operation does not involve the peritoneal cavity, so that there is little risk of peritonitis, while urinary infiltration is prevented by the depend- ing position of the Avound. The great objection to the procedure is the diffi- • As in the case of the late Mr. Startin, a Avell-knoAvn English surgeon.' TREATMENT OF ABDOMINAL ABSCESSES. 845 culty of deciding (1) whether renal calculus exists at all, (2) which kidney is affected, and (3) Avhether the calculus be not so adherent as to render its extraction impossible. Since the publication of Mr. Smith's paper, the ope- ration has been tried in seven or eight instances, by Durham, Gunn, DaAvson, Thornton, Callender, and in several other cases at St. Bartholomew's Hos- pital, but all, I believe, terminated fatally, except Durham's, Gunn's, and Thornton's cases, and in none of these Avas any calculus found. Nephrotomy for pyo-nephrosis will be referred to in another place. (See p. 847.) Extirpation of the Kidney. This operation Avas first performed by Simon, of Heidelberg, for urinary fistula following a wound of the ureter inflicted in removing the uterus and ovary; the patient recovered. A second case operated on by the same sur- geon for renal calculus, terminated fatally from peritonitis on the 31st day. Extirpation of the kidney has since been performed by Gilmore, Brandt, Marvaud, Campbell, Schetelig, Meadows, Wells, Durham, Von Bruns, AVolcott, Peaslee, Peters, Jessop, Langenbeck, Kocher, and an Italian sur- geon, Avhose case is reported in the Journal of the Royal Academy of Turin. Of the 18 cases, seven are known to have terminated successfully, and ten fatally, the result in Jessop's case not having, I believe, been published. Extirpation of the Spleen. The spleen has been excised for traumatic causes, and in cases of cystic disease and of chronic enlargement connected with leucocythemia : Dr. Otis has tabulated 26 cases of splenotomy for all causes, but from these should be deducted one (Dorsey's), in Avhich the organ does not seem to have been actually removed. To the remaining 2o, may be added other cases since recorded by Urbinati, Watson, Markham, Elias, Pietrzycki, Martin, Faris, H. L. Browne, Simmons, Lane, Billroth (two cases), Pean, Wells, and Koeberle (their second operations), giving a total of 40 cases, 20 having been for traumatic causes, and all having terminated successfully, while of the 20 operations for disease at least 13 ended in death. While, therefore, excision Avould appear to be justifiable in a case of Avound attended by protrusion of the organ, splenotomy for diseased conditions of the viscus has not been suffi- ciently successful to encourage a repetition of the procedure. Hemorrhage during or subsequent to the operation, appears to have been the cause of death in most of the fatal cases. Resection of the Pyloric Extremity of the Stomach is sug- gested by Gussenbauer and Winiwater as a remedy for cancer of that organ, but the operation does not appear to have been as yet practised on the human subject. Panereatotomy, or excision of a portion of the pancreas in cases of abdominal Avound with protrusion of that organ, appears to have been success- fully performed in six cases by CaldAvell, Laborderie, Kleberg, Thompson, Justin, and B. Allen. Treatment of Abdominal Abscesses. The surgeon is occasionally called upon to evacuate collections of pus which have been formed in connection with the liver, gall-bladder, spleen, kidney, intestinal canal, or ovary, or in the deep layers of areolar tissue found in the neighborhood of the broad ligament. 846 DISEASES OF THE ABDOMINAL ORGANS. Hepatic Abscess is not unfrequently met with in tropical regions. The pus may occasionally find a vent into a neighboring portion of intestine, or may perforate the diaphragm and enter the lung, or finally may point exter- nally. In the latter case surgical interference may be required, the treatment consisting in puncturing the abscess with an aspirator or a small trocar and canula, the latter being provided with a stopcock as in the operation for para- centesis thoracis. Sistach, however, employs a large trocar, and washes out the cavity of the abscess with injections of dilute tincture of iodine. The puncture should not be made until the signs of external pointing show that adhesions have been formed between the visceral and parietal layers of peri- toneum, but, if the other symptoms be urgent, an attempt may be made to hasten this occurrence, by the use of blisters or caustics, by making a super- ficial incision over the part, or by the introduction of acupuncture needles. The same means may be resorted to in dealing Avith other abdominal abscesses. Dr. Isham, of Ohio, has reported a remarkable case in which an hepatic abscess, bursting through the diaphragm, was successfully evacuated by an incision through the walls of the chest. Biliary Abscess.—The surgical treatment of abscess originating in the gall-bladder^ is to be conducted on the same principles as that of hepatic abscess. Splenic Abscess is of rare occurrence. The treatment consists in evacuating the pus by means of a trocar and canula, as soon as adhesion has occurred between the adjacent layers of peritoneum. Perinephritic Abscess, Pyonephrosis, and Hydronephrosis. —Collections of pus, originating in the areolar and adipose tissue around the kidney, may find a vent by bursting into the kidney itself, or into the bladder (the pus then escaping in the urine), by perforating the diaphragm and enter- ing the thoracic cavity, or by opening into the vagina or bowel, or on the external surface, usually in the hypochondriac or lumbar region. This affec- tion has been particularly studied by Trousseau, and more recently by Gibney, of New York, and Bowditch, of Boston, the last-named author having par- ticularly insisted upon the importance of early surgical interference. The treatment consists in making a puncture or incision to evacuate the contents of the abscess, as soon as the existence of pus has been ascertained with rea- sonable certainty: the opening should as a rule be made in the lumbar region, because the kidney can be reached from behind without wounding the peri- toneum ; if, however, absolute pointing of the abscess should have occurred anteriorly, indicating the formation of adhesion between the adjacent layers of peritoneum, the opening should rather be made at the point at which fluc- tuation is most distinct. With regard to the comparative advantages of incision, and of puncture with a trocar and canula, I should prefer the former; the objection usually urged, is, that the use of the bistoury is more apt to be followed by hemorrhage, but then, if hemorrhage should occur, a free opening would afford greater facility for its control. Perhaps the best plan Avould be to make a superficial incision, and then thrust in a grooved director in the Avay recommended by Hilton for the opening of deep-seated abscesses in other situations (see page 383). Even if the Aoav of pus do not immediately fol- low the operation, Dr. BoAvditch's experience has shown that the symptoms are quickly relieved, the swelling gradually melting away, as it were, under the influence of the suppuration which subsequently occurs. Pyonephrosis, or suppuration Avithin the kidney, has been successfully treated by Lente, by cutting into the organ and introducing a drainage tube ; nephrotomy has also ABDOMINAL ABSCESSES, HYDATIDS, AND CYSTS. 847 been resorted to under these circumstances by Ancrum, Heustis, Williams, Callender, and Loomis and Crane, the case reported by the last-named gentle- men being the only one which has terminated fatally. Nephrotomy for hydro- nephrosis, or accumulation of urine in the kidney, has been unsuccessfully employed by Nicaise, as has tapping and an attempt to secure adhesion between the orifice and the abdominal Avound, by Spencer AVells. The injec- tion of iodine has been successful in the hands of Schrotter and Billroth, as has double puncture, followed by incision and daily washing out the cavity, in those of Simon. Fecal or Stercoraceous Abscess may originate in connection with any part of the intestinal canal, but its most common seat is the neighbor- hood of the ciccum or appendix vermitormis, where it constitutes Perityphli- tic Abscess. Fecal abscess may result from injury, or from perforation of the boAvel occurring in the course of typhoid fever, but its most common cause is the irritation produced by a foreign body. The treatment consists in making a free incision, as soon as the occurrence of pointing renders it probable that adhesions have been formed between the parietal peritoneum and that covering the wall of the abscess. If the patient recover, it will probably be Avith a fecal fistula which must be treated as directed at page 373. Hancock, W. Parker, Buck, and others, recommend that the abscess should be opened by an early incision, Avhich may be made behind the peri- toneum as in the operation for tying the external iliac artery. Dr. Gouley, of New York, has collected 2o cases operated on in this manner, 23 having terminated in recovery, and only 2 in death. Ilio-Pelvic Abscess originates usually in connection with the ovary, broad ligament, or retro-peritoneal areolar tissue, the affection being, in most instances, met with as a complication of the puerperal state. The pus may find its way into the rectum, uterus or vagina, bladder, or peritoneal cavity, or, if peritoneal adhesions have been formed, may point externally. When it is thought proper to open the abscess, this may be done by cautious in- cision, or by puncture with a trocar and canula, through the posterior Avail of the vagina, the rectum, or the abdominal wall. If the latter situation be chosen, the operation should be delayed until after the establishment of ad- hesions between the adjacent layers of peritoneum. Suppuration occurring in an Ovarian Cyst (often though incor- rectly called Chronic Ovarian Abscess) has been successfully treated by Bryant, by making an incision in the median line of the abdomen, laying open the cyst, stitching its Avails to the edges of the external wound, and sub- sequently Avashing out the cavity daily by means of a syringe. Hydatids, Serous Cysts, etc. The surgeon is occasionally called upon to open hydatids, which occur in the liver, and more rarely in other organs. The opening may be made either with caustic or with the trocar and canula, with the same precautions against the escape of fluid into the peritoneal cavity as in the case of hepatic abscess. Dr. Southey, of St. Bartholomew's Hospital, London, has recorded a case of intra-thoracic hydatid, in which the cyst, after being tapped, Avas extracted through a free incision between the ribs : the patient recovered. The use of the trocar is also sometimes resorted to in cases of serous cyst of the liver, kidney, spleen, or urachus, or in those of distension of the gall- bladder from accumulation of the biliary secretion. 848 URINARY CALCULUS. The same precautions should be adopted here as in the case of hydatids. Cholecystotomy, or opening the gall bladder for the removal of biliary cal- culi, an old operation Avhich was described by Sharp in the early part of the last century, has been recently revived by Marion Sims, in the ease of a lady who died on the ninth day. CHAPTER XLIY. , URINARY CALCULUS. In the urine are found deposits of various solid substances, which when in the form of an impalpable powder are called sediments, when granular or crystalline are spoken of as gravel, and when concreted into masses constitute calculi or stones. The constitutional conditions Avhich precede or accompany the formation of these deposits are often called diatheses, and surgeons thus speak of the uric acid, the oxalic, and the phosphatic, diathesis. Varieties of Calculus. The most common and therefore the most important varieties of calculus are those composed respectively of uric acid, oxalate of lime, and phosphatic salts. Beside these, other varieties are occasionally met with, in which the concretion is composed of urates, cystine, xanthine, fatty matter, carbonate of lime, etc. Uric Acid Calculus__This is very common, constituting, according to Roberts, five-sixths of all renal calculi, and of vesical calculi which have Fig. 454. Fig. 455. Uric acid deposits. (Holmes.) Uric acid calculus. (Gross.) recently descended from the kidney. When uric (or lithic) acid is deposited as gravel, it occurs in the form of little crystalline masses or flattened con- cretions of a yellowish or reddish-brown color. The uric acid calculus ia VARIETIES OF CALCULUS. 849 ordinarily of moderate size, of a flattened oval form, and of a fawn color : on section, it is often found to be composed of concentric lamina?.. Its Aveight rarely exceeds an ounce. The surface of the stone is usually smooth and someAvhat mamilkted, but occasionally rough and manifestly crystalline. The best test for uric acid is the development of a bright violet or purple hue (murexid), on applying the vapor of ammonia to the residue left by treat- ing the suspected substance with nitric acid and heat. The urine of patients Avith uric acid calculus, is acid and frequently high-colored ; it often deposits uric acid crystals and amorphous urates. This form of stone is met Avith among free livers, especially those of a gouty habit, and among strumous, over-fed children. Urates—The urates of potassium, sodium, and ammonium are not unfre- quently deposited in the form of an amorphous sediment in urine after it has been voided, constituting the common lateritious deposit Avhich is met Avith in febrile affections, or Avhich may occur from mere concentration of the urinary secretion ; but calculi composed of urates are very rare. They are almost exclusively observed in young children, and as renal concretions ; though it is probable that urates occasionally form the nucleus of a vesical stone. The exact chemical composition of these calculi is a matter of some doubt, most authorities regarding them as concretions of urate of ammonium, though one of the latest Avriters, Roberts, of Manchester, appears to regard them as consisting of urate of sodium. Urate calculi are soft, and never large; they may he recognized by their solubility in hot Avater. Urate of' ammonium is often deposited in connection with phosphates from ammoniacal urine, and is thus met Avith in the outer layers of vesical calculi. Oxalate of Lime Calculus (Mulberry Calculus)__When evacuated in the form of gravel, oxalate of lime occurs as minute seed-like concretions, Fig. 456. Fig. 457. 0 Oxalate of lime deposits. (Holmes.) Mulberry calculus. (Miller.) of a smooth and rounded form, and of a grayish-brown color. The oxalate of lime calculus is hard, of a somewhat spherical shape, dark-brown or black (more rarely bluish-gray) in color, and tubercukted on the surface, somewhat resembling a mulberry. It rarely attains a large size. Oxalate of lime and uric acid are often deposited in alternate layers, the calculus consisting of more or less perfect concentric lamina;; the nucleus of such a calculus is usually composed of uric acid. Oxalate of lime is soluble in nitric and hydro- chloric acids, and when treated Avith the bloAvpipe leaves a residue of lime, 54 850 URINARY CALCULUS. Avhich blues reddened litmus, and browns turmeric. The deposit of oxalate of lime appears to be due to an imperfect metamorphosis of the azotized con- stituents of the blood, originating sometimes in errors of diet, or in exposure to bad hygienic conditions of various kinds. The oxalate of lime calculus is, as shown by Carter, much commoner in India than in cooler countries. Phosphatic Calculus__Of this there are three varieties :— 1. Amorphous Phosphate of Lime (Bone Earth) is rarely met Avith as the sole constituent of a calculus. Stones of this variety are of a whitish, chalky, or pale-broAvn color, are smooth and friable, and sometimes attain a consider- able size. The phosphate of lime calculus maybe recognized by its solubility in nitric and hydrochloric acids, and by its being totally infusible before the blowpipe. Phosphate of lime is also met with in the urine in a crystalline Fier. 458. Fig. 459. Phosphate of lime. (Holmes.) Triple phosphate. (Holmes). form (stellar phosphate), but does not under these circumstances occur as a calculus. The presence of amorphous phosphate of lime in the urine depends solely on the alkaline condition of that secretion. 2. Phosphate of Ammonium and Magnesium ( Triple Phosphate).—This is more common than the phosphate of lime; the stones are of a whitish-gray color, and evidently composed of crystals. The triple phosphate is soluble in acetic, or in hydrochloric acid, and is precipitated by an excess of ammonia, in a crystalline form. It is Avith difficulty fusible before the bloAvpipe. 3. Mixed or Fusible Calculus___This variety is formed of a mixture of the phosphate of lime and triple phosphate ; it often occurs as a Avhite mass, easily broken up, and resembling mortar; it is characterized by the great facility with which it may be fused before the bloAvpipe. The mixed phosphates rarely constitute the whole of a calculus, but, on the other hand, very fre- quently form some of the outer layers, deposited Fig. 4G0. upon uric acid or other nuclei, or upon foreign bodies. The triple phosphate and mixed phosphates are met with in alkaline and especially in ammo- ^z^ niacal urine. Cystine Calculus___This is a rare form of calculus. It is of a yellow color and has usually an oval shape, and a mamillated and slightly lustrous surface. On section, it presents a radi- ated appearance, and is at first of a yellow, Avax- like color, turning to a pale green by long exposure Section of a cystine calculus, with a nucleus of uric acid, and an external coat of phos- phates, (Roberts.) RENAL CALCULUS. 851 to the light. Cystine is soluble in the mineral acids, and in ammonia; Avhen precipitated from a solution in the latter (by evaporation of the sol- vent), it appears in the form of characteristic six-sided crystals. Xanthine or Xanthic Oxide is a very unusual constituent of calcu- lous concretions ; it is soluble in ammonia, but does not crystallize when precipitated. Fatty or Saponaceous Matters (Urostealith) have been occasion- ally found in calculi; the origin and precise nature of the substances in ques- tion are not positively knoAvn. Carbonate of Lime Calculi are very rarely met Avith. They are ahvays small; are white, yelloAV, or ash-colored; and are smooth, hard, and sometimes lustrous. Fibrinous Calculi and Blood Calculi have been described by vari- ous writers, but can scarcely be considered as urinary deposits. They are called by Poland pseudo-calculi. Silica is occasionally met with as a constituent of calculi, but the masses which have been supposed to be entirely formed of this substance, have been, according to Poland, pebbles or small stones introduced from without. The same may probably be said of calculi reported to be composed of iron. Indigo has been found as a constituent of renal calculus by Dr. W. M. Ord. For further information Avith regard to the various forms of urinary deposit and urinary calculus (of which the foregoing very brief sketch is all that the limits of this volume "will alloAv), I would refer the student to special works on the diseases of the urinary organs, and particularly to the writings of Bird, Jones, Beale, and Roberts. Renal Calculus. Renal calculi are, in the large majority of instances, composed of uric acid. The symptoms produced by a renal calculus consist of pain of an aching cha- racter in the lumbar region, with occasional aggravations (nephritic colic) in which the pain shoots doAvnwards tOAvards the scrotum and inner part of the thigh, and is attended by nausea or vomiting, and by dysuria and increased frequency of micturition. The urine at such times may contain blood, pus, or epithelial scales. When a calculus escapes from the kidney into the ureter, giving rise to a fit of the stone, the symptoms are greatly aggravated. The patient is suddenly seized Avith intense pain, radiating down the inside of the thigh and into the spermatic cord and testicle, the latter organ being retracted. There is constant vomiting, with a feeling of great prostration, constipation, partial suppression of urine, and, if the attack continue, decided febrile dis- turbance. The symptoms quickly subside Avhen the calculus reaches the bladder, but if, as sometimes happens, the concretion become impacted in the ureter, dilatation of that tube will ensue, with consequent disease of the corresponding kidney. Should impaction occur on both sides, a fatal result Avill be inevitable. In order to facilitate the diagnosis of renal calculus, catheterization of the ureters has been practised, in the male by Tuchman 852 URINARY CALCULUS. and Griinfeld (the latter by the aid of the endoscope), and in the female, after a preliminary vaginal cystotomy, by Simon. Treatment of Renal Calculus—During the descent of a calculus, Avhich may occupy several days, the patient should be kept fully under the influence of opium—warm baths, Avith hot fomentations or poultices to the loins and abdomen, being also of service. In some cases, cupping over the region of the kidney may be required. The boAvels should be acted on by means of enemata, and diluents may be freely administered (if the stomach do not reject them) to encourage the Aoav of urine. During the intervals between the paroxysms of nephritic colic, an attempt should, in suitable cases, be made to effect the solution of the concretion by the administration of the citrate or acetate of potassium, which are easily taken, and which enter the urine in the form of carbonate. The cases which, according to Roberts, Avho has specially studied this subject, admit of solvent treatment, are those in which the urine has an acid reaction, and in which the concretion is probably composed of uric acid. In such cases, from two to three scruples of either of the salts named may be given in three or four fluidounces of Avater, regularly every three hours. The operation of nephro- tomy for the relief of renal calculus has already been referred to (p. 844). The alkaline or solvent course of treatment above described is adapted to cases of renal calculus when the stone is already formed. In the preventive treat- ment of calculus, however, more may be accomplished, as pointed out by Sir Henry Thompson, by the use of saline laxatives, and particularly of certain natural mineral waters, such as those of Friedrichshalle and Carlsbad. Vesical Calculus. A vesical calculus may, as has been seen, originate from a concretion which has descended from the kidney ; but in other cases stone is primarily formed in the bladder, by the aggregation of small granular particles, around which, as a nucleus, fresh deposits subsequently take place, or by the deposit of cal- culous matter around some extraneous substance, such as a bullet, pin, straw, or broken catheter, Avhich has been introduced from Avithout. Structure and Physical Characters of Vesical Calculi__ Structure___Calculi may be composed throughout of the same substance, but in many instances consist of several layers or laminae of different chemical characters, deposited around a central portion or Fig. 461. nucleus. These stones are called alternating calculi. The nucleus is usually composed of uric acid, oxalate of lime nuclei coming next in frequency. AVhen the nucleus is phosphatic, the stone is not alternating, the layers subsequently deposited being phosphatic likeAvise. Whatever be the primary nature of the calculus, it may become encrusted with phosphates in consequence of an ammoniacal state of the urine, due to vesical irritation. Calculous matter may be de- posited around a mass composed of several small con- cretions aggregated together, the stone then appearing on section to contain several nuclei. In addition to Section of an alternating . . calculus. (Erichsen.) the various constituents of vesical calculi which have already been considered, Carter has shoAvn that an animal basis is invariably present; this is never found alone, and is probably not always identical in character. It is best developed in the urate calculi, and is found to present a finely granular, striated, or fibrillated appearance. CAUSES OF CALCULUS. 853 Number.—In the majority of instances the bladder contains but a single calculus, but occasionally two or more are found in the same case, and in a feAV instances very large numbers of stones coexist; the most remarkable case on record is, perhaps, that of Chief-Justice Marshall, from Avhose bladder Dr. Physick is said, on the authority of Dr. Randolph, to have removed by litho- tomy more than one thousand calculi. Sometimes several calculi become glued together by sabulous matter and inspissated mucus, forming one large stone someAvhat resembling a grape-shot in miniature. Shape—The most common shape of a vesical calculus is a flattened ovoid, though mulberry calculi are often someAvhat rectangular, or irregularly rounded, while phosphatic stones are occasionally curiously branched or con- stricted. When several calculi are present, the opposing surfaces become worn by attrition, various facets being thus developed on the sides which are in contact. Size—The size of calculi varies from that of a pin's head to that of a mass several inches in diameter. One of the largest stones known Avas extracted by a Belgian surgeon named Uytterhoeven, by the supra-pubic method, the concretion in this instance being six and a half inches long and four Avide, and Aveighing over tAvo pounds. Such large stones are, hoAvever, seldom seen at the present day, and one or tAvo inches may be considered an average length of the calculi ordinarily met Avith in practice. Weight.—The weight of vesical calculi varies as much as their size. The lightest stones mentioned in Crosse's tables weighed three and four grains respectively, and the heaviest, seven and eight ounces ; but even this weight has been greatly exceeded by that of stones seen by Mayo, Harmer, Cooper, Mott, Cline, Morand, MacGregor,1 and other surgeons. The average weight is from one or tAvo drachms to an ounce. Of 704 calculi referred to in Crosse's tables, there were 340 in which the Aveight was under and 361 in Avhich it Avas ovrer three drachms. I have myself cut patients successfully for stones Aveighing less than two grains and more than three ounces. Hardness.—The hardness varies according to the chemical nature of the calculus—stones of the mulberry variety being the least, and those of the phosphatic the most easily broken. Some of the latter variety are extremely friable, and of a mortar-like consistency. Situation.—The situation of calculi in the bladder varies Avith the amount of urine contained in the organ, the size of the stone, and the position of the patient. The locality in which a stone is usually found upon sounding, is, at least in the case of small calculi, at the bas-foud of the bladder; but a stone may at other times rest directly upon the neck of the viscus, or may be lodged above the pubis, or behind the prostate—the latter being, indeed, the usual locality in cases of chronic prostatic enlargement. A calculus usually floats loosely in the bladder, but may be fixed in one of the pouches of the organ (if this be sacculated), Avlien the stone is said to be encysted; it may also be adherent to the side of the bladder, or may be caught in the orifice of a ureter, or may be partially surrounded by a fungous growth. In other cases calculous matter, instead of being concreted into the form of a stone, is depo- sited in ridges or layers upon the vesical mucous membrane. Causes of Calculus.—The causes of stone are in most cases very obscun;; the formation of calculous concretions is no doubt, as pointed out by Carter and Ord, due to the presence of colloids in the urine, but the circum- stances under which these colloids occur have not yet been clearly ascertained. 1 Morand is said to have seen a calculus weighing six pounds ; in MacGregor's case, over 520 small calculi are said to have coexisted with a large one Aveighing 51 ounces. 854 URINARY CALCULUS. Occasionally, hoAvever, the development of calculus is evidently due to tbe presence of a foreign body, as a broken catheter, slate-pencil, or hair-pin, or, in some rare cases, the presence of hairs, etc., extruded from a dermoid cyst opening into the bladder. Age___Age appears to exercise a decided influence upon the occurrence of calculus, the statistics collected by Civiale, GrOss, Coulson, and Thompson, shoAving that, in round numbers, about tAvo-thirds of the Avhole number of cases are in persons under twenty, and about two-fifths in those under ten years of age. These figures furnish, however, but an approximation to the true statement, for while, on the one hand, a stone may persist for many years before it is detected, the total number of persons between (e. g.) the ages of five and ten is, on the other hand, much larger than at any quinquen- nial period of adult life, so that the relative proportion of patients at any par- ticular age may be a-cry different from that above given. Sex___Persons of the male sex are undoubtedly more apt to be afflicted Avith vesical calculus than women ; but the difference is probably not greater than can be accounted for by the respective anatomical peculiarities of the male and female urethra, the escape of small calculi tlirough the latter being much easier than through the former. Residence___The frequency of calculous disorders A/aries in different locali- ties ; thus in our own country stone is, according to Gross, more common in the States of Kentucky, Virginia, Tennessee, and Ohio, than in any other regions. In the neighborhood of Philadelphia it is certainly \Tery rare, the records of the Pennsylvania Hospital showing that of about eighty thousand patients treated in its wards, in one hundred and sixteen years, there were but one hundred and twenty-five cases of stone, a proportion of less than one- sixth of one per cent. Other Causes___Among other circumstances which have been supposed to influence the frequency of the occurrence of calculus, may be mentioned race, climate, diet, the use of limestone water, social condition, hereditary predis- position, etc. Finally, any circumstance Avhich, by interfering with the excretion of urine, leads to vesical irritation, and, in consequence, to an ammoniacal state of the contents of the bladder, may be considered as predisposing to the production of stone ; thus stricture of the urethra, enlargement of the prostate, and para- lysis of the bladder from injuries of the spine, may all act as causes of vesical calculus. Symptoms of Vesical Calculus__These vary according to the shape and size of the stone, the age and general condition of the patient, etc. A smooth and rounded calculus produces less irritation than one Avhich is sharp and angular, and a small stone usually causes less disturbance than a large one. In children, though there may be a good deal of local distress, there is seldom much constitutional suffering, the patients often appearing particularly rosy and hearty. This is not, hoAvever, invariably the case, and children are occasionally seen who are much emaciated and Avorn down by the constant irritation produced by the stone. In adults, the general health suffers at a comparatively early period, and inflammation of the bladder and kidney are common complications of stone at this period of life. Phosphatic calculi are usually said to produce more irritation than those of other varieties ; but this is, I believe, erroneous, the fact being that cystitis (with an ammoniacal con- dition of the urine) almost invariably precedes and accompanies the deposit of phosphatic matter. Pain is usually a prominent symptom of stone, and often the first which attracts attention; beside a dull pain and feeling of weight in the region of SOUNDING FOR STONE. 855 the bladder and in the perineum, there is pain referred to the groins, testes, thighs, or even the arms or soles of the feet, Avith a peculiar, sharp, cutting pain in the glans penis. Avhich is most marked in children—leading to a habit of squeezing and dragging at the part, and giving rise to elongation and hyper- trophy of the prepuce. The pain is usually Avorst immediately after urinating, from the stone then falling foi'Avard on the neck of the bladder, Avhich is the most sensitive part of that organ. In order to prevent this, calculous patients get the habit of making water in the recumbent position. The pain is ahvays increased by riding or walking, or by any movement which causes the stone to jolt about in the bladder; these variations in the amount of pain felt, are less marked in those cases in which the stone is habitually lodged behind an enlarged prostate, and are almost absent in cases of encysted calculus. Frequent and Painful Micturition is a very constant symptom of vesical calculus ; in some instances there is absolute incontinence of urine, and in others retention ; the Aoav sometimes stops suddenly from the stone falling OA'er the orifice of the urethra, beginning again when the patient changes his position. The urine often contains blood, and, if there be cystitis, may be heavily loaded with mucus or pus; when the kidneys become implicated, the urine is commonly albuminous. The detection of crystals of uric acid or oxalate of lime in the urine, Avould serve to throAv some light upon the nature of the calculus. Prolapse of the Rectum is a not unfreqnent accompaniment of stone in children, and is occasionally seen in adults; it evidently results from the straining efforts made in the endeavor to empty the bladder. Priapism and Involuntary Seminal Discharges are among the rarer symp- toms of A'esical calculus, as is subconjunctival ecchymosis, Avhich I have seen in one case from the violent straining efforts in micturition. Diagnosis__From observation of some or all of the symptoms men- tioned, the surgeon may suspect the existence of a calculus in the bladder, but cannot be certain of it until he has elicited physical evidences of the presence of the stone. In children the calculus may sometimes be felt by the finger introduced into the rectum, and in women by a similar exploration, per vaqinam, but the common means of determining the presence of a stone is bv the introduction of a sound into the bladder. Very small stones may be detected in this Avay, and I haA'e thus distinctly recognized, in a child, a calculus Avhich when removed by lithotomy Avas found to weigh less than tAvo grains. Sounding for Stone__A sound is a solid steel instrument of the gene- ral shape of a catheter, but Avith a shorter beak (not much exceeding an inch Fig. 402. Sound for examining bladder. in length), and more abruptly curved ; the handle is made broad and smooth, and the shaft narroAver than the beak, which is of a somewhat bulbous shape. The sound may be plated with nickel, Avhich renders it less liable to rust. Sir II. Thompson recommends, as preferable to the ordinary sound, one which is IioHoav, so as to allow, if necessary, the gradual escape of urine, and with a grooved cylindrical handle, which permits more delicacy of manipula- 856 URINARY CALCULUS. Fig. 463. L Thompson's sound, with slide and scale for ascertaining the magnitude of a stone. The handle, which resembles that of a modern lithotrite, but smaller, affords great facility in sounding. tion than the broad and flat handle of the instrument commonly employed ; the shaft is graduated and provided with a slide, so as to measure the size of the stone. The operation of sounding is occasionally followed by some pain and constitutional disturbance, and should therefore not be performed during the existence of great vesical irri- tation, but should, under such circumstances, be postponed for a ftuv days, until the irritation has been allayed by the administration of demulcents and other suitable remedies. The operation is thus performed : The patient is laid on his back on a hard mattress, with the hips slightly ele- vated, and may be etherized if this be thought desirable ; there should be a moderate quantity of liquid in the blad- der, and therefore if the patient have passed his urine shortly before the examination, a few ounces of tepid water may be injected through an elastic catheter. The surgeon, standing between the thighs of the pa- tient, or on either side,1 and holding the sound previously Avarmed and oiled in his right hand, and in a horizontal direction, introduces the beak into the urethra, and draAv- ing the penis forwards Avith the left hand, gradually ele- vates the shaft of the instrument, Avhich passes in by its own weight, until from being horizontal it has assumed a vertical position ; it is held thus for a few seconds while it traverses the membranous portion of the urethra, Avhen by gently depressing the handle between the thighs, the beak rises through the prostatic portion into the bladder. In many cases the stone will be immediately touched by the sound, Avhich then communicates a peculiar sensation to the hand of the surgeon, accompanied by a distinct noise or "click," which is commonly audible to the by- standers, and which may be intensified by attaching a small sounding-board to the handle of the instrument, or, as suggested by Head, of Dublin, and Andrews, of Chicago, by attaching a flexible tube, the other end of Avhich is applied to the surgeon's ear.2 In other instances, the stone will not be so easily discovered, and the surgeon must then cautiously search for it, turning the sound first on one side and then on the other, and varying the position of the handle so as to explore Avith the beak every portion of the bladder in succession ; this is done Avith a kind of tapping motion, imparted by lightly rotating the instrument betAveen the thumb and forefinger. The stone "vvill usually be found on one or other side of the neck of the bladder, or at the fundus of the organ near the orifices of the ureters ; it may, hoAvever, in an adult, be lodged behind the prostate, or may rest above the pubis. To explore the former region, the position of the sound is reversed, the beak being turned downwards and the han- 1 The beginner may stand on tbe left side, as in catheterization, and cross over to the right side when the sound has reached the bladder, but, Avith a little practice, it will, I think, be found more convenient to stand on tbe right side, when no change of position will be required to enable the exploration of tbe bladder to be conducted with the right hand. Fergusson prefers to stand on the right side and introduce the instrument with the left band. When it is desired to aid the diagnosis by means of the fingBr in the rectum, tbe surgeon should stand between the patient's thighs. 2 Sir H. Thompson and Dr. H. M. Taylor, of Richmond, Va., have recently em- SOUNDING FOR STONE. 857 die elevated, Avhile the stone may be pushed upwards by means of the finger in the rectum ; to find a stone above the pubis, the beak of the sound is tilted Sounding for stone above the pubis. (Erichsen.) Sounding for stone behind the prostate. (Erichsen.) forwards while the handle is well depressed between the thighs, the bladder being at the same time pressed doAvnwards by placing the hand over the loAver part of the abdomen. Occa- sionally the position of the pa- Fig. 465. tient may be ad\Tantageously varied, by placing a high pil- low beneath the buttocks, or by causing him to lie on either side, to sit, or even to stand ; or the bladder may be dis- tended with water which is then alloAved to escape sloAvly through the hollow sound, when, as the organ contracts, the stone will probably fall against the instrument. If the presence of the calculus is not determined in the course of five or ten minutes, the instrument should be AvithdraAvn, and further explo- ration postponed for three or four days—prolonged sounding being attended with some risk of producing cystitis. After the use of the sound, it is better that the patient should keep pretty quiet, and, if there be any pain, an opium suppository may be introduced into the rectum. Beside determining merely the existence of a stone in the bladder, the surgeon may by sounding acquire valuable information as to the number, size, and hardness of the calculi, whether they be adherent or encysted, and as to the general condition of the bladder and prostate—all points of importance in regard to treatment. If the sound strike a stone on either side of the bladder, the surgeon knoAvs that there is more than one calculus ; but this can be better determined by the use of a light lithotrite, seizing one stone and then using the instrument as a sound in searching for others. The lithotrite affords also the best means of ascertaining the size of a stone, though this ployed tbe microphone for tbe detection of small calculi. Von Brabandt recommends exploration with the canula of an aspirator, introduced above the pubis. Napier uses a sound blackened by dipping it in a solution of nitrate of silver, the contact of the stone producing scratches on the surface. 858 URINARY CALCULUS. may be done with approximate accuracy by moving the sound from side to side, or by touching the calculus first with the convex and then with the con- cave surface of the instrument. The hardness of the stone mav be estimated by the character of the '' click" produced by the contact of the instrument, a phosphatic concretion giving a dull thud, Avhile a uric acid, and more espe- cially an oxalate of lime, calculus gives a sound of a clear, ringing character. Fig. 466. Sounding for encysted calculus. (Erichsen.) If the stone were invariably found in the same locality, no matter Avhat the amount of liquid in the bladder nor what the position of the patient, the sur- geon Avould suspect that the calculus Avas adherent; and if, in addition, the sound, Avhile touching the stone but at one point, passed over a prominent swelling projecting into the bladder, the inference Avould naturally be that the calculus Avas encysted. The condition of the bladder, Avhether sacculated, ribbed, or incrusted with phosphatic deposits, and the size and relations of the prostate, can also be pretty accurately determined by exploration with the sound. A stone, though present, may escape detection, from its being encysted or lodged in one of the sacculi of the bladder, from being coated with blood or mucus, or even from its small size enabling it to slip away and elude the sound. Hence, in any case in which the rational symptoms indicate the pre- sence of a calculus, though none can be found, the surgeon should repeat the exploration from time to time, varying the conditions under which the exami- nation is conducted, until the diagnosis is rendered certain. The surgeon may, on the other hand, think that he has detected a stone when none is present, being misled by striking the sound against a calculus incrus- tation, against a tumor in the bladder, or in the neighborhood of and com- pressing that organ, or even against the walls of the bony pelvis. That the possibility of these errors being made is not merely imaginary, is shown by the fact that such eminent htliotomists as Cheselden, Crosse, and Roux, each cut for stone (the former in three instances) in cases in Avhich no stone could be found after the operation. Sounding for Stone in Women is effected with a short and very slightly curved instrument, resembling in shape the ordinary female catheter. Great assistance may be derived from tilting fonvard the stone by means of tAvo fingers introduced into the vagina. Prognosis—Stone in the.bladder, unless removed by treatment, leads to serious morbid changes in the urinary organs, a fatal result being, sooner or later, almost inevitable. The prostate commonly becomes enlarged, and cys- titis occurs, the bladder usually being contracted and ribbed, but sometimes LITHOTRITY. 859 dilated ; congestion and ultimately granular degeneration of the kidneys fol- low, and the patient dies Avorn out by suffering, or from the progress of the renal affection. If, on the other hand, the presence of the stone be recognized at an early period, and proper treatment adopted before the viscera, and espe- cially the kidney, have become seriously involved, the prognosis is quite favorable, lithotomy being an exceedingly successful operation in the case of children, and lithotrity (Avhen not too long delayed) equally so in the case of adults. Treatment of Vesical Calculus___There are several modes of treatment employed in cases of vesical calculus, and each may be properly resorted to in suitable cases. That surgeon will do more to promote both the Avelfare of his patients and his oavii reputation, who, in the treatment of stone, varies his remedies in accordance Avith the particular circumstances of each individual case, than he Avho uniformly folloAvs one exclusive mode of practice. Litholysis. Litholysis, or the Solvent Treatment of Stone, is unfortunately applicable to but a A-ery limited number of cases. In the management of renal calculus, as already mentioned, a trial of this plan is often proper, for there is nothing else to be done ; but, in dealing with stone in the bladder, the surgeon has no right to Avaste time and deprive his patients of the great ad\Tantages to be de- rived from an early operation, by resorting to a mode of treatment Avhich is at best sIoav and uncertain. There are cases, however, in which the solvent treatment may be proper. Thus, as an adjuvant to lithotrity, in the case of a uric acid (or cystine) calculus, advantage may be sometimes gained from the administration of the citrate or acetate of potassium in the ivay already mentioned, so as to keep the urine moderately alkaline, provided that there be no tendency to ammoniacal decomposition. If the urine be ammoniacal, the alkaline treatment is positively contra-indicated. In dealing with phosphatic calculi, injections of dilute nitric acid (Ac. nitric, dilut. (U. S. P.) f'5ijj Aqua? Oj) may be employed, as an adjuvant to lithotrity (as has been done by Southam, Harrison, and Richardson), or alone, when the general condition of the patient forbids operative interference, as in the well-knoAvn case recorded by Sir Benjamin C. Brodie. A similar mode of treatment, under the name of lithoclysmy, has been recently advocated by Dr. Pignoni. Injections of acetate of lead (gr. j to fjiij) and of hydrochloric acid (nvj-ij to f^j) are favorably spoken of by Sir Henry Thompson. Oxalate of lime calculi do not appear to be amenable to any form of solvent treatment. Lithotrity. Lithotrity, or the operation of Crushing a Stone in the Bladder, is noAv generally, and in my opinion justly, considered the best mode of treatment for any case of vesical calculus to which it is applicable. The first formal proposition to treat calculus in this manner is usually attributed to Gruithui- sen, a Bavarian surgeon, who Avrote in the year 1813; hut a claim of priority has been advanced, and upon apparently good grounds, for tAvo Italian sur- geons named Santorio and Ciucci, Avho flourished in the seventeenth century.1 HoAvever this may be, it is to Civiale that is unquestionably due the credit of giving the operation a place among the recognized procedures of practical surgery, his first operation upon the living subject having been done in the 1 Brit, and For. Mud. RevieAV, vol. xi., Jan. 1841, p. 270. 8G0 URINARY CALCULUS. year 1824. Since then lithotrity has been very frequently practised in France and England, and to a certain extent in our oAvn country ; and the instru- ments employed have been brought to a high degree of perfection, chiefly through the labors of Civiale, Fergusson, and Thompson, aided by the Avell- knoAvn manufacturers, Charriere, MattheAvs, Coxeter, and AVeiss. Tavo instruments are usually required, one Avith the female blade fenestrated, for crushing stones or large fragments, and one "with both blades plain for reduc- ing the smaller fragments to powder ; the plain-bkded lithotrite is often though incorrectly called the scoop, and is now used by Thompson almost to the entire exclusion of the fenestrated instrument. The blades of the lithotrite are rather Avider than the shafts1 (Avhich should be as light and slender as may be com- patible Avith sufficient strength), and the male blade should be narroAver than the female. The shaft and blades, which are united at an angle of 110°- 120°, should be cut out of solid pieces of steel, as they will thus fit more accurately and be much stronger than when bent into shape from flat plates of metal. The handle of Weiss and Thompson's improved lithotrite (Fig. 467), Avhich is probably the best noAv before the profession, is in the form of Fig. 467. Weiss and Thompson's improved lithotrite. a grooved cylinder, the force being applied by means of a screw, and the handle being furnished Avith a button, which by an ingenious mechanism enables the screAving to be instantly comTerted into a sliding motion, and vice versa. In Fergusson's instrument the force is applied by means of a Fig. 468. Fergusson's lithotrite ; the male blade is moved by the key. rack and pinion. Amussat employs a lithotrite (or lithoclast) in which a certain amount of lateral motion can be given to the male blade, thus render- ing it more easy to free the instrument from calculous detritus. Prof. Bigelovv employs a very powerful lithotrite Avith a tube or groove betAveen the blades, for the injection of Avater Avithout removing the instrument. Preparatory Treatment.—For a feAV days, at least, before submitting a patient to lithotrity, the surgeon should enjoin rest in a recumbent position, and should adopt suitable means to bring the digestive system into a good condition, and to combat any vesical irritation that may exist, by the use of hip baths, anodynes, demulcents, etc. Sir II. Thompson speaks very highly of a decoction of the triticum repens, or couch-grass, of which he directs a 1 The shaft attached to the male blade is technically called the sliding rod. OPERATION OF LITHOTRITY. 861 pint to be taken in divided doses in the course of the day. The use of an exclusive milk-diet is recommended by Dr. George Johnson and by Dr. S. "Weir Mitchell, of this city. The urethra may also be accustomed to the use of instrujjients by the introduction first of elastic, and subsequently of metallic, bougies of gradually increasing sizes, and, finally, of an ordinary sound with which the stone may be touched and some notion gained of its size and composition. If the introduction of instruments produces great con- stitutional disturbance, the operation should be postponed for a short time until the irritable condition of the urethra has been overcome ; and if this cannot be done, the surgeon may be induced by this circumstance alone to abandon crushing and resort to lithotomy. The urine should be examined, and if it contain much mucus or pus. the bladder may be Avashed out (through a flexible catheter) with simple injections of tepid Avater, Avhich may be re- placed by a very Aveak solution of nitric acid, if there be a copious deposit of phosphates. The conditions wished for and sought to be obtained by pre- paratory treatment are, according to Thompson, (1) a fairly capacious and not very tender urethra; (2) a bladder capable of retaining three or four ounces of urine, not very irritable, and yet with sufficient tone to be able to expel its contents ; and (3) fair general health. With these conditions and a stone of but moderate size and hardness, the operation of lithotrity offers an exceedingly favorable prognosis. Operation.—Some difference of opinion exists as to the propriety of employing anaesthetics in lithotrity. If performed with skill and delicacy, the operation is attended with little or no pain, and anaesthesia is therefore not required unless iu exceptional cases. There is, moreover, a certain ad- A-antage in operating without ether, in that the surgeon can thus judge of the irritability of the bladder, and extend or abridge the duration of the " sitting" accordingly. The operation itself may be described as occupying three stages, viz.. (1) the introduction of the lithotrite; (2) the seizing, and (3) the crush- ing of the stone. The patient should lie on his back on a firm mattress, Avith his right side close to the edge of the bed, and the hips slightly elevated; the thighs should be slightly flexed and supported upon pillows, and should be sufficiently separated to allow the free play of the lithotrite betAveen them, the knees being for this purpose kept at least tAvelve inches apart. If the prostate be much enlarged, a firm cushion should be placed beneath the peh"is, so as to raise this part from four to six inches above the level of the shoulders ; the stone thus rolls backwards from its position behind the prostate, and comes more readily Avithin the grasp of the instrument. If the patient has passed his urine within half an hour of the time fixed for operating, three or four ounces of tepid Avater may be sIoavIv injected through a flexible catheter ; but this is not usually necessary, and the preliminary catheterization is in itself undesirable, as prolonging the sitting. Introduction of the Lithotrite___The surgeon, standing on the right side of the patient, holds the lithotrite, previously Avarmed and Avell oiled, lightly in his right hand, in a horizontal line, and in a direction nearly parallel to the long axis of the patient's body. The left hand raises the penis, and sloAvly draws the urethra upwards over the blades of the instrument, Avhich is alloAved to enter by its own Aveight as it is gradually raised into a A'ertical line. The lithotrite thus reaches the bulbous portion of the urethra, and must then be held vertically for a few seconds, until the membranous portion has been traversed, when, by gently depressing the handle between the patient's thighs, the blades of the instrument slowly rise through the pros- tatic portion of the canal into the bladder. Sir II. Thompson advises that at this time a slight lateral rotatory movement should be given to the 862 URINARY CALCULUS. Fig. 469. lithotrite, and that the surgeon should press over the pubes so as to relax the triangular ligament of the penis. As the instrument enters the bladder, its shaft forms an angle of 20° or 30° Avith a horizontal plane, and Avhen the introduction is completed the urethra loses its curve and is brought into a straight line. Finding and Seizing the Stone— There are two ways in Avhich this may be done. Heurteloup's plan, Avhich Avas followed by Brodie, and Avhich has been usually adopted in England, Avas to depress the base of the bladder with the angle or convexity of the litho- trite, and then, draAving back the male Introduction of the lithotrite. (Erichsen.) blade, give the instrument a tap 01' jerk so as to cause the calculus to fall within its grasp. The other method, Avhich originated Avith Civiale, is adopted by Thompson, and seems to me the best. In this method the blades of the lithotrite are passed to about the centre of the bladder, the handle (wliich is attached to the female blade) being lightly held in the left hand, while the sliding-rod is Avorked with the right. If, as often happens, the stone is touched by the instrument as it enters the bladder, the blades are slightly inclined in the opposite direction, the male blade gently withdrawn, and the opened blades then inclined towards the stone, Avhich is readily caught betAveen them Avhen the lithotrite is closed. Under other circumstances, the instrument is made to go in search of the calculus, by opening the blades in the centre of the bladder, turning them to the right, and closing; opening them again in the centre, turning to the left, and closing; then repeating the same move- ments with the handle of the lithotrite depressed, and so on until, if neces- sary, the Avhole cavity of the bladder has been explored. During the rotation of the blades the handle of the lithotrite is held steadily Avith the left hand, so that the shaft, Avhich is in contact with the urethra and neck of the bladder, shall have no motion except upon its own axis, wliile the blades are inclined in various directions by the rotatory movement imparted by the right hand, and greatly facilitated in Thompson's instrument by the cylindrical shape of the handle. The folloAving formula is given by Thompson as expressing the different directions in Avhich the blades of the instrument are to be made to seek for the calculus : Vertical, right and left incline, right and left horizontal, and (if the prostate be enlarged) right and left reversed incline, and reversed vertical. For the reversed exploration a short-bladed lithotrite is preferred. In the description given above, the female blade is supposed to be fixed, and the jaAVS of the lithotrite to be opened by draAving the male blade back- Avards, but it is often found conArenient in practice to fix the male blade and open the instrument by projecting the female blade. Crushing the Stone.—When the calculus has been seized, the surgeon rotates the lithotrite a little, to make sure that none of the vesical mucous membrane is included in its grasp, and then fixes it by draAving up the but- ton attached to the handle of the instrument, Avhich changes the sliding into the screwing action ; the stone, being now held firmly in the centre of the bladder, the screw is to be turned sloAvly until the resistance yields, wliich it will do gradually or suddenly, according to the consistence of the calculus. The male blade is then to be drawn out (the screAving being, for this purpose AFTER-TREATMENT IN LITHOTRITY. 863 reconverted into the sliding motion), Avhen, Avithout altering in any respect the direction of the instrument, one of the fragments may be picked up and Fig. 470. Position of the lithotrite in crushing the stone. (Liston.) crushed as before ; and this process may, Fig. 471. under favorable circumstances, be repeated tAvo or three times. The instrument is then accurately closed and sIoavIv draAvn out by e reversing the steps by which it was intro- duced. It is better not to attempt too much at the first sitting, and Thompson's rule is that the lithotrite should not remain in the bladder more than tAvo minutes, or, if the patient be anaesthetized, about ten minutes. In the first sitting it is sufficient to crush the stone (which, if the calculus be large, is best done Avith the fenestrated lithotrite), the pulverization of fragments being left for subsequent occasions. The sittings, if all go well, may be repeated at intervals of from three to six days. Prof. BigeloAv, of Boston, has recently advised that the Avhole operation should be completed at one sitting Avhich he does not hesitate to prolong to three or four hours. He has devised special instruments for crushing the stone and evacuating the fragments, and has pub- lished a number of cases in Avhich his operation, which he calls litholapaxy, has been successfully performed. After-treatment__For at least tAventy-four or thirty-six hours, after each of the earlier sittings, the patient should lie in bed, and particularly avoid passing water except in the recumbent posture, so as to prevent angu- lar fragments from falling upon the neck of the bladder or becoming impacted in the urethra. He should be Avarmly Avrapt up, and a hot napkin or poultice may be applied over the pubes and perineum, an opium and belladonna sup- pository being at the same time introduced into the rectum. The sharp cor- ners of the fragments are soon Avorn off by the contact of the urine, and after Bigelow's lithotrite. e. Male blade, preseuting, on alternate sides, triangular notches. The small portion of debris not discharged laterally by these notches is driven through the slot iu the female blade. /. Slot in the female blade. 864 URINARY CALCULUS. tAvo or three sittings a considerable quantity of debris will be passed when- ever the patient makes AA^ater, or may be Avithdrawn in the grasp of the plain- bladed lithotrite. The final exploration, by which it is designed to detect and pulverize the last fragment, is best made Avith a small, short-bladed litho- trite, Avhich is successively directed to all parts of the bladder, and particu- larly to the pouch behind the prostate. As a test of the complete removal of Fig. 472. Fig. 473. Clover's evacuating apparatus. Bigelow's evacuating apparatus for litholapaxy. a. Elastic bulb and glass receptacle with brass cap for debris. 6. Kubber tube two feet in length, c. Evacuating tube of silver. the calculus, W. J. Coulson advises that the patient should take a drive over a rough road, when, if any fragment remain, its presence will be revealed by the irritation produced by the jolting. Washing Out the Bladder—In ordinary cases, it is probably wiser, as ad- vised by Tliompson, for the surgeon to content himself with breaking up the stone, leaving the extrusion of detritus to the unaided efforts of nature ; but in some instances, as, for example, if there be enlargement of the prostate with retention of urine, it is necessary to adopt artificial means to accomplish this object. In some cases it will be sufficient to use an " evacuating catheter," provided with a large eye near its extremity, through which the debris of the ACCIDENTS AND COMPLICATIONS OF LITHOTRITY. 865 stone may escape,1 but in other cases it will be better to wash out the bladder through a double catheter, or to employ one of the ingenious instruments devised for the purpose by Air. Clover, Prof. Dittel, and Prof. Bigelow. Clover's apparatus (Fig. 472) consists of an elastic bottle, Avith a glass reservoir, and evacuating tubes of different sizes and shapes; the bottle is filled Avith tepid water Avhich is sloAvly injected into the bladder, bringing with it as it returns the detritus, which is detained in the reservoir. The process may be repeated 10 or 12 times at each sitting, Avith great gentleness, however, lest the mucous membrane of the bladder be injured by the eye of the catheter. Dr. Gouley, of Xew York, has recently suggested that the bottle of Clover's apparatus may be conveniently replaced by an aspirator. Prof. Dittel, of Vienna, has suggested an ingenious application of the siphon principle to the evacuation of detritus after lithotrity, and his instru- ment appears to me even better than that of Clover; the evacuating catheter is connected with a long, flexible siphon tube which reaches to a vessel placed on the floor; Avhile an arrangement of valves permits Avater to be thrown into the bladder, the outward current depending upon the force of atmospheric pressure ; the advantages of this method are that the bladder can be more completely emptied than by any other plan, Avhile there is comparatively little risk of inflicting injury upon the vesical mucous membrane. The siphon principle is also employed in the evacuating apparatus of Prof. BigeloAV (Fig. 473). Accidents and Complications of Lithotrity__If the lithotrite be properly employed, there can be no danger of lacerating the urethra or injuring the mucous lining of the bladder; it has happened that the instru- ment has broken in attempting to crush a hard calculus, and should such an unfortunate event occur, there would be no alternative to cutting into the neck of the bladder and extracting the foreign body. To prevent the possi- bility of such an accident, every lithotrite should be tested before it is used, by crushing with it a lump of sandstone about the size of an English AA'alnut. One of the most annoying complications wliich can be met with after the operation of lithotrity, is the impaction of a fragment of calculus in the urethra—an accident which is usually traceable to the restlessness of the patient, and particularly to the neglect to keep the recumbent posture when urinating. Apart from the pain and local irritation produced by the impacted fragment (Avhich may cause cystitis, or abscess in the neighborhood of the urethra, leading perhaps to urinary extravasation), there is often great con- stitutional disturbance, Avith repeated rigors and possibly the development of a pyaemic condition. The course to be pursued in the event of impaction oc- curring, varies according to the point at Avhich the fragment has been arrested : should this be in front of the membranous portion of the urethra, the offend- ing body should be extracted through the external meatus with delicate urethral forceps, such as Mathieu's (Fig. 474), Avith a curette, or with Civiale's scoop; while if lodged in the prostatic or membranous portion, it should be pushed back into the bladder with a full-sized bougie or a stream of Avater directed through a catheter Avith an open end, or, if these means fail, should be removed through an incision in the median line of the perineum; under these circumstances, it might be Avell to convert the operation into what has been named by Dolbeau, perineal lithotrity, reducing the remaining frag- ments to a sufficient size to enable them to be extracted through the Avound. 1 After the earlier sittings these means of artificial evacuation should not be em- ployed, for there is then no fine debris to be Avashed out. If retention exist, the urine may be drawn off Avith an ordinary catheter. oo 866 URINARY CALCULUS. Other complications of lithotrity (Avhich, however, are not peculiar to this operation, but may follow the use of a simple bougie or catheter) are urethral fever, hematuria, and inflammation of the bladder, prostate, or testis: these Avill be considered hereafter. Retention of urine is another complication Fig. 474. Urethral forceps. which not unfrequently occurs, particularly in old persons, and which, on account of the insidious manner in which it is developed, should be carefully watched for; here, as in other cases, the true condition is masked by appa- rent incontinence; the treatment consists in using the catheter at regular intervals, until the natural tone of the bladder is restored. Statistics of Lithotrity___The statistical results of lithotrity, in the hands of any operator, Avill necessarily vary very much according to the good or bad judgment which he exercises in the selection of his cases, and, as justly remarked by Sir Henry Thompson, unless the surgeon can arrive at an accurate diagnosis of the nature and size of the stone (and, I may add, of the condition of the urinary organs of his patient), it is probably safer to avoid lithotrity entirely, and uniformly resort to lithotomy. But if an accurate diagnosis can be made, the risk to life, in suitable cases, is, I think, certainly less (in the case of an adult) if the stone be crushed than if it be removed by cutting : to establish this, it will be sufficient to refer to the experience of those surgeons who have practised the operation most frequently, and who may therefore be supposed to have brought it to its highest state of perfec- tion. Omitting Civiale's cases (the record of which is considered inaccurate by many of those best qualified to form an opinion on the subject), the expe- rience in lithotrity upon male adults of Brodie, Fergusson, Keith, Thompson, and Cadge, may be summed up in the following table :— Brodie...... 115 cases, 9 deaths, or 7.83 per cent. Fergusson.....109 " 12 " 11 " Keith (of Aberdeen) . . . 116 " 7 " 6.03 " Thompson.....422 " 32 " 7.58 " Cadge......86 " 8 " 9.30 " Aggregate.....848 " 68 " 8.02 " These results, it will be seen, are very satisfactory ; they cannot, of course, be in any Avay compared Avith the results of lithotomy—and still less Avitli those of lithotomy since the introduction of the crushing method; for lithot- rity is now confessedly chosen for the most favorable, and lithotomy for the least favorable cases. An approximate judgment as to the actual benefits derived from the introduction of lithotrity, may, however, be arrived at by comparing the mortality in all cases of stone submitted to operation by those avIio practise both methods, with that of cases in the hands of surgeons Avho employ lithotomy only : from such a comparison it appears that the death-rate, CONTRA-INDICATIONS TO LITHOTRITY. 867 in cases of adult males, is reduced nearly six per cent, by the adoption of the former course:— 1215 cases operated on by both methods, by Fergusson, Keith, Thompson, and Cadge, gave 180 deaths, or 14.81 per cent. 799 cases operated on by lithotomy exclusiArely, collected by Thompson, gave 161 deaths, or 20.15 per cent. It is thus seen that a considerable gain is derived by resorting to lithotrity in suitable cases; and it is surely, therefore, the surgeon's duty to employ the crushing rather than the cutting method, whenever the former is not posi- tively contra-indicated. Circumstances -which forbid a Resort to Lithotrity__These have regard to the age of the patient, the nature and size of the stone, the condition of the urinary organs, and the state of the patient's general health. 1. Age___In the first place, lithotrity is contra-indicated in the treatment of children below the age of puberty : the grounds for this assertion are, that (1) tbe urethra is too small at this age to permit the free play of an instru- ment of sufficient strength; (2) the bladder is placed so high—in the abdo- men rather than in the pelvis—as to render the use of the lithotrite difficult and not very safe; (3) children do not bear Avith impunity the frequent repe- tition of operations required in the various sittings of lithotrity; (4) the operation can scarcely be performed in children Avithout the aid of anesthesia (which is in itself undesirable); and (•'>) lithotomy is such a successful pro- cedure in early life, as to render it difficult for any other mode of treatment to compete with it. I know of no extended statistics of lithotrity in children, but Guersant reports 40 cases (5 of them, hoAvever, in girls), Avith 7 deaths, or a mortality of 17^ per cent. Several cases, moreover, required subsequent lithotomy. His lithotomies number 100, Avith 14 deaths, and his total number of cases, treated by both methods, 140, Avith 21 deaths, or a mortality of lo per cent. Thus, even in his oavii hands, lithotrity (in children) has been less successful than lithotomy, Avhile the results of the latter operation Avhen indis- criminately applied to all cases under puberty, have been still more favorable, 1028 cases collected by Thompson giving but C>8 deaths, or a mortality of less than 7 per cent. Comparing these figures with those given in the pre- ceding pages, we find that indiscriminate lithotomy, in children, is safer even than lithotrity, in selected cases in adults : and that, on the other hand, li- thotrity, in selected cases in children, is not much less dangerous than indis- criminate lithotomy in adults. Hence, the inference seems to me inevitable, that an age below puberty is a positive contra-indication to lithotrity. 2. Nature and Size of the Stone.—No absolute rule can be laid down upon these points, but it may be said, in general terms, that in the case of hard calculi (as of oxalate of lime), one inch is the maximum diameter Avhich admits of crushing, and for lithotrity to be properly applied to a mulberry calculus of this size, all the other circumstances of the case should be favor- able; in the case of uric acid, and particularly of phosphatic calculi, this limit may be someAvhat exceeded, but even in dealing-with such stones, if more than an inch and a half in diameter, lithotomy will usually be a safer operation than lithotrity. Two inches would be the maximum, even if the calculus Avere phosphatic and the bladder healthy—a combination of circum- stances which is not very likely to occur. The existence of multiple calculi is in itself no contra-indication to lithotrity ; on the contrary, if, as then usually happens, the calculi be small, the operation of crushing may be con- sidered as having been partially accomplished by nature ; if, however, the stones be numerous and large, lithotomy Avould'undoubtedly be a safer pro- 868 URINARY CALCULUS. cedure. If the calculus be adherent or encysted, lithotrity is of course out of the question. 3. Condition of the Urinary Organs—Several circumstances require con- sideration under this head. (1.) Stricture of the Urethra is almost ahvays a contra-indication to litho- trity, though Sir Henry Thompson has sIioavh that the crushing operation may occasionally be successfully resorted to in these cases, the stricture being of course submitted to dilatation as a preliminary measure ; in the large ma- jority of instances, however, and certainly in the hands of the majority of operators, lithotomy either by the lateral or median method, according to the size of the stone, Avould be a preferable procedure in cases of this kind. (2.) Enlargement of the Prostate is not in itself a contra-indication to lithotrity, though it renders the operation more difficult, and requires the use of Clover's apparatus or some similar contrivance to aid in the evacuation of detritus; if, hoAvever, the enlargement be complicated Avith an irritable condi- tion of the bladder, lithotomy should be preferred, particularly if the calculus be of considerable size. (3.) Atony, or Paralysis of the Bladder, is usually thought to contra- indicate lithotrity, but does not, in the judgment of Sir H. Thompson, Avhose opinion upon this point is entitled to great respect. If, however, the stone be large, in a case of atony of the bladder, the crushing operation should probably not be performed. (4.) A Sacculated Condition of the Bladder, if it could be detected be- forehand, Avould ordinarily contra-indicate lithotrity, on account of the pro- bability of fragments becoming lodged in the sacculi, Avhere they would produce irritation, and might elude the efforts of the surgeon to find and dis- pose of them. It is possible, hoAvever, that by using Dittel's siphon arrange- ment, much of this difficulty might be avoided. (o.) Cystitis, if present in an aggravated degree, may be a bar to the per- formance of lithotrity. If the urine be loaded with mucus, or still worse with pus, and the introduction of the sound be productive of great pain and irrita- tion, lithotomy will usually be the better operation. If, however, the stone be small and friable, an attempt may be made to lessen the irritability of the bladder by keeping the patient in bed and daily injecting tepid Avater, as advised by Brodie, when, if this plan succeeds, lithotrity may perhaps be safely resorted to. When cystitis occurs during treatment by lithotrity, Tliompson advises that the patient should be etherized, the fragments of stone freely crushed, and the debris evacuated by means of Clover's appa- ratus. (6.) Malicjnant Disease of the Bladder would certainly diminish the chances of successful lithotrity, but Avould still more positively contra-indicate lithotomy; if the stone in such a case Avere friable and of moderate size, it would, I think, be justifiable to crush it, merely as a palliative measure. (7.) Organic Disease of the Kidney, as evidenced by the presence of albumen and tube-casts in the urine, is usually considered to contra-indicate the performance of lithotrity. It undoubtedly renders the prognosis of the case very gloomy, and it is even a question Avhether any operation should be performed under these circumstances. If in any case of this kind it be de- termined to attempt the removal of the stone, and the surgeon has to choose between lithotrity and lithotomy, his decision should, I think, be chiefly guided by the character of the calculus ; if this be such that the bladder can probably be cleared in one or two sittings, the crushing operation should be preferred; but under opposite circumstances, lithotomy would be the safer procedure. (8.) A Tendency to the Development of Urethral Fever is, I think, a posi- LITHOTOMY. 869 tive contra-indication to lithotrity ; if the surgeon finds that a rigor, Avith subsequent febrile disturbance, follows every introduction of an instrument into the bladder (and this can be tested by the preliminary use of bougies), all idea of crushing the calculus had better be abandoned, and lithotomy re- sorted to instead. If lithotrity be persisted in under these circumstances, the operation will not improbably be folloAved by deep-seated suppuration, pya'mia, and perhaps death. 4. General Condition of the Patient—If the health of the patient be feeble, and his strength failing, Avithout there being any special disease of the urinary organs, lithotrity is unquestionably preferable to lithotomy, and should be performed if the size of the stone permit. This condition is not unfrequently met Avith in old people, Avhose constitutional poAvers seem to have deteriorated, without any particular lesion being present to account for the change. If, on the other hand, the patient be of a nervous, anxious, and irritable disposition, the length of time Avhich the successive sittings of lithotrity necessarily occupy, constitutes in itself an objection to the opera- tion, and in a doubtful case may serve to turn the scale in favor of lithotomy, Avhich rids the patient at once of the source of his discomfort. Lithotomy. T Lithotomy, or the operation of Cutting into the Bladder to Extract a Stone, is the remaining resource in all cases (among patients of the male sex) not admitting of lithotrity; it is, therefore, the mode of treatment to be adopted in all cases below the age of puberty, and in a certain proportion, variously estimated by authors at from one-half to one-sixth, of the remainder; hence every surgeon avIio sees a fair proportion of both youthful and adult patients, will have to cut at least twice for each time that he crushes once. It is not my intention to give any account of the history of lithotomy, for wliich I Avould refer the student to the Avorks of John Bell; but to describe the principal operative procedures Avhich are in use at the present day, be- ginning Avith the ordinary lateral method, Avhich is essentially that introduced by Cheselden, and considering subsequently the median, bi-lateral, and other forms of operation, and the circumstances by which, in my judgment, each is specially indicated. Preparatory Treatment___It is seldom, if ever, that there is any necessity for an immediate resort to lithotomy; but, on the contrary, there is usually ample time for the surgeon to satisfy himself, by careful and repeated sounding, and by chemical and microscopical examination of the urine, as to the nature, size, and relations of the calculus, the condition of the urinary organs, and any other points which it may be necessary to imestigate, in order to form a correct judgment as to the state of his patient. An impor- tant question, Avhich occasionally arises in practice, is Avhether the surgeon should operate in every case, provided that the patient desire it—gh-ing him the "ghost of a chance," as it is sometimes called—or Avhether the operation should be declined Avhenever the surgeon's experience and judgment lead him to believe that operative interference can be productive of no benefit. The latter course is, I think, the one to be pursued ; the case is very differ- ent from that of amputation for injury, or herniotomy, or colotomy for imper- forate rectum, or even tracheotomy for croup. In those cases the patient is in imminent danger, and the operation, even if it do not avert, Avill at least not hasten death ; but in lithotomy, as in OA-ariotomy, in the excision of tumors from the parotid region, and in other operations for diseases not at- tended with immediate risk, if the surgeon's interference do not cure, it Avill 870 URINARY CALCULUS. certainly kill; hence, in any case of vesical calculus, if, after careful exami- nation and deliberate reflection, the surgeon comes to the conclusion that the patient Avill, in all human probability, not survive the operation, that opera- tion should, in my judgment, be positively declined. Fortunately this contingency is of rare occurrence, and it is almost ahvays possible (unless the case be complicated by far advanced renal disease) to bring the patient into a fit state for operation, by enforcing rest for a week or ten days previously, and by adopting means to bring the digestive functions into a good state, and to lessen or relieve any existing irritation of the urin- ary organs (see page 860). A full dose of castor oil should be given on the previous day, and a simple enema a short time before the operation, so that the awkward accident of the patient's defecating over the surgeon's hand may be avoided, and that the rectum, being empty, may be less exposed to the risk of being Avounded. It is Avell also, in the case of an adult, to have the perineum shaved before the patient is brought under the influence of the anaesthetic. Lateral Lithotomy. For the performance of lateral lithotomy a firm operating table is required, of rather less than the ordinary height, so that Avhen the surgeon kneels or sits before it his breast shall be about on a level Avith the patient's buttocks. Four assistants are required, one to hold the staff, one to give the anaesthetic, and two to fix the patient's limbs, one on either side. Many operators prefer to have a fifth assistant to hand the instruments, but if the surgeon adopt the kneeling posture (which I think the best), the instruments may be conve- niently placed within his own reach, on a tray upon the floor. Instruments___The instruments required are a staff, a simple straight bistoury or scalpel, of a size proportioned to the age of the patient, a probe- pointed knife, two or three pairs of forceps, a scoop, and a large long-nozzled syringe. It is Avell, in addition, to have Avithin reach a blunt gorget, a searcher, aud a lithotomy tube. The staff should be boldly curved, and of as large a size as the urethra will admit. It should have a deep and smoothly-finished groove on the left side, Fig. 475. Lithotomy staff, with groove on the back. or (Avhich I prefer) in the middle line of its convexity, beginning two or three inches above the commencement of the curve, and terminating abruptly in a right angle about a quarter of an inch from the extremity of the instru- ment. In using the common staff, the groove of which becomes gradually shallower, till it ends on the surface, there is great risk of the knife slipping off and wounding the posterior Avail of the bladder. The handle of the staff should be broad and roughened, so as to give the assistant avIio holds it a firm grasp of the instrument. LATERAL LITHOTOMY. 871 The particular form of the knives used in lithotomy, may vary with the fancy of the operator. Almost every distinguished lithotomist has devised some special form of instrument, Avhich bears his name, but, for my OAvn part, I do not know of any Avhich is better than the common straight bistoury, which is found in every " minor operating-case." The probe-pointed knife is useful in case it is found necessary to enlarge the incision after the with- draAval of the staff. The forceps should be of A-arious sizes and shapes, some straight and some curved. It is better, I think, to have the blades fenestrated, which gives Open-bladed lithotomy forceps. more room and diminishes the weight of the instrument, and the blades may be lined Avith linen (as advised by Liston), thus alloAving extraction to be effected without the application of so much force as to endanger the crushing of the calculus. The scoop, well curved and of a moderate size, should be firmly fixed in a roughened handle, to prevent its slipping. Fig. 477. Lithotomy scoop. The syringe should have a capacity of at least half a pint, and may be made of gutta-percha or of metal. The blunt gorget, which is often combined with the scoop, should be probe- pointed, and is used to guide the introduction of the forceps Avhen the peri- neum is too deep for the finger to reach the bladder. The searcher is merely a sound of slight curve, Avhile the tube, Avhich is introduced through the Avound in case of hemorrhage, maybe made either of silver, or of gum-elastic, Tube for plugging the wound in lithotomy. and should be rounded at the end, Avith large, laterally-placed eyes, and rings at the outer extremity to admit the tapes by Avhicli it is held in place. Operation___The operation is thus performed : The patient being tho- roughly etherized (with his rectum empty, and his perineum skwed), the surgeon usually injects a few ounces of tepid Avater into the bladder (though this is not absolutely necessary), and then introduces the staff, with which, 872 URINARY CALCULUS. used as a sound, he should recognize the presence of the stone. If this can- not be done, the staff is withdraAvn and an ordinary sound introduced, Avhen, if the stone still cannot be found, the operation must be postponed. This is a well-established rule of surgery, and should be inflexibly adhered to ; for (1) the stone, if small, may have been spontaneously evacuated upon some occasion of the patient's passing water; (2) it may have become caught in some pouch or sac of the bladder, from Avhich it cannot, be dislodged ; or (3) the instruments may not have entered the bladder at all, but may have gone through some false passage into the recto-vesical space ; under any of Avhich circumstances the operation, if persisted in, could but result in injury to the patient and in the utter discomfiture of the operator. It is safer, indeed, unless the surgeon's skill should enable him to be sure that the staff is actually in the bladder, not to proceed witli the operation unless the stone can be touched Avith this instrument, as Avell as with the sound. The staff having been introduced, the patient is brought to the foot of the table, with his buttocks projecting over the end, and is secured in the " litho- tomy position " by fastening to- gether his hands and feet with bandages, or with leather straps provided for the purpose. As- sistants then take charge of the limbs on either side, and expose the perineum by draAving the thighs outAvards and backAvards. The surgeon now fixes the staff in the Avay in which he Avishes it to be held, and intrusts it to an assistant, avIio, standing on the patient's left side, holds it firmly in his right hand, Avhile with the left he draAvs aside the patient's scrotum. It is this assistant's duty to keep the staff exactly as the operator has fixed it, until he is directed to Avith- draw it from the bladder. There are tAvo Avays in Avhich the staff may be fixed. Liston's plan, Avhich I think much the best, avus to hook the staff firmly under the pubic arch, and draAv it almost vertically upwards, and exactly in the median line, thus obtaining a point d'appui Avhich insures the steadiness of the instrument, and widening the space betAveen the urethra and the rectum. Many surgeons, however, believe that the operation is rendered easier by turning the staff a little to the left, and by making its convexity bulge into the perineum. The surgeon now, casting a glance to see that all his instruments are in readiness, sits, or, Avhich I much prefer, kneels on his right knee before the patient, and introduces a finger into the rectum, so as to insure the contrac- tion of this tube, and, at the same time, fix in his mind the relative positions of the staff, prostate, rectum, and tuber ischii. Holding the knife lightly but firmly as a pen between the fore and middle fingers and thumb of the right hand, he now begins his incision a little to the left of the raphe and (accord- ing to the size of the perineum) from an inch to an inch and a half in front of the anus, and cuts obliquely downAArards and outAvards to a point beloAV and betAveen the anus and tuberosity of the ischium, but rather nearer the latter than the former. This incision should divide the skin and superficial fascia Position of patient and line of incision in lateral litho- tomy. (Erichsen.) LATERAL LITHOTOMY. 873 and fat, and should be rather deeper beloAV than above ; the left forefinger is next placed in the wound so as to press doAvn the rectum and feel for the staff, Avhich is soon reached by making a feAV light touches Avith the edge of the knife, diAuding the transversus perinei, and opening the triangular space Fig. 480. Deep incision in lithotomy. (Fergusson.) between the accelerator urinas and erector penis muscles. The finger-nail is pressed into the groove of the staff at as low a point as can be felt, and upon the nail the point of the knife is introduced, so as to open the membranous part of the urethra; the surgeon then drops the handle of his knife a little, so as to fix it firmly beneath the knuckle of the index finger, and turning the blade half sideAvays (laterafizing the knife) and slightly depressing its handle, pushes it steadily onwards along the groove of the staff (Avhich it must never leave), following it constantly Avith the left forefinger to protect the rectum, until the cessation of resistance and the escape of urine sIioav that the bladder has been reached; the knife is then cautiously Avithdrawn, still lateralized, and kept closely to the staff, so as not to enlarge the incision. The surgeon noAv lays doAvn his knife, and placing his left forefinger above the staff, insinuates it by a tAvisting movement into the bladder, between the concavity of the staff and the roof of the urethra; by observing this precau- tion, there is no danger of the surgeon pushing the neck of the bladder before him, and thrusting his finger into the recto-vesical space. The stone is usually felt lying at the end of the staff. If the perineum be very deep and the prostate much enlarged, the surgeon's finger may not be long enough to reach the bladder, and then the blunt gorget must be substituted, being in- troduced by cautiously pushing it along the groove of the staff. The finger having entered the bladder, the surgeon directs his assistant to withdraAv the staff, and then, while selecting the forceps which he is going to use, dilates the incision of the prostate by pressing his finger in different directions ; the forceps are next introduced closed, along and above the palmar surface of the finger, Avhich is slightly Avithdrawn as the forceps enter; the forceps having touched the stone, are opened, one blade being depressed against the Avail of the bladder, when the calculus Avill commonly fall into the grasp of the instrument; the left forefinger is noAv placed upon the stone, rectifying its position, if necessary, so as to make its long axis correspond to the line of the wound, and extraction is then effected, in the direction of the axis of the 874 URINARY CALCULUS. Fie. 481. Position of finger and scoop in extracting stone. (Erichsen.) pelvis, with a sIoav, SAvaying, to-and-fro movement, such as obstetricians em- ploy in applying the forceps to the foetal head. In some cases it is more convenient to lay aside the forceps, and effect ex- traction Avith the scoop employed as a vectis; should, unfortunately, the stone be broken in extraction, the scoop must likewise be used to remove the fragments. After the calculus has been extracted, the surgeon again introduces his finger (or the searcher, if the perineum be deep and the. bladder sacculated), and makes a careful exploration to ascertain if there is another stone remaining, such being cautiously dealt Avith in the same manner as the first. AYhen all calculous matter has been removed, the surgeon, as a matter of precaution, washes out the bladder through the wound Avith a sy- Fig. 482. Fig. 483. ringeful of tepid water, and then, having seen that there is no hemorrhage, has the patient untied and placed in bed. After-treatment__This is sufficiently simple. The bed must be protected Avith India-rubber cloth covered with a folded sheet or blanket, to absorb the urine (\vhich of course Aoavs through the wound), the sheet being frequently changed, so as to keep the patient dry and comfortable. For a day or tAvo the urine escapes entirely by the wound, then probably for a few hours by the urethra (OAving to the swelling of the deep part of the incision), and then again partly by the wound in gradually decreasing quantities as the healing process continues. No dressing should be applied as long as any water es- capes through the perineum, but after this, the incision may be treated as a superficial Avound in any other situation. Opium may be administered in the form of a suppository, to relieve pain and insure sleep, the diet and general treatment of the patient being adapted to his constitutional condition. PhysickV cut ting gorget. Frere Coine's lithotome cach.6. Variations—The operation of lateral lithotomy, as above described, is varied in different Avays by many surgeons ; thus as regards the staff, many, as already men- tioned, have the groove on the left side, and project the instrument into the perineum ; Aston Key employed a straight staff, and Buchanan, of Glasgow, uses one which is not curved hut rectangular; the latter instru- ment has been further modified by Hutchin- son, by making the staff IioIIoav and adding a stopcock, so that it can be used as a cathe- DIFFICULTIES IN LATERAL LITHOTOMY. 875 ter. Still more complicated forms of apparatus have been devised by Earle, N. R. Smith, Corbett, AYood, and Avery, designed to render it impossible for the surgeon to miss the groove of the staff in making his incision. In- stead of using the same knife for the deep as for the superficial part of the wound, some surgeons employ a probe-pointed or beaked knife after opening the urethra, while others prefer the cutting gorget (Fig. 482), and still others the lithotome cache (Fig. 483) ; excellent operations have been done Avith each of these instruments, and I have no Avish to decry their usefulness in the hands of those who feel that the procedure is thereby rendered easier or safer; but for my oavii part I am quite satisfied with the simple bistoury, and think it an advantage not to have to change the instrument during the operation. In common Avith most surgical Avriters of the present day, I have advised a very limited incision of the prostate and neck of the bladder, the Avound to be subsequently dilated with the finger—and I certainly believe this to be the best mode of practice ; other surgeons, however, as Teevan, recommend a free division of the prostate, and believe that by this course they increase the pro- bability of a successful result. I have not advised the introduction of the litho- tomy tube in cases uncomplicated by hemorrhage, but many surgeons employ it in every instance, partly to prevent the accumulation of clots in the Avound, and partly with the idea that its use diminishes the risk of urinary infiltration ; I do not think it necessary in ordinary cases, but there is no particular objec- tion to its employment, and, if the surgeon cannot see his patient at short intervals after the operation, its use would be proper as a measure of pre- caution. Difficulties in the Operation__The most difficult part of the ope- ration, in the case of children, is to reach the bladder, the extraction of the stone being then usually effected Avithout any trouble. If the rule which has been given, to pass the finger between the upper surface of the staff and the roof of the urethra, be folloAved, there will be little risk of missing the bladder. If, however, the finger be thrust in from beloAV, it may readily tear across the membranous portion of the urethra, and, pushing the neck of the bladder be- fore it, enter the recto-vesical space. If such an accident should happen, and should be noticed before the staff is Avithdrawn, the surgeon may retrace his steps, and, fixing the knife firmly in the groove of the instrument, notch the neck of the bladder, and cautiously introduce his finger into the organ ; if the staff has been already withdrawn, it should be reintroduced, if possible, when the surgeon may proceed as before ; but if this cannot be done, the operation should be abandoned and the Avound allowed to heal. This course, though mortifying to the surgeon's pride, is infinitely preferable to endangering the life of the patient by attempting to reach the bladder without a guide. In the adult, the bladder is usually reached without trouble, but there may be considerable difficulty in seizing and extracting the stone. This is com- monly due either to the position or to the size of the calculus. (1.) Difficulty in Extraction from the Position of the Stone___The stone may be lodged at the inferior fundus of the bladder, behind an enlarged pros- tate; extraction is to be eflected by using forceps with a decided curve, and by pushing up the bladder with the finger in the rectum. If the stone, on the other hand, is at the superior fundus, above the pubis, it may be brought into reach, as advised by Aston Key, by compressing the Avail of the abdomen. If the stone be caught between the folds of the vesical mucous membrane, or between the enlarged fasciculi of the bladder, an attempt may be made to dislodge it by patient manipulation with the finger and scoop, or perhaps by directing upon the calculus a stream of tepid water; it is sometimes recom- 876 URINARY CALCULUS. mended to expand the Avails of the bladder by opening very large forceps Avithin it, in the hope that the stone may then drop out from its hiding-place, but the plan is not free from danger, and there is reason to believe that rup- ture of the bladder has been thus produced. Spasm of the bladder—a kind of hour-glass contraction of the organ—is said to occur sometimes, preventing the seizure of the stone; all that could be done in such a case would be to wait patiently until the spasm should disappear, postponing, if necessary, the completion of the operation until another day. If the calculus be adherent or encysted, its removal will be attended with great difficulty ; if merely adhe- rent, the stone may perhaps be coaxed aAvay from its bed with the scoop— with all gentleness, however, lest the bladder itself be torn. If the calculus be encysted, it will probably be necessary to abandon the operation, though an attempt might in some instances be made to enlarge the orifice of the cyst (as was done by Brodie), with a probe-pointed knife, and then enucleate the stone, as it Avere, Avith the scoop. Deformity of the pelvis from rickets may prove an obstacle to extraction, as in cases observed by Erichsen, Thompson, and others. (2.) Difficulty arising from the Size of the Stone—If the short diameter of the calculus exceed an inch and a half in length, extraction Avill ahvays be difficult, and if it exceed tAvo inches, almost impossible Avithout dangerous bruising of the prostate. Under these circumstances the surgeon must either (1) gain more room by incising the right side of the prostate, (2) reduce the size of the stone by crushing it Avithin the bladder, or (3) resort to the recto- vesical, or to the supra-pubic operation. Incision of the right side of the prostate was the plan recommended by Liston, and is readily accomplished with the probe-pointed knife, guided by the finger. Crushing the stone within the bladder1 is attended Avith some risk, on account of the contracted state of the organ, unless the calculus be soft, Avhen it may be readily broken up Avith strong forceps. This plan aa;is adopted by Prof. Nathan Smith, of New Haven, who, according to his son Prof. N. P. Smith, of Baltimore, " Avas always desirous of accomplishing that which many operators have deprecated, the fracture of the stone by the forceps." After crushing, the fragments must be carefully removed, and the bladder repeatedly Avashed out Avith a stream of tepid water. If the incision of the right side of the prostate does not give sufficient room, and the stone cannot be crushed Avithout endangering the integrity of the bladder, the only remaining course is to perform either the recto-vesical, or the high operation—the former being probably the preferable procedure. Dangers, Complications, and Accidents of the Operation__ These may arise during or after the operation. Thus, in making the inci- sion, if the knife be entered too far forwards, or penetrate too deeply at the upper part of the wound, the artery of the bulb, or the vessels of the corpus cavernosum, may be cut, giving rise to troublesome hemorrhage ; if, on the other hand, the incision be placed too low, there is some risk of Avounding the rectum, of cutting tlirough the entire breadth of the prostate and neck of the bladder, thus alloAving infiltration of urine behind the pelvic fascia, or even of opening the bladder entirely behind the prostate, an accident Avhich Avould in all probability be fatal. Again, if the knife be too much lateralized, in making the deep incision, the pudic artery may be Avounded ; -while, if not sufficiently lateralized, the rectum will be endangered. Finally, if the knife 1 Dr. Dyer, of Hartsville, Tenn., has recorded a most remarkable case in which a surgeon split a stone in the bladder by repeated blows with a chisel and mallet; the patient recovered! COMPLICATIONS OF LATERAL LITHOTOMY. 877 be not kept closely to the staff, in the deep incision, the posterior Avail of the bladder may be injured, and it has, according to Miller, even happened (with the cutting gorget) "that by a more heroic thrust the bladder has been com- pletely perforated, the intestines have protruded, and after death the liver has been found Avounded." Dangers may arise during the extraction of the stone from a portion of mucous membrane being caught in the grasp of the forceps, from the surgeon pulling too much upwards—not in the direction of the axis of the pelvis— and thus attempting to force the stone through the narroAvest part of the pel- vic outlet, or from the extraction being effected with such rapidity as to bruise and tear instead of dilating the prostate. It occasionally happens that the extraction of a stone is impeded by a portion of an enlarged prostate—a lobule, as it Avere, resembling an adenoid tumor—becoming entangled in the triangu- lar space between the blades of the instrument and the calculus. The usual practice, under these circumstances, is gently to push back the protruding body, but Sir "William Fergusson has given the high sanction of his name in commendation of a bolder course, no less than the enucleation of these semi- detached prostatic masses—a plan which he declares is perfectly safe, Avhile it has the manifest advantage of enabling the surgeon to relieve the prostatic affection at the same time that he removes the stone. Among the rarer accidents occasionally met Avith after lithotomy are (1) the discovery, after a feAV days, that a second stone or calculous fragments, which at first escaped detection, remain in the bladder—to be remedied by dilating the wound and extracting, or by lithotrity ; (2) the persistence of a perineal fistula—the treatment of Avhich condition will be described hereafter ; (3) sexual impotence, or sterility, usually attributed to Avound of the seminal duct, but, according to Thompson, really due to sloughing or inflammatory action—probably incurable ; (4) incontinence of urine—to be treated as Avhen arising from other causes ; and (5) no stone being discoverable Avhen the for- ceps are introduced—a most mortifying occurrence, which may result from an error of diagnosis, no calculus having existed, from the stone being encysted or lodged in a pouch of the bladder, Avhere it cannot be found, from its having escaped from the Avound with the first gush of urine, or, finally, from the sur- geon having missed the bladder and cut into the recto-vesical space. If the stone cannot be found, all that can be done is to abandon the operation for the time, and this should be done before the patient is exhausted by the re- peated but fruitless introduction of instruments into the bladder. If the symptoms of calculus persist after the wound has healed, a careful examina- tion with the sound should be again instituted, Avhen, if the stone be unmis- takably present, the operation may be repeated. It has occasionally happened that a second lithotomy has enabled the surgeon to extract a calculus which completely eluded discovery at the time of the first operation. Treatment of Complications__1. Hemorrhage—The superficial and transverse perineal arteries, one or both, are always divided in lateral lithotomy, but rarely give trouble, though, if large, they may require liga- tures. The artery of the bulb or the internal pudic may be Avounded, even in the hands of the most skilful operator, on account of an abnormal distribu- tion of these vessels, and, from a similar cause, the dorsal artery of the penis or the inferior hemorrhoidal may be likewise exposed to injury. The appli- cation of ligatures to the deep arteries of the perineum is sometimes attended Avith great difficulty, or may even be impossible. Under such circumstances the surgeon may rely upon pressure, kept up by the fingers of assistants for several hours, or may pass a tenaculum beneath the bleeding vessel and tie the instrument in the wound, as Avas successfully done by Physick, in 1794, 878 URINARY CALCULUS. and as has since been recommended by Thompson, and l>Ar Keith, of Aberdeen, the latter surgeon haA'ing devised for the purpose a tenaculum, from Avhich the handle can be detached at will. Another plan, also suggested by Physick, is to pass, with suitable forceps, a curved needle armed with a ligature beneath the vessel, and then, disengaging the forceps, draw out the needle and secure the vessel with a knot. AAken the bleeding artery is far back, at the side of the prostate or by the neck of the bladder, " I knoAV," says John Bell, "of no way of securing it but by laying hold of it Avith the old artery-forceps and letting them remain for the night." The same purpose may be accomplished by using the " artery-compressor" Avith movable handle, devised by Prof. Gross, or by catching the vessel Avith an ordinary serre-fine, provided with a ligature hanging out of the wound, to facilitate its withdrawal. Venous hemorrhage sometimes occurs very insidiously, the blood floAving backAvards into the bladder, where it may become coagulated, instead of escaping externally. AVhen the bleeding is from a superficial vein, this should be unhesitatingly tied; but if the hemorrhage proceed from the pros- tatic plexus, it Avill be better to introduce the lithotomy-tube, surrounded Avith a piece of muslin arranged as a " petticoat" or " shirt" (canule a che- mise), into which strips of lint can be stuffed so as to firmly plug the entire wound, or, as recommended by Crequy, Guyon, and Buckstone Browne, Avith an India-rubber bag Avhich can be distended with air after it is placed in position. Cold irrigations and the application of ice-bags to the perineum and hypogastrium may also be of service, or cold and pressure may be com- bined by using the tube and India-rubber bag, and filling the latter with iced Avater. Hemorrhage, though seldom the immediate cause of death after lithotomy, is alwaArs to be dreaded, as it certainly predisposes the patient to the occur- rence of diffuse inflammation of the areolar tissue around the wound. Secondary hemorrhage is a comparatively rare complication of lithotomy. It is to be treated by the application of ligatures, if the source of hemorrhage can be discovered, but if not, by the use of styptics and pressure, or by the actual cautery. 2. Wound of the Rectum is an annoying, but usually not a very serious, accident. If the Avound be of small extent and low clown, it will probably heal spontaneously, but, under other circumstances, may lead to the formation of a rccto-vesical fistula, Avhich must be remedied in the Avay described at page 819. 3. Diffuse Inflammation of the Areolar Tissue surrounding the Neck of the Bladder and the Rectum may arise from infiltration of urine, or from bruising of the part in the attempt to extract a large stone. Urinary infil- tration, which is probably not so often met with as Avas formerly supposed, arises from too free division of the prostate in the deep incision. It has been suggested that the occurrence of this accident might be prevented by the use of the lithotomy-tube, but as the urine always Aoavs out alongside of the tube as Avell as through it, it is evident that nothing can be gained in this Avay. The second condition which gives rise to diffuse areolar inflammation, bruis- ing of the parts around the neck of the bladder, is due to rough manipulation and the endeavor to bring a large stone through an opening Avhich is too small for the purpose. The remedy is not to hastily enlarge the incision, for this exposes to the risk of urinary infiltration, but to effect gradual dilatation by means of the finger and by the lever-like action of the forceps, notching, if necessary, the opposite side of the prostate, crushing the stone, or even re- sorting to the recto-vesical section (see p. 876). The occurrence of diffuse inflammation of the areolar tissue is certainly predisposed to by the existence of renal disease, and by excessive loss of blood at the time of the operation. BILATERAL LITHOTOMY. 879 The treatment consists in the administration of nutritious food, with stimu- lants and tonics, and in making free incisions to allow the escape of pent-up fluids. Brodie in one case saved his patient by freely dividing all the tissues betAveen the perineal wound and the rectum. 4. Other Complications may arise, such as sloughing of the wound, inflam- mation of the bladder or kidneys, peritonitis, erysipelas, pyemia, or tetanus, the treatment of Avhich affections is to be conducted on the principles Avhich guide the surgeon in their management Avhen they occur under other circum- stances. Results of Lateral Lithotomy—The results of lithotomy are un- questionably more influenced by the age and general condition of the patient, the size of the stone, etc., than by the greater or less degree of skill with which the operation is executed; manual dexterity is, however, by no means to be despised, and lithotomy is justly declared by Sir Henry Thompson to be a " grand operation," and " one of the best practical tests of a good surgeon." The statistics of lithotomy have been investigated by numerous authors, and the general mortality—for all ages and conditions—appears to be about one in seven or eight. The effect of age in influencing the result of the ope- ration is very marked; 377 operations on patients betAveen 6 and 11 years old gave, according to Thompson, but 16 deaths, a mortality of but little over 4 per cent., Avhile, on the other hand, 233 operations on patients between 59 and 70 gave 63 deaths, a mortality of over 27 per cent. In neither category were the cases in any Avay selected. That the size and weight of the stone influence the result of the operation is seen from Crosse's tables, which sIioav that the mortality of cases in which the stone weighed less than half an ounce was 8± per cent., and of those in Avhich it Aveighed more than half an ounce, 191 per cent. But nothing influences so decidedly the results of lithotomy as the condition of the urinary organs ; " it is," says Brodie, " organic disease of the urinary organs, the kidneys, or bladder, or parts connected with them, that is to be especially apprehended, as increasing, tenfold, the hazard of the operation. Of persons in whom the calculus is not of a large size, on Avhom the operation is performed, I will not say very well, but not very unskilfully, and Avho are free from all organic disease, there are very few avIio do not recover; while of those in whom organic disease exists, there are few avIio do not die." For the statistical results of lateral lithotomy, as compared with lithotrity, see page 867. Bilateral Lithotomy. This operation was introduced in its present form by Dupuytren, in 1824, and has been, in this country, particularly illustrated by the late Prof. Eve Fig. 484. Dupuytren's lithotome cachi, operfed. and Prof. Briggs, of Nashville, and by Prof. Hughes, of Keokuk. The first- named surgeon is said to have performed it in 92 cases, Avith only 8 deaths. The instruments required are a staff, grooved in the median line, a scalpel, a 880 URINARY CALCULUS. double lithotome cache (Fig. 484), modified by Dupuytren from the single lithotome of Frere Come (Fig. 483), which is still used by French surgeons in the lateral operation, forceps, scoops, etc. The first incision is made in a curve around the rectum, the extremity on each side reaching to a point mid- way between the anus and tuber ischii, or a little nearer the latter, and the Fig. 485. Bilateral lithotomy. middle of the incision passing from a half to three-quarters of an inch in front of the anus ; the Avound is then deepened until the membranous portion of the urethra is exposed, Avhen this is opened sufficiently to admit the beak of the lithotome, Avhich is introduced, closed, along the groove of the staff into the bladder. The instrument having touched the stone, is turned Avith its concavity downwards, when the staff is withdrawn ; the surgeon noAv expands the blades of the lithotome to an extent previously determined, and regulated by means of a screw, and divides both lobes of the prostate from Avithin outwards by drawing the instrument out with the handle Avell depressed and exactly in the median line of the patient's body. The finger is then passed into the bladder, and upon this the forceps are introduced, extraction being completed as in the lateral operation. The theoretical advantages of this operation are, that the wound being placed low, there is little or no risk of hemorrhage, the arteries of the bulb and the transverse and superficial perineal arteries being all above the line of incision, and that the prostate is equally divided upon both sides, thus giving a free opening into the bladder; in practice, hoAvever, the bilateral is not found to be any more successful than the lateral method, which is, I think, an easier operation. Gross has collected 511 cases of bilateral lithotomy, with 41 fatal results, a mortality of about 1 in 12^. Instead of pushing in the lithotome along the groove of the staff, some operators take the latter instrument in their own hands, as soon as the beak of the lithotome is lodged in its groove, and, by depressing the handle with a quick rocking motion, bring both instruments together into the bladder; this manoeuvre I have seen skilfully executed by Prof. Joseph Pancoast, of this city. kf MEDIAN LITHOTOMY. 881 Pre-Rectal Lithotomy. This, which is a modification of the ordinary bilateral method, Avas intro- duced by Nekton, and consists in making a careful dissection in front of the rectum, so as to open the urethra at the apex of the prostate, Avithout coming in contact Avith the bulb; the remaining steps of the operation are the same as in Dupuytren's method. Medio-Bilateral Lithotomy. This operation Avas introduced by Civiale, in 1829, and Avas adopted in several instances by Sir Henry Thompson, avIio has, hoAvever, since abandoned it in favor of the lateral method. The staff being firmly held by an assistant, an incision about an inch and a half long is made in the median line of the perineum, terminating a little in front of the anus, and cautiously deepened so as to open the membranous portion of the urethra Avithout Avounding the bulb ; a straight double lithotome is then lolged in the groove of the staff and pushed on into the bladder, dividing both lobes of the prostate as it is withdrawn, just as in Dupuytren's method. Sir AVki. Fergusson has imitated this plan, as regards the external wound at least, by making a perineal inci- sion in the form of an inverted \. Civiale's seems to me on the Avhole better than Dupuytren's operation, but neither presents any particular advantage over the lateral method; either may, hoAvever, be properly resorted to in cases in Avhich the stone is large, and in Avhich hemorrhage is to be for any reason specially dreaded. Prof. Briggs, of Nashville, has successfully employed the medio-bikteral method in nine cases. Median Lithotomy. This is an old operation, formerly known as the "Marian" (from Marianus Sanctus Barolitanus, a surgeon of the sixteenth century), but revived Avith improvements by Manzoni, De Borsa, and Rizzioli, and perfected by Allarton, whose name it noAv generally bears. A staff grooved in the median line is firmly held against the pubis by an assistant, Avhen the surgeon introduces his left forefinger with the palmar surface upAvards into the rectum, placing its tip upon the apex of the prostate; a straight bistoury, double-edged at the point, is then entered with its principal cutting edge upwards, in the median line of the perineum, half an inch in front of the anus, and pushed steadily onwards until it penetrates the membranous portion of the urethra and lodges in the groove of the staff; the apex of the prostate is now notched by push- ing the knife a feAV lines tOAvards the bladder, and the urethra then slightly divided and the external wound enlarged to about an inch and a half, by cutting upwards as the knife is AvithdraAvn. A ball-pointed probe is next passed into the bladder, along the groove of the staff, Avhich is then removed —the surgeon's finger following the probe and dilating the prostatic incision in its course ; the forceps are then introduced, and the stone extracted as in other operations. In order to assist the dilatation of the prostate, Allarton has suggested the use of fluid pressure applied by means of an Arnott's dilator, and Teale, Dolbeau, and others, have devised metallic instruments for the same purpose; as pointed out, however, by both Erichsen and Thompson, instrumental is much less safe than digital dilatation. Allarton's operation has been variously modified by other surgeons, as by Thompson, who exposes the staff by cutting from before backAvards, and by Erichsen, who employs a rectangular staff, passes a beaked director along the 56 882 URINARY CALCULUS. groove after making the incision (to open the Avay for the finger), and effects digital dilatation before Avithdrawing the staff, as in the lateral operation. The advantage of the median over the lateral operation is the diminished risk of hemorrhage (though, according to Thompson and Cadge, the gain in this respect has been greatly exaggerated), and of urinary infiltration. Its disadvantage is the limited amount of space which it affords for the extrac- tion of the stone. Hence its application should, it seems to me, be practically limited to those cases among adults in which, though the stone is small, litho- trity is inadmissible, and hemorrhage particularly to be feared. It is decidedly contra-indicated by the presence of a large stone, and by hypertrophy of the prostate, which interferes with the manipulation of the forceps through the small opening afforded by the median incision. There is, however, another class of cases, in which the median operation often ansAvers a very good purpose, and that is when it becomes necessary to cut into the bladder to remove a. foreign body (see p. 376). Allarton has collected 139 cases of the median operation, with 13 deaths, or a little over 9 per cent. ; his tables are, hoAvever, according to Poland, not very accurate, many knoAvn cases of death after the median operation being unrecorded, and section of the prostate having been required in two of the author's own cases which are reported as successful. The statistics of the Norfolk and NorAvich Hospital, as collected by Mr. Cadge, give a much less favorable picture, 90 cases, at all ages, having given 16 deaths, a mortality of nearly 18 per cent. Dolbeau has introduced a modification of the median method, which he calls perineal lithotrity, and which consists in opening the membranous por- tion of the urethra, dilating the neck of the bladder, crushing the stone, and removing the fragments through the perineal wound, all at one operation. The principal advocate of Dolbeau's method in this country is Dr. Gouley, of NeAv York. Medio-Lateral Lthotomy. This operation, wliich was introduced by Buchanan, of Glasgow, in 1847, has been already referred to as a modification of the ordinary lateral method. It is performed with a rectangular staff, grooved upon the left side, which is fixed so that the angle corresponds to the apex of the prostate, and well pressed down so as to be readily felt from the perineum. The operator, keeping his left forefinger in the rectum, "enters a long straight bistoury opposite the angle of the staff, and therefore immediately in front of the anus : he holds it in his right hand, with the palm upwards ; the blade hori- zontal and its edge directed to the left; and he pushes it straight into and along the groove as far as to the stop at its extremity. He thus enters the bladder at once, taking care to keep the blade parallel with the horizontal or grooved portion of the staff throughout the whole of the thrust. Next he withdraws the bistoury slowly, but, as he does so, cuts outwards and down- wards a distance rather more than equal to another breadth of his blade [a quarter of an inch], and then directly downwards to the same extent, describ- ing, in this manner, a curved line equal to about one-fourth of a circle round the upper and left side of the rectum." This operation makes an external wound of about an inch and a quarter in length, and has, according to Thompson (from whose pages the preceding description is taken), been per- formed over 60 times, with results corresponding very closely to those obtained by Allarton's method. The name medio-lateral is also given by H. Lee to a somewhat similar operation devised by himself. These are the principal operations by which it is sought to remove a stone SUPRA-PUBIC LITHOTOMY. 883 from the bladder by incisions through the perineum, and from which the sur- geon has to choose in ordinary cases. Each method has certain merits and demerits, and each may be properly adopted in particular circumstances. As, hoAvever, the success of lithotomy depends to a considerable extent upon the readiness and skill with which the operation is performed, and as to acquire equal facility in each of these methods would require a Avider experience in stone cases than falls to the lot of most surgeons, I would strongly advise the general practitioner to familiarize himself with one procedure fand the ordi- nary lateral method I consider decidedly the easiest and safest in the large majority of instances), and, having acquired sufficient skill in its performance, to be content. It is doubtless desirable for the professed lithotomist, who counts his cases by scores or even by hundreds, to try every neAv plan that is suggested, and to publish his experience with it for the benefit of the whole profession; but there is no reason Avhy the general practitioner, who, perhaps, sees but half a dozen cases in the whole of his career, should feel obliged to operate by three or four different methods. It will, on the contrary, I believe, be much better for his patients for him to be able to do one operation well, than a larger number with doubt and hesitation. Recto-A'esical Lithotomy. This operation, Avhich was devised by Sanson, aims to extract the stone by an incision through the rectum. A staff is held in the ordinary manner, and into its groove the surgeon thrusts the point of his knife (guarded by the left forefinger) through the prostate, from the rectal surface, cutting then upwards and outwards through the sphincter ani and perineum. The finger-nail is then placed in the groove at the membranous portion of the urethra, and the bladder opened by an incision from before backAvards, joining the original wound. Extraction is effected as in other operations. Maisonneuve has modified this procedure by making an incision through the rectum above the sphincter, Avhich is not divided, the section of the prostate being completed with a double lithotome. Chassaignac has performed recto-vesical lithotomy with the ecraseur. This operation, in addition to the risk of diffuse cellulitis and peritonitis by which it is attended, exposes the patient to the possibility of the formation of a recto-vesical fistula; to meet this contingency, Prof. Bauer, who is the most prominent advocate of the method in this country, adjusts the edges of the ivound with metallic sutures, Avith the view of securing primary union, and a similar plan has been followed by Dr. Noyes. Konig has collected *3 cases of this operation, which gave 56 cures, 11 recoveries with fistula, and 16 deaths. The operation is, in my judgment, only to be recommended in cases of very large stone, in Avhich extraction by the lateral incision has been found impracticable (see page 876). Surra-Pubic Lithotomy. (The High Operation.) This operation, which appears to have originated Avith Pierre Franco, in the latter part of the sixteenth century, and Avhich was first performed in this country by the late Prof. AVm. Gibson, is designed, as its name implies, to effect the extraction of a vesical calculus through an incision above the pubis, Avhere the bladder is not covered by peritoneum. It maybe performed as follows : The parts having been shaved, and the rectum emptied by means of an enema, the patient is etherized, lying on his back with the pelvis ele- 884 URINARY CALCULUS. vated, so that the abdominal viscera may not press upon the bladder; this organ is then fully injected (but not over-distended) Avith tepid water, and a well-curved sound or solid catheter introduced, so that by depressing its handle between the patient's thighs, the beak of the instrument may become prominent in the supra-pubic region. An incision, about three inches long, is now made, exactly in the median line, and reaching at its loAvest point to the upper margin of the pubic symphysis : the Avound is cautiously deepened until the linea alba is reached, when this is opened at the lowest part of the incision, and divided upAvards with a probe-pointed knife for a distance of an inch and a half or tAvo inches, taking great care not to wound the peritoneum, by gently pushing it out of the Avay of the knife. The surgeon noAv care- fully cuts clown upon the extremity of the sound, which is made to project in the Avound, and thus opens the bladder—the incision into this organ, which should be held forward Avith tenacula, being then enlarged by cutting down- Avards tOAvards its neck (and therefore below the symphysis) with a probe- pointed knife. One or two fingers are next introduced so as to ascertain the position of the stone, Avhich is extracted with forceps in a line corresponding to the oblique direction of the Avound. Civiale devised several special instruments for use in this operation, the most important being the sonde a dart, a catheter Avith a stylet which could be protruded from the concave surface of the instrument, designed to make the opening into the bladder from Avithout inwards. The after-treatment is very simple ; the patient should be kept in bed with the limbs drawn up so as to relax the abdominal muscles, the Avound being allowed to heal by granulation1 under simple dressing. A flexible catheter may be introduced through the urethra and allowed to remain so as to prevent urinary accumulation, but should be removed if it produce any vesical irri- tation. Diffuse areolar inflammation may follow the operation, and is usually at- tributed to the occurrence of urinary infiltration : it is probable, however, that, as in the case of the lateral method, bruising of the edges of the wound in extracting a large calculus is at least equally efficient in giving rise to this complication. The high operation has been recommended by some of its advocates as a method of universal application, but is now generally and, in my opinion, properly reserved for cases in which the calculus is of unusual size—more, for instance, than two or tAvo and a half inches in its lesser diameter—or in which the lateral or other perineal methods are contra-indicated by the exist- ence of pelvic deformity. The mortality after this operation is variously estimated by Belmas, Humphry, Gross, and Dulles, at from 22 to 30 per cent. Of 56 terminated American cases, collected by the last-named Avriter, 40 ter- minated successfully and 16 proA-ed fatal, thus giving a death rate of 2 in 7. It is to be remembered, hoAvever, that the supra-pubic, unlike the median operation, is habitually reserved for unfavorable cases. Recurrent Calculus. The recurrence of vesical calculus after an operation for its removal, may be due to the persistence of the causes Avhich gave rise to the existence of the first stone, or to the imperfect removal of the stone, a fragment having been allowed to remain in the bladder. The descent of a renal calculus is comparatively seldom a cause of recurrent stone, Avhich is more frequently 1 Brims, of Tiibingen, recommends the introduction of sutures, in hope of obtain- ing primary union. PROSTATIC CALCULUS. 885 due to the continued deposit of phosphatic matter in the bladder, as the result of cystitis with an ammoniacal state of the urine. Fragments may be left in the bladder after either lithotomy or lithotrity, but are more likely to form the nuclei of fresh calculous formations after the latter than after the former operation, because in this the AA'ound affords a free means of exit, by Avhich any portions of stone that may be chipped off are readily Avashed out by the floAv of urine. In the early days of lithotrity, recurrence Avas, indeed, a fre- quent event, and aa as not unreasonably considered a grave objection to that operation ; it is satisfactory, therefore, to knoAV that Avith larger experience, and with the aid of the improved forms of instrument hoav in use, the proba- bility of a relapse has been considerably diminished ;l moreover, as pointed out by Brodie, patients are willing to submit to a repetition of lithotrity, when they Avould refuse a second cutting operation. The treatment of recurrent calculus consists in removing the stone by either lithotrity or lithotomy, the choice of operation being made in accordance Avith the principles already laid down. If it be decided to cut a patient a second time, the incision may be made in the line of the cicatrix left by the first operation. Urethral Calculus. Urethral calculi usually consist of renal or small vesical concretions, Avhich, being too large for spontaneous evacuation, have become impacted in the urethral canal; but calculous matter may occasionally be primarily deposited in the urethra, in cases of urinary obstruction from organic stricture, etc. The symptoms of urethral calculus are difficult or painful micturition, and in some instances complete retention of urine, folloAved, perhaps, by ulceration and urinary extravasation ; the stone can usually be felt through the structures of the penis, perineum, or rectum, and can generally be touched with a sound introduced into the urethra. The treatment consists in effecting removal, either by gentle manipulation with the finger and thumb, pushing the stone towards the meatus, by the use of narrow forceps,2 etc., as in the case of foreign bodies or of fragments impacted after lithotrity, or by cutting into tbe urethra and extracting the stone through the incision. Before resorting to the last mode of treatment, the calculus should if possible be pushed back into tbe perineal portion of the canal, as urethotomy in the scrotal portion is attended with risk of urinary infiltration, and in the penile portion Avith dan- ger of the formation of a fistula. The operation may be facilitated by intro- ducing a full-sized staff as far as the position of the calculus, the incision being made directly upon the point of the instrument. In some instances it may, perhaps, be thought better to push the calculus back into the bladder, and then dispose of it by lithotrity. In all cases of urethral calculus, a care- ful exploration of the bladder should be made, to ascertain if vesical concre- tions be likewise present; if any be found, they may, if of suitable size, be crushed; or, if the urethra have already been opened in the perineum, the incision mav be readily extended so as to convert the operation into a median or into a lateral lithotomy. Prostatic Calculus. Calculous concretions are sometimes found in the prostate gland, resulting from the deposit of phosphatic matter upon the inspissated secretion of the 1 Of 36 cases submitted to lithotrity by Civiale, in the year 1860, no less than 10 were cases of recurrent calculus, while of 201 cases operated on by Thompson, during six years ending in 1870, only 19 were cases of recurrence. 2 Dr. Will, of Aberdeen, recommends a Avire loop ; tbe same plan was successfully employed sixty years ago in this country by Dr. Conant. 886 URINARY CALCULUS. part; they may be conveniently referred to in this place, though not strictly belonging to the category of urinary calculi. Prostatic calculi usually con- sist of about eighty-five parts of phosphate of lime, with fifteen parts of animal matter, and a trace of carbonate of lime ; hence they may be readily distinguished from the vesical calculi which occasionally lodge near and be- come imbedded in the prostate. Prostatic calculi rarely attain a large size, have a rather smooth surface—often presenting numerous facets—and are usually of a light brown or gray color; they may exist in considerable num- bers, occupying the various cells and ducts of the gland, or several may become aggregated into a single mass, through the gradual disappearance by absorption of the intervening intercellular substance. The symptoms are a sensation of weight and distension in the perineum, often attended by a flow of mucus, and sometimes by retention of urine ; the calculus can usually be detected by exploration with a sound, aided by digital examination tlirough the rectum. The treatment consists in extraction by the urethra, with long and delicate forceps—this is rarely practicable—or through a perineal incision as in the operation of median lithotomy. If the concretions are small and very numerous, it may, perhaps, be better not to resort to operative interfer- ence, but to employ palliative measures only, to relieve the irritation of the part. Treatment of A^esical Calculus in AA'omex. Fig. 486. The operations for the removal of stones from the female bladder are lithectasy, lithotrity, and li- thotomy. Iiitheetasy,1 or Dilatation of the Urethra and Neck of the Bladder, is much the best mode of treatment for all stones of a moderate size. The dilatation may be effected slowly, by the introduction of sponge tents of gradually increasing sizes; or, Avhich is much preferable, rapidly, by means of a two-bladed dilator, or simple dressing forceps, intro- duced closed, and then opened so as to dilate the part upon with- draAvah The stone is extracted with ordinary lithotomy forceps or with the scoop, as may be found most convenient. The operation should be performed with the aid of anaesthesia. Bryant, who has Urethral dilator. ably investigated the literature of the subject, finds that, in children, calculi one inch in diameter, and, in adults, calculi tAvo inches in diameter, can be safely removed by rapid urethral dilatation, without any resulting incontinence of urine. » This name was applied by Dr. Willis to an operation which he proposed for stone in the male, and which consisted in opening the perineal urethra and dilating the neck of the bladder ; a procedure which has been supplanted by the median opera- tion as modified by Allarton. CALCULUS in women. 887 Lithotrity is adapted for cases in Avhich the stone is too large to be removed by lithectasy, and yet in Avhich the urinary organs are in a healthy condition. The operation may be performed with a short-bkded lithotrite, or Avith strong forceps ; it is not necessary (as it is in the niale) to reduce the calculus to powder, but is sufficient to break it into fragments—these being then immediately extracted with lithotomy forceps through the urethra, Avhich is rapidly dilated for the purpose. The patient should be in a state of ana3S- thesia, so that the Avhole operation may be completed at one sitting; injec- tions of tepid water are required to insure the removal of detritus. Lithotomy___This may be performed in several Avays. 1. Urethral Lithotomy is often combined with lithectasy; the operation consists in introducing a probe-pointed bistoury into the urethra, and incising the mucous membrane with or Avithout the submucous tissue, directly upwards as practised by Brodie, directly dowiiAvards as suggested by Chelius, down- wards and outwards on both sides as done by Liston, or, in fact, in any direc- tion that suits the surgeon's fancy. The operation is very apt to be followed by incontinence of urine, and appears to me in eAery way inferior to the method by simple rapid dilatation. 2. Vaginal Lithotomy lias been particularly commended by Marion Sims, Aveling, Emmet, and Collins "Warren, and is probably the best mode of treatment for cases in which the calculus is large, and in which crushing is inadmissible, but seems to me, under ordinary circumstances, decidedly in- ferior to lithectasy and lithotrity. The operation may be thus performed : A straight staff is introduced into the bladder and held by an assistant so as Fig. 487. Fem:ile staff. to depress the vesico-vaginal septum, the point of the instrument being fixed by the surgeon's left forefinger introduced into the vagina. A sharp bistoury is then thrust through the septum into the groove of the staff, just behind the urethra, and the incision carried backwards for the space of about an inch and a half, taking care not to infringe upon the peritoneum ; the stone is extracted Avith forceps, and the edges of the wound immediately brought together with sutures, the case being, in fact, treated as one of vesico-vaginal fistula. Simon, of Heidelberg, recommends vaginal cystotomy as a prelimi- nary to catheterization of the ureters in cases of suspected impaction of a renal calculus, etc. 3. TJie High Operation may be required in cases in Avhich the calculus is too large to admit of vaginal lithotomy. The operative procedure is the same as in the male sex, but requires even more care not to wound the peritoneum. Prof. Parker has, according to Gross, practised suprapubic lithotomy in the female on three occasions, and in each instance with a successful result. 4. Buchanan, of Glasgow, has practised the lateral operation, cutting through the left nympha upon a grooved staff introduced into the urethra. AAklsham has collected four cases of this operation in children, all of which terminated favorably. 888 DISEASES OF THE BLADDER AND PROSTATE. Extra-pelvic Vesical Calculus. Calculus is occasionally developed in the protruded bladder, in cases of hernia of that organ, or cystocele. Prof. Gross has collected eight cases of this description. The treatment consists in cutting down upon the hernia (which has no peritoneal investment), and extracting the calculus—a catheter being kept in the bladder during the healing of the wound to prevent urinary infiltration. A calculus has been extracted by a Polish surgeon from a child's scrotum, whither it had made its way by ulceration of the walls of the blad- der. Dr. Vosburgh has removed a calculus from the umbilical region, appa- rently from a patent urachus, as has Henriette, of Brussels; and other cases of urachal calculus have been recorded by T. Paget and Amussat. CHAPTER XLY. DISEASES OF THE BLADDER AND PROSTATE. In no department of surgery is it more necessary for the practitioner to be a good physician, than in that which relates to diseases of the urinary or- gans. So immediately connected with each other are these organs, both anatomically and physiologically, that it is impossible to treat satisfactorily even those affections which are usually considered purely surgical, as, for instance, stone in the bladder, hypertrophy of the prostate, or stricture of the urethra, without an accurate knowledge of the whole subject of urinary j athology, and more particularly a practical acquaintance with the methods of examining the urine, both chemically and by the aid of the microscope. It is the more necessary to make this statement, because the limits of this volume will only admit a description of those diseases of the urinary organs Avhich the surgeon is habitually called upon to treat; and I must therefore refer the student for information on the other topics mentioned, to works on the Practice of Medicine, and to treatises specially devoted to the subject of Urinary Disorders. Malformatioxs axd Malpositions of the Bladder. In some cases the bladder has been totally absent, the ureters opening directly into the urethra, or into the rectum or vagina, while in other instances tAvo or more bladders are said to have coexisted in the same subject, though, as justly remarked by Thompson, it is probable that in most of these cases the condition has not been congenital, but rather one of extreme sacculation, the result of disease. Extroversion or Exstrophy of the Bladder is by far the most common congenital defect of this viscus, and is met with sufficiently often to make its treatment a subject of considerable importance. This deformity, which is much commoner in the male than in the female sex, and which ap- pears to be due to an arrest of development during foetal life, consists in an absence of the anterior wall of the bladder, with a corresponding deficiency of the loAver part of the abdominal parietes, and usually of the pubic sym- physis. The penis, in the male, is epispadiac and shortened, and the clitoris, EXTROVERSION OF THE BLADDER. 889 in the female, is split into two portions corresponding to the nymplnv, the anterior commissure of the vulva being Avanting, and the bladder and urethra thus opening betAveen the labia and directly into or immediately above the vagina; the uterus is commonly well formed, and in one of my cases the vaginal orifice was normally closed with a hymen. The anus is placed in front of its usual position, and, in the male, the scrotum not unfrequently contains a hernia on one or both sides. The recti abdominis muscles are separated at their lower part, passing obliquely outAvards to their insertions into the pubic bones, and in many, but by no means in all, cases, the separa- tion is continued upwards almost to their costal attachments, in Avhich case there is no umbilicus, the interval betAveen the recti being filled with a fibrous tissue analogous to the linea alba.1 The appearances in a case of exstrophy of the bladder are quite character- istic. The posterior wall of the bladder (covered, of course, with mucous membrane) is pushed forward by the abdominal viscera which are behind it, and forms a prominent but reducible tumor in the situation of the pubes. The mucous surface, which is red, papillated, and vascular, is continuous at its periphery Avith the abdominal walls, the line of junction having a thin cica- tricial appearance. At, the loAver part of the projecting vesical surface, the ureters can be seen, giving exit to the urine by drops, or sometimes in a stream. The exposed mucous membrane, Avhich is constantly irritated by the contact of the patient's garments, becomes inflamed, and bleeds when touched, while the groins, thighs, and buttocks are excoriated from urine flowing over them. In addition to the physical distress thus occasioned, the patient has the annoyance of knowing that he is deformed in a part which few are so philo- sophical as to consider of no importance in their oAvn persons, and is besides rendered, by the continual dribbling of urine, an object of disgust to himself as well as to others. Otherwise the deformity does not particularly interfere with the general health, and is by no means incompatible with a long life ; though in a remarkable case related by Dr. J. A. Masterson, of AAkterloo, Wisconsin, the extroverted posterior wall of the bladder formed the sac of a hernia, which, by pressure on the ureters, led to dilatation of those organs, and ultimately to renal disease, which proved fatal. In the female the repro- ductive function is not impaired, and instances are on record in which women with extroverted bladders have borne children ; but in the male sex the ac- companying deformity of the genital organs is so great as to render procrea- tion impossible. Treatment___Until Avithin a few years, this malformation was thought to be beyond the reach of surgical aid, and the utmost that Avas attempted for patients thus affected, was to supply a mechanical apparatus to shield and pro- tect the exposed bladder from injury, and to convey the urine into a suitable receptacle ; but the apparatus was necessarily cumbrous and irksome, and ful- filled its design in, at best, a Aery unsatisfactory manner. AYithin a few years, endeavors have been made to remedy, or at least to alleviate, by ope- rative interference, the condition of patients afflicted with exstrophy of the bladder, and in many instances with very gratifying success. The opera- tions which have been devised for the purpose may be divided into two cate- gories, viz., 1, those which aim to divert the course of the renal secretion into 1 Cheever, of Boston, has recently reported a successful operation in a case which, as described, seems to have been one of congenitaffistula rather than of extroversion of the bladder. The penis and urethra were normal, and the posterior wall of the bladder protruded through an opening in the abdominal parietes, half an inch wide, and an inch above the pubes (Bost. Med. and Surg. Journ., Feb. 11, 1875). A some- what similar case has also been successfully operated on by Prof. Bigelow. 890 DISEASES OF THE BLADDER AND PROSTATE. another channel, and, 2, those the object of Avhich is merely to cover in the exposed bladder by a plastic operation, and thus render possible the adapta- tion of a, convenient receptacle for the urine. To the first category belong the operations of Simon, Holmes, and Levis, of this city, and to the second the plastic procedures of Pi chard, Pancoast, Ayres, Holmes, Wood, Bigelow, and others. 1. Mr. Simon, of St. Thomas's Hospital, in the case of a boy of 13, estab- lished, by an ingenious procedure, fistulous communications between the ureters and rectum, with the hope that, the Aoav of urine being diverted, the exposed mucous surface of the bladder would assume the character of skin. The operation was, from the first, only partially successful, and the patient died about a year afterAvards from disease of the ureters and kidneys, which apparently was set up by the irritation caused by the operation itself. In other cases in which similar procedures were undertaken, by Lloyd and Athol Johnstone, the patients died within a few days from acute peritonitis ; but someAvhat more successful efforts in the same direction have been recently made by Sydney Jones. Dr. Levis, of this city, in one case established a communication betAveen the bladder and perineum, and then covered in the former organ by a plastic operation, Avhich, however, terminated fatally on the twelfth day. Holmes has suggested a plan of effecting the desired object, by applying in the bladder and rectum the two branches of a pair of screAV- forceps (with a plate broad enough to extend from one ureter to the other), which, acting like Dupuytren's enterotome, should establish the necessary communication between the organs without risk of perforating the peritoneal cavity. 2. Plastic Operations, varying more or less in their details, have been em- ployed for the relief of extroverted bladder, and in many instances Avith very gratifying results. (1.) Richard, modifying Nekton's operation for epispadias, operated, in 1853, by dissecting a broad flap from below the umbilicus, turning it with its skin surface towards the bladder, and covering it in with a bridge of skin taken from the front of the scrotum. This operation, though most ingeniously planned, unfortunately induced peritonitis, Avhich proved fatal. Lefort has recently modified Richard's operation by taking the covering flap from the enlarged prepuce instead of from the scrotum. (2.) To Prof. Joseph Pancoast, of this city, belongs the honor of having, in 1858, performed the first successful plastic operation for exstrophy of the bladder. His method consisted in taking flaps from the groins, inverting them over the protruded organ, and attaching them together in the median line, thus leaving a broad granulating surface which sloAvly cicatrized. The patient recovered from the operation, but died some months later from another affection. (3.) In the same year Dr. Ayres, of Brooklyn, N. Y., operated on a woman (who had previously given birth to a child) by turning down an um- bilical flap—as had been done by Richard—covering it in by simply dissect- ing up the skin of the abdominal AAralls on either side, and bringing together the tissues thus loosened in the median line. The operation Avas perfectly successful. (4.) Mr. Holmes, who has operated in a number of cases, employs tAvo flaps, one from the groin, which is inverted, with its cutaneous surface tOAvards the bladder, and the other taken from the opposite side of the scrotum and slid over to cover in the first. This plan was also folloAved by J. AYood, in some of his earlier cases. (5.) Dr. F. F. Maury, of this city, has, in three cases, adopted Roux's method, taking a saddle-shaped flap, attached at both ends, from the scrotum, EXTROVERSION OF THE BLADDER. 891 and inverting it bridge-like over the bladder—leaving the raAv surface of the flap to heal by granulation and cicatrization. In one case the operation failed, but, in the other two furnished a good result, and in each of these Dr. Maury succeeded (as did Pancoast) in effecting the cure of a hernia by the contraction which accompanied the healing process. (<>.) Mr. Barker, of Melbourne, has successfully operated in a young girl, by simply dissecting up the integument on either side of the bladder, uniting the flaps thus formed with deep and superficial sutures, and relieving tension by means of lateral incisions. (7.) Prof. H. J. BigeloAv, of Boston, instead of endeavoring to restore the cavity of the bladder, simply dissects off the mucous membrane as Ioav as the level of the ureters, and covers the raAv surface with flaps taken from the groins. Fig. 489. Fig. 490. Plastic operation for extroversion of the bladder. (From a patl-at in the Children's Hospital.) (8.) Prof. AVood, of King's College, London, has operated in sixteen cases, and has latterly employed a method which is now usually knoAvn by his name, and to Avhich I have resorted in three cases, from one of which the annexed illustrations are taken. Three flaps are used, one taken from the umbilical 892 DISEASES OF THE BLADDER AND PROSTATE. region and inverted over the bladder, as in Richard's and Ayres's methods, and the others, one from each groin, united in the median line over the first, which they cover in. The great advantage of the inverted umbilical flap, is that it effectually prevents the escape of urine in an upward direction, while the groin flaps cover in the raw surface of the other Avithout undue tension, and, having broad bases, are in no danger of sloughing. In the case of a male subject, a roof may be formed for the urethra, at a subsequent operation, by inverting flaps from the neAvly-formed covering of the bladder, and from the sides of the penis, adjusting over them a bridge-like flap from the scrotum, as in Nelaton's and Richard's procedures. In tAvo of the three cases in Avhich I have operated, the result Avas quite satisfactory, but in the third, though a first operation was successful, a second terminated fatally, from shock, in a little over twelve hours. By this operation the patient is placed in a very comfortable condition ; incontinence of urine, to a certain extent, necessarily continues, requiring the patient usually to Avear a •' railway urinal," or some similar contrivance, but the bladder is effectually protected from irritation, and excoriation is readily prevented. The principal points requiring attention in the after-treatment, are to prevent tension on the fiaps and encourage the contraction of the granu- lating surfaces by the position of the patient, avIio should be placed in an almost sitting posture, Avith the knees flexed over pillows. In an adult, trouble may be caused by the growth of the pudendal hairs, if the reversed flaps em- brace any portion of skin naturally thus covered, and it will then be necessary, from time to time, to practise avulsion with suitable forceps, until the inverted surface shall have lost its cutaneous character and become assimilated in nature to mucous membrane. Injections of dilute acetic or nitric acid may also be required, to relieve vesical catarrh and prevent the deposit of phos- phates. The statistics of these plastic operations are quite as favorable as could be expected, 55 terminated cases to which I have references, having given 43 recoveries, 4 failures, and but 8 deaths. Malpositions___Under this head may be included two affections, one of which, Hernia of the bladder, or Cystocele, has already been referred to, the other being Inversion of the bladder, which is extremely rare, and which is almost exclusively met with in female children. Inversion of the Bladder consists in a protrusion or invagination of the bladder through the urethra, where it appears in the form of a red vascular tumor; this, in one of the few cases of the affection on record, Avas mistaken for a new growth, and preparations had been actually made to remove it by ligation, when the discovery of the orifice of a ureter fortunately prevented the consummation of the operation. The protruding organ is readily reduced by manual pressure, but is apt to re-descend when the pressure is removed, when incontinence of urine necessarily remains. To remedy this, Dr. John Lowe, of Lynn, made repeated applications of the actual cautery to the urethra, keeping the bladder in place by means of a catheter with a bulbous extremity; he thus induced sufficient contraction to prevent any protrusion whatever, and to diminish, though not entirely to remove, the incontinence. The same object might in some cases be accomplished by means of a plastic operation. The administration of nux vomica was of service in a case recorded by Dr. Aknce. Cystitis. Cystitis, or Inflammation of the Bladder, may be acute or chronic, and in the latter case may or may not be accompanied with vesical catarrh. CHRONIC CYSTITIS. 893 Acute Cystitis—The seat of inflammation is the mucous lining of the bladder, especially the part around the neck of the organ. In some cases, hoAvever, the submucous and muscular coats are also involved, and the inflam- mation may even spread to the adjacent layer of peritoneum. The vesical mucous membrane is found after death to be injected or deeply congested, and sometimes, if the inflammation have been long continued, of a slate-colored or chocolate hue. Occasionally, shreds or patches of lymph are formed, and in rare instances a complete cast of the interior of the organ has been thus produced. Ulceration and gangrene may be met with in the Avorst cases. Causes—Acute cystitis may result from various forms of injury, from the irritation produced by a calculus or foreign body, from the action of certain medicines, as cantharides or some of the mineral poisons, from the use of irri- tating injections, from acridity of the urinary secretion, from the extension of inflammation from neighboring parts (especially from the urethra, as in cases of gonorrhoea), from an exacerbation of chronic cystitis, from exposure to cold, from gout, etc. Symptoms.—There is pain OArer and behind the pubes, and in the sacral region, perineum, and thighs, attended in bad cases with tenderness on pres- sure, and increased by rectal exploration and by the use of the catheter. The desire to urinate is almost constant and irresistible, the act of micturi- tion itself being intensely painful and often accompanied with great tenesmus. In mild cases, such as ordinarily folloAV gonorrhoea, and in Avhich the inflam- mation is usually limited to the neck of the bladder, the urine is cloudy and contains a certain quantity of mucus and pus, but in severe cases it is tinged with blood, and soon becomes decidedly purulent, containing also shreds of partially organized lymph or false membrane. In these cases there is also a great deal of constitutional disturbance (avIii'cIi is almost absent in the milder forms of the affection), the patient soon falling into a typhoid condition, often attended with delirium ; death may ensue, usually in the course of the second Aveek. In the milder cases resolution occurs—Avhen recovery may be com- plete—though, in many instances, the inflammation subsides into a chronic state. Treatment___The patient must be kept in bed. A few leeches may be applied to the hypogastrium or perineum, and folloAved by hot poultices or fomentations. The bowels must be kept in a soluble condition, and pain and vesical irritation relieAred by the use of hyoscyamus and opium, given by the mouth, or in the form of suppository. Enemata of atropia are recommended by Dr. Semple, of Virginia. Hot hip-baths may be administered during the acute stage, and the patient should drink moderately of flaxseed tea, or other demulcent, medicated with a small quantity of citrate of potassium. AYhen the inflammation begins to subside, buchu or copaiba may be cautiously admin- istered. The diet should in ordinary cases be mild and unirritating ; but if typhoid symptoms appear, free stimulation must be resorted to. If retention of urine occur, catheterization with a flexible instrument must be cautiously practised, and if symptoms of nephritis are manifested, wet or dry cups should be applied over the kidneys, and folloAved by mustard poultices or turpentine stupes. Chronic Cystitis may result from the same causes as those which pro- duce the acute form of the affection (which indeed it often succeeds), from atony or paralysis of the bladder, or from any obstruction to the free evacua- tion of its contents—both of these conditions causing accumulation and partial decomposition of the urine, which then becomes very irritating to the vesical mucous membrane—or from tumors or other structural diseases of the bladder itself or of neighboring organs, as the rectum, uterus, or vagina. 894 DISEASES OF THE BLADDER AND PROSTATE. 1. Simple Chronic Cystitis, the form of the affection which is unat- tended with vesical catarrh, is the pathological condition which is present in most of the cases commonly called "irritability of the bladder"—a term wliich is not very avcII chosen, as it refers to a mere symptom. Microscopic exami- nation of the urine, in cases of simple chronic cyslitis, will always detect the presence of pus, and this, with increased frequency of micturition, and slight augmentation of the amount of vesical mucus, are the evidences by which the surgeon may recognize the existence of the disease. The treatment is the same as for the mildest cases of acute cystitis, the inflammation in many in- stances subsiding under the influence of rest alone. 2. Chronic Cystitis -with Vesical Catarrh is characterized by the deposition from the urine of a ropy, tenacious, muco-purulent substance, usually of a grayish-Avhite color, and of alkaline reaction. This is often mixed with phosphates, the urine itself being ammoniacal and extremely offensive. The bladder becomes thickened, roughened, and sometimes sacculated; ulcera- tion sometimes occurs ; and the case may terminate fatally by the patient fall- ing into a typhoid or uraemic condition, to which Roser gives the name of ammonemia. This form of cystitis is particularly apt to supervene in cases of vesical paralysis from injury of the spine (see p. 327). In the treatment of this condition, topical remedies are of the highest importance ; urinary accumulation should be prevented by the cautious use of the catheter, or, as suggested by McGuire, of Virginia, by the employment of a delicate flexible tube, which may be left in situ ; and great benefit may often be deri\Ted from washing out the bladder, by injecting at first warm Avater merely, and subse- quently, if this be Avell borne, mild astringent or sedative lotions ; the best, according to Thompson, are those containing acetate of lead (gr. ss to f^iv), nitrate of silver (gr. ss to f^iv),1 dilute nitric acid (ti^x to f^iv), carbolic acid (ni^ij to f|iv), or borax (Soda? boratis gr. viij-xxx, glycerinae f'5ij) aquae f§iv). In order to prevent ammoniacal de- composition of the urine, Dubreuil recommends injections of a Aveak so- lution of silicate of sodium (gr. iij-iv to f£j); Clemens, of Frankfort, and Purdon, of Belfast, frequent injections of healthy urine; and Erichsen and Nunn, injections of quinia (gr. j-f5J)* Salicylic acid and permanganate of potassium are favorably spoken of by Schuller. Vesical injections are most conveniently made by means of an India-rubber bottle Avith a nozzle, and an ordinary elastic catheter; not more than three or four fluidounces should be used on each occasion, the injected liquid being Keyes'e apparatus for washing out the bladder. 1 T. G. Richardson employs a much stronger solution, viz., gr. xx-xxx to f§j. STRUCTURAL DISEASES OF THE BLADDER. 895 kept in the bladder for a few minutes, and then alloAved to flow off.. AVhen the patient himself applies the injection, Keyes recommends an ordinary fountain syringe provided with a two-way stopcock, the injected liquid thus entering the bladder by simple hydrostatic pressure (Fig. 491). A some- Avhat similar arrangement is employed by Zeissl, McGuire (of Richmond, A a.), and Bertholle, avIio dispense Avith the catheter altogether, simply intro- ducing the pipe of the instrument, into the mouth of the urethra. Harrison, of Liverpool, has devised an ingenious instrument for introducing medicated pessaries into the bladder. Counter-irritation to the supra-pubic region is often of service, and pain may be relieved by the use of anodyne suppositories. A belladonna plaster over the pubes may be used for the same purpose. Hot hip-baths will often be found useful. A large number of internal remedies have been employed in this affection, and it must be confessed often in rather an empirical manner, those Avhich seem to succeed best in some cases, failing utterly in others. Those Avhich are probably most deserving of mention are buchu, uva ursi, pareira, matico, chimaphila, triticum repens, senega, copaiba, and cubebs. Alkalies, espe- cially the liquor potassas, in combination with the tincture of hyoscyamus, may be tried if there be much vesical irritation, but must be watched, lest they increase the tendency to phosphatic deposit. Chlorate of potassium is recommended by Edlefsen. The mineral acids may be useful on account of their tonic properties. AATien the urine is ammoniacal, benzoic acid is highly recommended by Gosselin. An exclusive milk diet is advised by Dr. George Johnson, of London, and Dr. AVeir Mitchell, of this city. It is scarcely necessary to add that if the condition of the bladder depend upon any re- movable cause, such as vesical calculus or urethral stricture, this must be attended to before the cystitis can be cured. In the case of a female, dilata- tion of the urethra may be employed as recommended by Papin, of St. Louis, Howe, of NeAv York, Teale, Duncan, Heath, and Hewetson, and in either sex, recourse may be had, as a last resort, to cystotomy, the bladder in the case of a male being opened from the perineum, as in lithotomy, and in the case of a female from the vagina ; the operation, which was originally sug- gested by Guthrie, has been advantageously employed in the male by several surgeons, including Syme, AVillard Parker, Bickersteth, Parona, Bryant, Holmes, PoAvell of Chicago, and Battey of Georgia, and in the female by Emmet, Sims, Bozeman, Simon, Hegar, and others. Structural Diseases of the Bladder. Sacculated Bladder.—Obstruction to the flow of urine, as from en- larged prostate or stricture, leads to hypertrophy of the muscular walls of the bladder, and gives its inner surface a roughened and fasciculated appearance. As a result of the violent contractions of the organ in the effort to expel its contents, the Aesical mucous membrane and submucous tissue protrude betAveen the interlacing bundles of muscular fibre, and form sacs or pouches, sometimes of very large size, in which the urine accumulates and undergoes decomposi- tion, giving rise to cystitis, and often leading to the formation of phosphatic calculi. The treatment should be directed to preventing accumulation, which may most conveniently be done by the use of an elastic catheter, aided by the siphon arrangement of Prof. Dittel (see p. 866). Tumors of the Bladder__A'arious forms of morbid groAvth are met Avith in the bladder—as the fibrous, fibro-cellular, and fibro-muscular, con- stituting the polypoid tumors met with in this organ, the papillary or villous, 896 DISEASES OF THE BLADDER AND PROSTATE. closely resembling in structure the chorion, very vascular, and sometimes, though by no means always, of a cancerous nature (see pp. 478 and 4D1), the encephaloid, the scirrhous (usually secondary to scirrhus of the rectum), and the epitheliomatous. Dermoid cysts have also been found to communi- cate with, if not to originate in, Fig. 492. the vesical cavity. Any of these tumors may become in- crusted Avith phosphatic matter, and thus simulate calculus; but the diagnosis can usually be made by careful sounding. Hemorrhage attends both the villous and the malignant growths—in cases of the former kind being of the character of capillary oozing, and in those of the latter occurring less con- stantly, but in considerable quantities at a time. The treat- ment, in the large majority of instances, must be merely pal- liative, consisting chiefly in the free administration of ano- dynes, Avith stimulants, if ne- cessary. Astringent injections may be tried in the cases of villous tumor, but should not be repeated if they produce vesical irritation. Polypoid groAvths may be re- moved from the female bladder by ligature, or the scoop, the urethra being dilated for the purpose ; and it may occasionally be possible to remove a vesical polypus in the male by avulsion with a litbotrite, as was done in one instance by Civiale. Billroth has removed a fibro-muscular tumor (myoma) from the bladder of a boy by incision above the pubis as in the high opera- tion for stone, and a similar operation has been performed by Volkmann on a man of 54, who died on the 4th day. Kocher has successfully removed a villous tumor from the bladder of a man 38 years of age, by opening the organ from the perineum, and scraping away the morbid groAvth with a sharp scoop. Tubercle of the Bladder is a rare affection, and is probably never met Avith except in connection with tuberculosis of other organs. The symptoms, as pointed out by T. Smith, closely resemble those of calculus, while the treatment, as far as the bladder is concerned, must be merely pal- liative ; Smith particularly recommends the confection of black pepper (Ward's paste), to relieve the hasmaturk which often accompanies the affection. Polypoid vesical tumors. (Civiale.) Bar at the Neck of the Bladder__This name was given by Guthrie to a rare form of obstruction situated at the neck of the bladder, and entirely distinct from the common hypertrophy of the middle lobe of the prostate. There are two forms of bar—one consisting in a ridge-like elevation of the mucous and submucous tissues, due to enlargement of the lateral lobes of the prostate, the median lobe being unaffected—and the other a similar fold or ridge, which Guthrie attributed to disease of an "elastic structure" (Avhich he described as existing at the neck of the bladder), and which occurs with- HEMATURIA. 897 out there being any apparent cause for its formation. The treatment in most cases must be palliative merely, though, if the condition could be accurately diagnosticated during life, it might perhaps be occasionally proper to divide the bar with a catheter carrying a concealed blade, as recommended by Guthrie and Mercier. Fissure of the Neck of the Bladder is a condition described by Spiegelberg as occurring in women, and as analogous to fissure of the anus. The treatment consists in dilatation and cauterization with nitrate of silver. Hjematukia. The existence of blood in the urine may be a symptom of various affections of the urinary organs, and it often becomes important to determine the source of the hemorrhage. 1. Bleeding from the Kidney may be due to blows on the loin, to the existence of acute Bright's disease, to the irritation produced by a renal calculus, to tuberculous deposit, etc. The blood is usually intimately mixed Avith the urine, but may form a clot, in which case, by floating out the coagulum in Avater (as suggested by Hilton), its shape may betray its origin. 2. Vesical Hsematuria may result from congestion of the bladder, from tuberculous disease, from the irritation caused by a calculus, or from the presence of a villous or malignant groAvth. The blood often coagulates within the bladder, but, when passed in a liquid form, the urine which first Aoavs is less tinged than that which folloAvs. If the hemorrhage be caused by a morbid groAvth, the appearance in the urine of shreds of the abnormal tissue, recog- nizable with the microscope, may aid the diagnosis. 3. Bleeding from the Prostate may depend upon congestion, inflam- mation, or tuberculous or malignant disease of that organ. The diagnosis from vesical hemorrhage may be aided by exploration Avith the finger in the rectum. 4. Hemorrhage from the Urethra may depend upon congestion or inflammation of the part; upon laceration from blows on the perineum, injuries inflicted by instruments, impacted calculi, etc. ; upon rupture from straining in the effort to urinate, or from violent coitus j1 upon ulceration from malignant disease, etc. The diagnosis of urethral hemorrhage may ahvays be made observing that, in urinating, blood precedes the Aoav of urine, and that this, if drawn off by the catheter, is clear. Treatment of Hsematuria__This must vary with the source of the hemorrhage. If due to renal injury, calculus, etc., the patient must be kept in bed, and astringents, such as gallic acid or acetate of lead, with opium, administered. The confection of black pepper is highly spoken of by T. Smith. AVhen of vesical or prostatic origin, cold applications are of service. It is better, as a rule, not to interfere with clots in the bladder, but to leave their disintegration to the efforts of nature. If, however, it becomes neces- sary to adopt artificial means of evacuation, a portion of the clot may be gently draAvn out through a large-eyed catheter, by means of Clover's litho- 1 The bleeding which occasionally follows immoderate sexual intercourse without rupture, is, according to Hilton, usually prostatic. 57 898 DISEASES OF THE BLADDER AND PROSTATE. trity apparatus or an ordinary stomach-pump. For persistent vesical haema- turia, Thompson recommends injections of nitrate of silver (gr. j-iv to f'liv), or of the tincture of the perchloride of iron (f3j to f'^iv). Hemorrhage from the urethra may be controlled by cold applications, or, if these fail, by intro- ducing a full-sized catheter, and compressing the penis upon it with strips of adhesive plaster or a bandage. Bates, of Brooklyn, has devised an ingenious apparatus for applying cold and pressure within the urethra. Intermittent or Paroxysmal Haematuria, or (as it should per- haps rather be called) Hematiuuria, has been observed in several cases, by Greenhow, Harley, Fuller, Gull, and other writers, the paroxysm usually following exposure to cold. The treatment consists in the administration of tonics, particularly iron and quinia. Paralysis and Atony of the Bladder; Retention and Inconti- xexce of Urine, etc. True Paralysis of the Bladder is not very often met with; it is most commonly seen in cases of injury or organic disease of the brain or spinal cord, though it occasionally occurs as a result of functional exhaustion of the spinal system from sexual excesses, as a reflex phenomenon dependent upon injuries or diseases of other parts of the body, or as a temporary conse- quence of the use of belladonna or similar drugs. AVhen the paralysis affects the neck of the bladder only, the urine constantly flows away, giving rise to incontinence; when the body of the organ alone is involved, the bladder can- not expel its contents, and the result is retention; Avhile, if the whole organ be affected, though most of the urine may escape, the bladder remains par- tially distended—and incontinence and retention may thus coexist. The treatment consists in keeping the bladder empty (when this is necessary) by the cautious and gentle use of a flexible catheter, and in relieving by suita- ble remedies any cystitis that may occur. In some cases, galvanism and the administration of various tonics, especially strychnia, may be of service. The latter remedy has been successfully used by injection, in doses of ^ gr., by Dr. W. E. Tarbell, of China. Atony of the Bladder, from over-distension of this organ, is, on the other hand, frequently met with. This condition may arise in the course of low fevers, if the catheter be not used—or even from voluntarily neglecting the calls of nature—but is most commonly due to some source of obstruction, either prostatic or urethral, which, while not giving rise to absolute reten- tion, yet renders the bladder unable to expel its whole contents. A certain quantity of " residual urine" thus remains, and gradually increases in amount until the organ is completely distended, Avhen the neck of the bladder be- comes partially dilated, and, as pointed out by Thompson, an overflow takes place, masking the real condition, and leading the patient—and sometimes his medical adviser—to consider the case one of incontinence rather than retention of urine. Retention of Urine, though merely a symptom, is one of such import- ance as to demand special consideration. AVhen it occurs gradually (as is the case when it arises from paralysis or atony of the bladder), the vesical cavity becomes slowly distended, until it may contain several quarts of urine, and forms a prominent tumor in the hypogastrium, reaching nearly to the umbilicus. The patient is usually not conscious of passing a smaller quantity of urine than in the normal condition, though a certain amount of difficulty INCONTINENCE OF URINE. 899 may be experienced in completing the act of micturition—the Avater beinf expelled Avith less force than in health, and dribbling of urine continuing after the bladder has been apparently emptied, or occurring during sleep or upon making any muscular exertion; Avhen the bladder has become fully dis- tended, overfloAv occurs in the Avay already described, and simulates inconti- nence. The diagnosis of retention is usually made with facility; even if there be no hypogastric tumor, there Avill be dulness on percussion over the pubes, and the distended bladder can be felt by placing a finger in the rectum, when by tapping over the supra-pubic region fluctuation can be distinctly recognized. If, however, the Avails of the bladder be thickened and con- tracted, the diagnosis may be more difficult. Retention of urine, if unre- lieved, leads to cystitis, with an ammoniacal state of the contents of the bladder; it may even prove fatal through the supervention of a typhoid or uramiic condition. Treatment—The treatment of retention with overflow, Avhich is the condi- tion met with in cases of atony of the bladder, requires in the first place the systematic use of the catheter, two or three times a day, so as to evacuate the " residual urine." A long and large flexible catheter is the best, but, what- ever form of instrument may be used, care must be taken that it actually enters the bladder, and not merely the prostatic portion of the urethra, Avhich in these cases is often dilated, and. may contain a couple of ounces of urine. AVhen the retention has lasted for a long period, it may be better not to evacuate the entire contents of the bladder at once—which Avould probably give rise to cystitis—but to draAv off a portion at a time, and thus enable the organ gradually to return to its normal state. In cases of short duration the bladder may perfectly regain its tone, but in many instances all that can be done is to palliate the patient's condition. Thompson recommends the appli- cation of the cold douche to the lumbar spine and abdomen, and the injection of cold water into the bladder. The hypodermic injection of ergotine has been successfully resorted to by Langenbeck, Iversen, and other surgeons. Spasmodic Retention of Urine, or, as Sir James Paget has happily called it, stammering with the urinary organs, is a condition occasionally met with, and wliich is more annoying than dangerous. A person who is liable to this form of retention should learn to use a catheter, and should con- stantly carry one with him, as the fear of being unable to urinate is often of itself sufficient to bring on an attack. Hysterical Retention of Urine is occasionally observed in women, in connection with various other phenomena Avhich are conventionally denomi- nated hysterical. The treatment consists in regulating the state of the bowels, and administering tonics and nerve stimulants, with the local use of the cold douche ; the catheter may be used once, to make sure that there is no actual obstruction, but should afterAvards be withheld ; rupture of the bladder never occurs in these cases, and the patient usually passes her water without diffi- culty, as soon as the distension becomes painful, and she is convinced that instrumental relief will not be afforded. Incontinence of Urine__This may occur either in children or in adults. 1. Nocturnal Incontinence in Children.—The patient may wet his bed during sleep only occasionally, or may do so once or oftener every night. This infirmity may result from habit (through neglect of the nurse to take the child up at proper intervals), from excessive secretion of urine or some irritating quality of this fluid, from irritation transmitted from neighboring 900 DISEASES OF THE BLADDER AND PROSTATE. organs, as the rectum, or from the existence of slight chronic cystitis, of phimosis, of preputial adhesions, etc. The treatment consists (1) in removing the cause, if this can be ascertained ; (2) in improving the general health ; (3) in obtunding the excessive sensibility of the bladder; (4) in endeavoring to induce a habit of attending to the calls of nature at suitable intervals ; and (5) above all, in developing a hearty Avish for relief on the part of the patient, for without his co-operation, as justly observed by Brodie, little can be ac- complished. The first indication is to be met by regulating the diet, attend- ing to the digestive functions, forbidding excessiAre use of liquids, etc.; the second, by the administration of tonics, and the employment of sea-bathing or the cold douche ; and the third, by the use of belladonna ghTen by the mouth, in the form of t ncture or extract, or by the hypodermic administra- tion of atropia, aided in obstinate cases by the application of a solution of nitrate of silver to the prostatic urethra. The patient should be aroused and made to urinate once or tAvice during the night, and should be induced to strive himself to get relief from his infirmity—not by threatening punishment, but by encouraging the formation of cleanly habits. A'arious remedies beside those mentioned above have been employed with more or less success, such as blisters to the sacrum, the use of an apparatus to prevent the patient lying on his back (the urine, when this position is assumed, resting on the trigone of the bladder, Avhich is its most sensitive part), the application of collodion to the meatus, as recommended by Corri- gan, circumcision, the application of electricity, the administration of hydrate of chloral, hypodermic injections of strychnia, etc. These may be, each or all, properly tried in obstinate cases. 2. True Incontinence of Urine in the Male Adult is very rare, the real condition in most cases so described being, as already mentioned, retention with overflow. In women, OAving to the shortness of the urethra, inconti- nence of urine is more common, resulting usually from injury received during parturition. True incontinence in the male may, however, result from paralysis of the neck of the bladder—in which case the treatment appropriate to that condition must he adopted—or from a peculiar form of hypertrophy of the prostate, in Avhich the enlarged third lobe projects Avedge-like between the lateral lobes, keeping the neck of the bladder constantly patulous. Under these circumstances little can be done beyond the adaptation of a well-fitting urinal to keep the patient dry. Irritability, Spasm, and Neuralgia of the Bladder are often spoken of as distinct diseases, but are almost invariably merely symptomatic of other conditions, such as cystitis, tumor of the bladder, or vesical calculus. The treatment must be addressed to the relief of the particular pathological condition to Avhich the symptoms may be due. Anodynes and antispasmodics are often useful as palliatives. Lund, of Manchester, recommends, in cases of females, dilatation of the urethra, and reports two instances in which this mode of treatment gave entire relief. Inflammatory Diseases of the Prostate. Acute Prostatitis—Acute inflammation of the prostate usually fol- lows urethritis, especially when due to gonorrhoea, but may also result from various forms of injury, as from the introduction of instruments or the use of strong injections, from exposure to cold and moisture, as from sitting in wet grass, from previously existing cystitis, or from vesical calculus. As a com- plication of urethritis, it is apt to be excited by the use of alcoholic stimulants or by excessive venery. The symptoms of acute prostatitis are pain and INFLAMMATORY DISEASES OF THE PROSTATE. 901 Aveight in the perineum, Avith great frequency of micturition, dysuria, and vesical tenesmus, the pain also being increased by the act of defecation. There is a good deal of constitutional disturbance, and the swelling is some- times so great as to induce complete retention of urine. The diagnosis can be readily made by rectal exploration. The inflammation may terminate in resolution, or may run on to the formation of an abscess, Avhich usually bursts into the urethra; even if resolution occurs, however, the urine will probably contain pus, from the coexistence of cystitis. The treatment consists in the enforcement of rest and the administration of laxatives, with the application of leeches or cups to the perineum, folioAved by hot hip-baths and poultices. Pain may be relieved by the use of anodyne enemata. Should complete re- tention occur, it may be necessary to use the catheter. Abscess of the Prostate usually occurs as a sequel of acute prostatitis, but may be developed in an insidious manner from bruising of the part in the use of instruments, etc. In the latter cases it is often the areolar tissue around the prostate Avhich is affected, rather than the organ itself, and the affection is then called peri-prostatic abscess. Pointing usually occurs, as already mentioned, in the direction of the urethra, but occasionally towards the rectum, or even externally in the perineum. The symptoms are those of deep-seated suppuration in general, and the diagnosis can be made by rectal exploration. Retention is apt to occur when the SAvelling is principally on the side of the urethra, and the introduction of the catheter may then serve the double purpose of opening the abscess and evacuating the contents of the bladder. AVhen the SAvelling makes its appearance in the perineum, an early and free incision is required, to relieve tension and prevent the formation of a rectal or urethral fistula. If fluctuation is distinctly felt in the rectum, it will be proper to make a puncture in that locality. Prostatic abscesses usually heal without difficulty, but occasionally fall into a chronic state, per- sisting as suppurating cavities Avhich form receptacles for urine. This condi- tion is often not recognized during life, the symptoms closely resembling those of chronic cystitis. Benefit may sometimes be derivred from the application of a Aveak solution of nitrate of silver. Chronic Prostatitis or Prostatorrhcea__This may be a sequel of acute prostatic inflammation, or may occur as a primary affection, result- ing from the urethritis Avhich accompanies organic stricture of long standing, from bruising of the perineum in equestrian exercise, from inordinate indul- gence in sexual intercourse, from onanism, or from piles, habitual constipa- tion, etc. The symptoms are pain and Aveight in the region of the prostate, increased during micturition or coitus ; diminution in the force with which the urine is evacuated; a slight, thin, glecty discharge, sometimes in suffi- cient quantity to discolor the clothing; and usually the presence of a little pus in the urine, with occasionally a few drops of blood. Nocturnal seminal emissions occur in some cases. The affection is chiefly important on account of the mental distress it often occasions to patients, avIio believe the gleety discharge to consist of the seminal fluid. This is, perhaps, the most promi- nent symptom of the disease, and has suggested the name prostatorrhcea, which is employed by Prof. Gross, avIio has given an excellent account of the affection. The diagnosis betAveen the prostatic fluid and semen can always be made by microscopic examination ; the former contains very feAV, if any, spermatozoa, while these are, on the other hand, abundant in the latter. The treatment consists in removing any cause that can be detected, in the administration of tonics, especially phosphoric acid and strychnia (Avith laxa- tives, if required), and in the application of blisters or other counter-irritants 902 DISEASES OF THE BLADDER AND PROSTATE. to the perineum. In cases accompanied by nocturnal emissions, a solution of nitrate of silver (gr. v-x to f gj), or, which is preferred by H. Lee, of the perchloride of iron (tti,xv-xxx to f;|j), may be occasionally applied to the prostatic urethra, by means of a syringe with a catheter-like nozzle. AVinter- nitz applies cold by passing a stream of Avater of a temperature from o5° to 60° Fahr. through a double-current catheter without eyes, Avhich he calls a psychrophor. Fie. 493. Chronic Hypertrophy of the Prostate. This is an affection of advanced life, being seldom if ever met with in men less than fifty years old, though inflammatory enlargement (a totally distinct condition) may of course exist at any age at which prostatitis itself is possi- ble. So often is prostatic hypertrophy seen among those past the middle period of life, that Sir Benjamin Brodie considered it almost a normal condi- tion under such circumstances ; but the statistical investigations of Thomp- son, Messer, Lodge, and Dittel, have shown that its actual frequency is less than has been supposed, appreciable enlargement existing in but about one- third of the cases examined in persons more than sixty years of age. The hypertrophy may affect only the unstriated muscular fibres and connec- th-e tissue of the prostate, or may involve its glandular structure as well; there may be enlargement of the whole organ, or the increase of size may be confined to its lateral lobes, or to its central portion, constituting what is commonly called the enlarged "third lobe of the prostate." In many cases independent or semi-isolated tu- mors are found—principally in the lateral lobes—almost identical in structure with the prostate itself, though containing less glandu- lar tissue, and that imperfectly developed; these prostatic tumors, which have been spe- cially studied by Thompson, are sometimes surrounded by a fibrous capsule, and may often be readily enucleated "with the finger, as has been done in the operation of lithotomy (see p. 877) ; they are in many respects analogous to the fibrous or fibro-muscular groAvths (rnyo- mata) met Avith in the uterus. Enlargement of median lobe of pros. Physical Characters—The weight of tate. (Erichsen.) an hypertrophied prostate may vary from one to tAvelve ounces, and its size from two to four inches transversely, and from one to three inches in an antero-posterior direction. The consistence may be firmer or softer than in.the normal con- dition, the increased firmness being usually attributable to the presence of the prostatic tumors which have been referred to. Hypertrophy of the prostate produces various changes in the form and di- rection of the prostatic portion of the urethra; this is increased in length and often rendered tortuous; it is usually contracted laterally, and widened from before backwards, so that on making a transverse section it appears as a narroAv chink instead of a round tube ; but in other cases this portion of the urethra is dilated into a pouch Avhich may hold an ounce or two of urine. AVhen the central portion or " third lobe" of the prostate is enlarged, the urethra is commonly bent forwards at an angle—its course being thrown also to the riglit or left if either lateral lobe is increased in size, and the HYPERTROPHY OF THE PROSTATE. 903 Section of bladder and prostate, the former hy- pertrophied, the latter forming prominent tumors within the bladder. (Thompson.) deviation being to the side opposite to that of the principal enlargement. The internal orifice of the urethra usually assumes a crescentic shape, the concavity of the crescent corre- sponding to that lobe of the prostate Fl£- 494, which is principally affected; but if the Avhole organ be irregularly en- larged, the urethral opening is much and curiously distorted. A project- ing portion from the median lobe not unfrequently hangs over the orifice in a valve-like manner, closing it more or less completely Avhen the patient attempts to urinate. An- other mode in Avhich the urethral orifice may be occluded, is by the formation of a bar at the neck of the bladder from the elevation of the mucous and submucous tissues by enlargement of the lateral lobes (see p. 896). In the large majority of cases, hy- pertrophy of the prostate interferes with the complete evacuation of the contents of the bladder in one of the Avays mentioned, leading to a thickened, roughened, and saccu- lated condition of that organ, Avhich becomes sloAvly distended and falls into a state of atony attended with habitual overflow of urine ; under these circumstances, a Aery slight cause, such as exposure to cold, or local conges- tion produced by alcoholic indulgence or sexual emotion, may be sufficient to produce an attack of complete retention. On the other hand, it occasionally happens that the median, projecting betAveen the lateral lobes, keeps the ure- thral orifice constantly patulous, thus giving rise to true urinary incontinence (p. 900). In cases of long standing, the ureters and pelves of the kidneys often become dilated, and chronic renal disease supervenes. Symptoms.—The early symptoms of enlarged prostate are diminution of the force with which the contents of the bladder are expelled, the stream, though perhaps not smaller than in health, being feeble and slow, and tending to drop vertically from the meatus. The patient has to strain at the begin- ning of micturition, and the process requires a longer time than usual, because the bladder is in a state of partial atony; as the organ, moreover, is never completely emptied, the desire to make water recurs Avith undue fre- quency, and the normal sense of relief is not experienced from the act of urination; the water continues to dribble after the discharge of all that can be voluntarily evacuated, and particularly at night Avhen the control of the Avill is withdrawn. There is a feeling of weight and distension about the perineum, with irritation of the rectum, tenesmus, piles, or prolapsus; and ultimately the symptoms of chronic cystitis are developed, with an ammoniacal state of the urine, and perhaps the formation of phosphatic calculi. Diagnosis___Hypertrophy of the prostate may always be recognized by careful exploration Avith the catheter, aided by the finger in the rectum ; in this Avay the surgeon can ascertain not merely that the prostate is enlarged, 904 DISEASES OF THE BLADDER AND PROSTATE. but can determine approximatively the degree of hypertrophy, which lobe or lobes are particularly affected, and the direction in which the urethra deviates from its normal course. The ordinary catheter frequently will not reach the bladder, on aceount of the elongation and altered direction of the prostatic urethra which have been referred to : hence the surgeon should have at hand some prostatic catheters, which are from tAvo to four inches longer than the ordinary instruments, and have a larger curve (Fig. 496). Rectal explora- tion will also enable the surgeon to ascertain if the distended bladder can be felt beyond the prostate—an important point in case the question of punc- turing the organ for relief of retention should arise. By conjoined urethral and rectal exploration, the surgeon can distinguish prostatic hypertrophy from paralysis or from simple atony of the bladder, from the bar at the neck of the organ unconnected "with prostatic disease, and from chronic cystitis ; the diagnosis from stricture of the urethra, may be made by observing the locality of the obstruction (which in stricture is rarely more than six, and in prostatic hypertrophy at least seven, inches from the meatus), and the different characters of the stream, Avhich in stricture is small and often forked, but is not ahvays reduced in force, and sometimes keeps its normal parabolic curve, while in prostatic obstruction, though per- haps not diminished in size, it is always weak, and tends to drop vertically from the meatus. The diagnosis from calculus may be made by careful ex- ploration with a sound ; but it must not be forgotton that calculus and pros- tatic disease often coexist. Acute prostatitis can be recognized by rectal exploration alone, through the pain which is thus excited ; Avhile the catheter alone will show whether or not there is atony of the bladder, the flow when the obstruction is overcome being forcible and partially under the control of the Avill, Avhen this organ is healthy, but weak and totally uninfluenced by volition, if it be in a condition of atony. This circumstance Avill of itself suffice to distinguish simple atony from prostatic obstruction. Tumor of the bladder is to be diagnosticated by observing the presence of blood and of fragments of the morbid growth in the urine, and by careful instrumental exploration (see pages 896 and 897). Treatment.—The most important point is to obviate the effects of ob- struction, by emptying the bladder at suitable interArals by catheterization. TAvice a day—morning and evening—is usually often enough, but the fre- quency with which the instrument is used, must depend upon the deoree in Avhich obstruction is present. The patient should be taught to pass the in- strument for himself, the best form for ordinary use being the " English" gum-elastic catheter, which should be kept, as advised by Brodie and Thomp- son, on an over-curved stylet (Fig. 496, a), so that, Avhen this is removed, it may pass readily into the bladder. For special cases it may be necessary to use silver instruments, some of which should have a large curve—a third of the circumference of a circle the radius of which is 2| inches__and others a short beak like a lithotrite, which form of instrument is known as the elbowed catheter (sonde coud'ee) ; flexible catheters of the same form are also useful, and are knoAvn as Mereier's (Fig. 49o). In other cases it may be necessary to use the gum instrument with the stylet, so that the curve may be altered at Avill, or so that the curve may be increased Avhen the catheter reaches the point of obstruction, by partially AvithdraAving the stylet, in the way recommended by Hey, of heeds. An ingenious instrument for use in cases of retention of urine from prostatic enlargement, has been devised by Dr. Squire, of Elmira, under the name of vertebrated catheter ; its construc- tion can be seen from Fig. 497. Dr. CoAvan, of Danville, uses a soft "rim catheter containing a spiral coil of brass Avire, so as to give sufficient firm- TREATMENT OF ENLARGED PROSTATE. 905 ness to the instrument Avithout interfering Avith its elasticity ; someAvhat similar instruments are employed by Dr. Otis and Dr. Keyes, of New York, and by Fig. 495. Fig. 496. ^ Mercier's elbowed catheter. a, Gum catheter mounted on a stylet of the proper curve for use in cases of prostatic obstruction; b, c, d, silver prostatic catheters of different curves. Dr. S. AV. Gross, of this city. If it should be necessary to leave a catheter in the bladder—wliich should, as a rule, only be done in cases of retention in Fig. 497. Squire's vertebrated prostatic catheter. which the introduction of the instrument has been attended with great diffi- culty,—the vulcanized India-rubber catheter should be chosen, and may be 906 DISEASES OF THE BLADDER AND PROSTATE. introduced with or without the stylet, as may be found most convenient ; if the stylet is used, it is, of course, to be withdraAvn as soon as the instrument is in place. The catheter may be most conveniently secured by means of adhesive strips, reaching from the instrument to the penis, and fastened to the latter by other strips applied circularly around the organ. Care must be taken not to produce so much constriction as to lead to ulceration or slough- ing. Self-retaining catheters have been devised by several surgeons, but, I confess, have always seemed to me more ingenious than practically useful. Beside periodically emptying the bladder by the use of the catheter, the surgeon must pay great attention to the general condition of the patient, avIio should live temperately, dress warmly, and take moderate Avalking exercise in the open air. The treatment of cystitis Avith vesical catarrh, a frequent complication of enlarged prostate, has already been referred to. Akrious drugs, particularly conium, mercury, muriate of ammonia, and iodine, have been employed in the hope of causing absorption of prostatic enlargement, and systematic compression (first proposed by Physick) has been used for the same purpose : none of these remedies have, however, sustained the reputa- tion which was claimed for them, and they are now generally abandoned. A'arious operations, such as incision, excision, cauterization (the use of the galvanic cautery has been lately recommended by Bottini), avulsion, strangu- lation with the ligature, crushing Avith a lithotrite, etc., have also been sug- gested, but do not appear to offer any hope of benefit commensurate with the risk which they entail. Prof. Gross speaks highly of the occasional applica- tion of leeches to the perineum. Heine recommends the injection of tincture of iodine, and Langenbeck and Iversen that of ergotine, the injections being given through the rectum. Heine's method has been successfully employed by Dr. Melville Taylor, of Maryland, but, according to Dr. B. HoAvard, several cases thus treated by Dittel, of A'ienna, terminated in suppuration and death. The internal administration of ergot is advised by Atlee, of this city, and by Satterthwaite, of Ncav York. Sir Henry Thompson advises that, in cases which require the very frequent use of the catheter, an opening should be made above the pubis, and a flexible tube introduced, and permanently retained in position. A similar plan has also been recommended by Dittel. Treatment of Retention from Prostatic Obstruction. Fig. 498. Catheterization in enlarged prostate. (Erichsen.) If complete retention occur, the surgeon may try the effect of a hot bath with a full dose of opium ; but if this fail (as it usually will), persevering attempts must be made to pass a catheter. The patient should be in a recumbent position, for if erect, fatal syncope might occur from the rapid withdrawal of a large quantity of fluid (as in the operation of tapping the abdomen), and the sur- geon should then try in succession, with all gentle- ness hoAvever, prostatic catheters of various kinds and shapes, until, if possible, relief is afforded, when, if thought proper, the instrument may be fastened in the bladder. If the distension has been very great, it may be prudent to remove only a portion of the urine at a time (see page 899). The chief points to be attended to in cathe- terization, in these cases, are (1) to firmly depress the extremity of the instrument between the patient's thighs, so that its beak may ride over PUNCTURE OF THE BLADDER. 907 the enlarged third lobe into the bladder, and (2) to make sure that the bladder is actually reached, and that the catheter does not merely enter the elongated and dilated urethral pouch which often exists in cases of prostatic enlargement. If catheterization cannot be accomplished, the bkdder must be punctured in one of four Avays, viz., (1) through the prostate; (2) through the rectum ; (3) above the pubis; or (4) through or below the pubic symphysis. Puncture through the Prostate (Tunnelling the Prostate)___This operation Avas recommended by Home, Brodie, and Liston, the two former surgeons simply perforating the obstruction by pushing through it a silver catheter, Avhile the latter employed a large and slightly curved canula carry- ing a concealed blade. The surgeon first satisfies himself that the instru- ment is exactly in the median line, and has not deviated from the urethra, and then pushes steadily onwards Avhile he depresses its handle, until the ces- sation of resistance and the Aoav of urine shoAv that the bladder has been reached. A false passage is thus made through the projecting third lobe of the prostate, and in this false passage the instrument should be left for about forty-eight hours, Avhen the parts will usually be sufficiently consolidated to allow the catheter to be withdrawn and re-introduced as often as neces- sary. This mode of treatment is by no means free from risk, and should never be resorted to unless the surgeon can positively satisfy himself that his Fig. 499. Puncture of the bladder through the rectum, and above the pubis. (Phillips.) instrument has not left the channel of the urethra, and that it impinges directly upon the obstructing portion of the prostate. Under other circum- stances the bladder might not be reached at all, and the operation would prob- ably be followed by the most serious consequences. 908 DISEASES OF THE BLADDER AND PROSTATE. Puncture through the Rectum is not applicable to cases of very great prostatic enlargement. If, hoAvever, the fluctuation of the distended bladder can be distinctly recognized above the prostate, by digital exploration through the rectum, this operation may be safely resorted to, as the puncture can then be made beloAV the recto-vesical fold of peritoneum. The patient being in the lithotomy position, the bladder is steadied and pressed down- wards by an assistant placing one hand on either side of the abdomen ; the surgeon, then, bavins; satisfied himself as to the extent and relations of the prostate, introduces upon the left forefinger, Avhich serves as a guide, a curved trocar and canula, seven or eight inches in length, and by depressing the handle of the instrument carries its point through the contiguous Avails of the rectum and bladder, the cessation of resistance showing when the latter organ has been entered. The trocar is then carefully Avithdrawn, and the canula secured in place by means of tapes fastened to a bandage around the Avaist. After a few days, probably, the catheter can be introduced Avithout difficulty, Avhen the rectal canula may be taken out, the wound usually closing without any trouble. The risks of rectal puncture, apart from wound of the perito- neum (Avhich can scarcely occur if the operation be reserved for cases in which vesical fluctuation is distinctly recognized by the finger in the rectum), are injury of the seminal vesicle, abscess of the recto-vesical septum, leading perhaps to urinary infiltration, and the formation of a recto-vesical fistula. Emphysema has occasionally followed the operation. The statistics of rectal puncture have been investigated by Deneffe and Akn AVetter, who have col- lected 97 cases, with 86 recoveries and 11 deaths. Puncture ahove the Pubis__The bladder may also be safely tapped above the pubis (in Avhich position it is uncovered by peritoneum), by making a small incision in the median line just above the symphysis, and then intro- ducing a straight or slightly curved trocar and canula (Avith the convexity upwards) in a direction doAvmvards and backAvards, so as to penetrate the bladder: the canula may be left in for tAvo or three days, after which a gum- elastic tube may be substituted—the latter instrument being subsequently renewed as often as may be found necessary. Dr. Dieukfoy, of Paris, has suggested a modification of this operation, by Avhich the bkdder is emptied by means of the " aspirator," and numerous cases have now been recorded in which this operation, which does not appear to be attended Avith any particular risk, and which I have myself employed with satisfaction, has been successfully performed. It has the advantage over other modes of treatment, that it may be repeated as often as necessary, and therefore does not require the retention of an instrument. Denelfe and Akn AAktter find that 152 cases of the ordinary supra-pubic puncture gave 125 recoveries and 27 deaths, while 55 cases of puncture with the aspirator gave 52 recoveries and only 3 deaths. Puncture through the Symphysis Pubis was first suggested by Brander, of Jersey, in 182.3, and has since been successfully resorted to by Leasure, of Pennsylvania, and several other surgeons. It is accomplished with a strong hydrocele trocar and canula, by pushing the instrument through the symphysis in a direction " obliquely dowmvards and backAvards towards the sacrum." This mode of treatment is only applicable to cases in Avhich the cartilage of the symphysis is unossified, and does not appear to present any advantage over the supra-pubic puncture, particularly when the " aspirator" is employed ; and the same may be said of the SUD-pubic mode of operation attributed to Akillemier. Dr. AV. R. AVhitehead recommends, as preferable to any form of puncture, EXPLORATION OF THE URETHRA. 909 a supra-pubic cystotomy, the bladder being opened in the median line, and the cut edges of the viscus attached by silver sutures to the edges of the ex- ternal Avound. Other Diseases of the Prostate. Atrophy of the Prostate is occasionally observed either as a con- genital or as an acquired affection. The prostate may be considered as atrophied Avhenever its Aveight (in an adult of medium size) is less than half an ounce. The affection presents no special symptoms and requires no special treatment. Cancer of the Prostate is usually of the encephaloid variety, though, according to Jolly, true scirrhus is occasionally found in this organ. The affection, which is one of great rarity, may occur either in early childhood or in late adult life ; the symptoms are those of prostatic obstruction, with pain, hematuria, glandular implication, and, ultimately, general cachexia. The diagnosis is almost impossible during the early stages of the disease; and, indeed, according to Jolly, has rarely been made during the life of the patient. The treatment must be purely palliative, and instrumental interference should be, if possible, aA'oided. If absolute retention occur, puncture of the bladder may be required as a means of prolonging the life of the patient, though, of course, ultimate recovery is impossible. For further information on the sub- ject of prostatic cancer, the reader is referred to the Avritings of Gross and Thompson, and especially to an elaborate and exhaustive memoir published by Jacques Jolly, in the numbers of the Archives Generales de Medecine for May, June, July, and August, 1869. Tubercle of the Prostate occurs in connection with tubercle of other organs, but presents no special indications for treatment. Cysts of the Prostate are of the kind called by German pathologists, retention cysts, resulting from obstruction of the glandular tubes of the organ by calculous concretions ; they are seldom recognized during life, but in one instance, recorded by LansdoAvne, the cyst attained so great a size as to cause retention of urine. In this case the cyst Avas punctured through the rectum, and suppuration folloAved, resulting in the entire recovery of the patient. LoAvdell has observed a true hydatid cyst in this locality. Prostatic Calculi have already been referred to at page 885. CHAPTEE XLVI. DISEASES OF THE URETHRA AND URINARY FISTULA. Exploration of the Uretiiha. Tins is accomplished by the aid of catheters, bougies, or sounds, and may be aided in some cases by the use of the endoscope. Catheterization of the urethra is an operation which is very frequently required, and in the per- formance of which every surgeon should strive to acquire such skill as to inflict the least possible amount of pain upon his patient. 910 DISEASES OF URETHRA AND URINARY FISTULA. Catheters___These are hollow tubes, made either of metal—when they must have a curve corresponding to that of the normal urethra—or of India- rubber, or other flexible substance. There are tAvo principal varieties of flexible catheter in the market—the English and the French. The former is of a yellowish-broAvn color, and is provided Avith a stylet; it can be made of any curve the surgeon chooses, by moulding it in hot water and then quickly plunging it into cold Avater, when it becomes stiff, and Avill retain its Fig. 500. ^^---o French flexible bougie and catheter. curve long enough to allow its introduction in all ordinary cases. The French instrument, of a black color, is, on the contrary, perfectly flexible, bending with the utmost facility in every direction; it is conical towards its extremity, and terminates in an olive-shaped point, to prevent its catching in the lacunae of the urethra. Another form of French catheter, known as Nelaton's, is made of thin India-rubber, and is chiefly employed when it is desired to keep an instrument constantly in the bladder (sonde a demeure). A catheter should be ten or eleven inches long, and provided with one Of-tw©«4a^B, smoothly finished eyes near its vesical extremity; the metallic instrument should be heavily silver or nickel plated, and should have rings at its outer end to enable the surgeon to judge, by their position, of the exact situation of the beak of the instrument, when it is in use. The curve of a catheter should correspond to that of the normal urethra; the instrument employed by Thompson has a curA*e Avhich forms a quarter of the circumstance of a circle Avith a radius of one and five-eighths inches (three and a quarter inches in diameter). Benique's instrument, Avhich is preferred by Bumstead, has the same curve, hut occupies a greater arc of the circle. The curve of the cathe- ter should be continued quite up to its point. The sizes of catheters are arranged by either the English, American, or French scale—the latter being the best, as having more numbers, and therefore allowing more nicety of graduation. The English scale runs from one to tAvelve, the American from one to twenty, and the French from one to thirty, the numbers in the latter representing the exact circumference in millimetres. For purposes of explo- ration, or for ordinary use, a medium-sized catheter should be chosen, as it is less likely to inflict injury than a smaller one, and will not be caught in the lacunae of the urethra. A double-curved or S catheter is a convenient form of the instrument for office use. Hueter, of GreifsAvald, employs flattened cathe- ters, Avhich he considers easier of introduction than those of the ordinary form. Bougies and Sounds.1—These may he regarded as solid catheters. The bougie (originally made of Avax, Avhence the name) is a flexible instru- ment, and there are tAvo varieties, corresponding to the English and French catheters. Beside the ordinary conical, olive-pointed French bougie,2 the 1 Or urethral sounds, in contradistinction to the vesical sounds used for exploring the bladder. 2 To obtain an instrument intermediate in firmness between an ordinary bougie and a sound, Thompson suggests tbe introduction into the former of a leaden stylet, which terminates about four and a half inches from the extremity of the instrument. INTRODUCTION OF THE CATHETER. 911 surgeon should have some of the kind which go under the name of bougies a boule, or, as Bumstead more accurately terms them, acorn-pointed bougies. These are particularly valuable for purposes of exploration, enabling the sur- geon to judge of the extent of a stricture by noting the point at which resist- ance is felt, both upon the introduction and upon the withdrawal of the instrument. Care must be taken, however, not to mistake for stricture the Fig. 501. Bougies d boule. normal narrowing of the urethra in the region of the triangular ligament, at which point, as shown by Dr. J. W. White, of this city, the bulbous-pointed bougie is apt to be arrested Avhen it is being withdrawn. Filiform bougies are simply bougies of very small size; they may be made of whalebone, or of the same material as the ordinary French bougie or catheter, the latter being upon the Avhole the best. These instruments are indispensable for the treat- ment of tight strictures. Sounds are made of steel, pewter, or other metallic substance, and should be perfectly smooth and highly polished, or, Avhich is better, plated with silver or nickel. Their curve should be that of a Avell-made metallic catheter, and they should have a broad handle to prevent them from slipping when in use. Their sizes are graduated by the same scale as catheters. Sir C. Bell em- ployed a bulbed sound for purposes of exploration, and Richardson, of Dublin, lias recently devised an ingenious instrument, the extremity of which is formed by the approximation of tAvo half-bulbs, which are introduced closed, and can be divaricated after passing the stricture, thus clearly marking the posterior limit of the contraction as the instrument is withdrawn. Introduction of the Catheter—The patient may be in a standing, sitting, or lying posture, the last being much the best under ordinary circum- stances. He should lie perfectly flat on his back, with the shoulders slightly elevated and the thighs somewhat flexed and separated ; the draAvers should be slipped doAvn, and the shirt tucked up so as to fully expose the genital organs. The surgeon, sitting or standing on the left side of the patient, raises the penis with his left hand, and, holding the catheter or sound (previously Avarmed and oiled) lightly between the thumb and two fingers of the riglit hand, introduces its beak between the lips of the meatus, its shaft being nearly horizontal and lying in the direction of the fold of the patient's left groin. The penis being steadied and slightly draAvn upAvards so as to efface the folds of the urethra, the instrument is very gently pushed onwards, entering almost by its own weight, and being " swallowed," as it were, by the canal, until the beak has passed beneath the symphysis pubis. During the first two inches of its course the catheter should be kept to the floor of the urethra, so as to avoid the lacuna magna, but should afterwards be made to cling to the roof of the canal, to avoid the sinus of the bulb and the openings of any false passages that may be present. When the point of the catheter has passed beneath the pubis, the shaft is to be brought into the median line and slowly elevated to a vertical position, Avhen, by gently depressing the handle between the pa- tient's thighs, supporting at the same time the convexity of the instrument by pressing on the perineum or with the finger in the rectum, the beak will glide into the bladder. If any difficulty be experienced, the instrument should 912 DISEASES OF URETHRA AND URINARY FISTULA. be slightly AvithdraAvn, and re-advanced Avith its point held more closely to the roof of the canal. The points requiring special attention are, to avoid the lacuna magna, to keep the handle of the instrument doAvn until its point is Avell beneath the pubis, and to combine the progressive and curving motions in a slow and gentle sweep, so that the beak of the instrument may IoIIoav the normal course Fig. 502. (f A, Introduction of the catheter. (Voillemier.) of the urethra, which the surgeon must constantly bear in mind. Above all, the surgeon must avoid the use of force. If the resistance be from spasm, this will yield to very gentle pressure ; if from congestion and engorgement of the prostate, from excessive development of the uvula vesicae, or from the presence of a bar at the neck of the bladder, it may be necessary to employ a prostatic catheter; Avhile if from organic stricture, a smaller instrument must be used. Under no circumstances should the surgeon attempt to overcome the obstruction by violence, for the walls of the urethra are readlily lacerated, and a false passage is very easily made ; whereas, in the words of Sir Henry Thompson, "temper, patience, and a light hand will overcome almost all cases of difficulty." Instead of oiling the catheter, it is INTRODUCTION OF THE CATHETER. 913 sometimes better to distend the urethra with oil, throAvn in with an ordinary penis-syringe.1 If the patient be very fat, difficulty may be experienced in bringing the catheter to the median line of the body Avithout prematurely elevating its handle, and under these circumstances a manoeuvre knoAvn as the " tour de maitre" should be adopted. This is, indeed, a very convenient mode of catheterization, and I often employ it instead of the ordinary method. The surgeon stands on the riglit side of the patient, and introduces the catheter with its convexity upwards and its shaft lying obliquely across the patient's left thigh ; as the point of the instrument reaches the bulb, the handle is SAvept around tOAvards the abdomen—Avhen the beak enters the membranous portion of the urethra, and is carried into the bladder by depressing the shaft between the patient's thighs in the way already described. One or other of these plans is to be adopted in using metallic catheters or sounds, and English flexible catheters and bougies. To employ either of the latter with satisfaction, the surgeon must haA'e at hand two basins, one of hot Avater and the other of cold. The instrument is moulded to the proper curve in the first, and then instantly plunged into the other, by Avhich method its curvre is fixed and will remain unchanged long enough for ordinary pur- poses. If, hoAvever, there be much delay in the introduction, the Avarmth of the urethra will again soften the instrument, and it will lose its curve. The English catheter should, as a rule, be used without the stylet. The object of the latter is not to aid in the introduction of the instrument, but to enable the surgeon to give it a permanent curve by keeping it on the stylet Avhen not in use. When the catheter Avithout the stylet is not sufficiently firm, a metallic instrument will commonly be safer and more efficient. If, hoAvever— in a case of enlarged prostate, for instance—it be necessary to leave the cathe- ter in the bladder, the metallic instrument is undesirable, and it may then be necessary to introduce the flexible catheter with the stylet, the latter being, of course, AvithdraAvn as soon as the catheter is in place. The French instrument is introduced by simply pushing it gently in the line of the urethra." It is impossible to guide its point, Avhich will, however, unless in cases of great obstruction, readily find its own way into the bladder. The French catheter is, unfortunately, a perishable form of instrument, and is with difficulty kept in order in warm climates. A great difference of opinion prevails among surgeons as to Avhich is the best, the flexible or the metallic instrument; it is commonly said that though a gum catheter may be the safest in the patient's oavii hands, yet that, for the surgeon, an undeviating instrument is preferable ; such was formerly my OAvn opinion, but increasing experience has convinced me that Sir Henry Thomp- son is rkht in declaring that for all ordinary cases the flexible catheter is quite as easy of introduction as, and much less dangerous and painful to the patient than, the metallic. In dealing, however, with some very tight stric- tures, a silver catheter may undoubtedly be preferable to any other, Avhile, again, in the later stages of dilatation, use may properly be made of finely polished conical steel sounds ; in fact, in this as in most other departments of surgery, the practitioner will do wisely not blindly to follow one exclusive method, but to vary his remedies according to the exigencies of each par- ticular case. Before using any catheter, whether flexible or metallic, the surgeon should carefully examine into the condition of the instrument; from neglect of this precaution the end may be broken off in the bladder, and form the nucleus of a calculous concretion. 1 Dr. Tytler, of Manchester, suggests inflation of the urethra, either with Politzer's bag or by the successive injection of carbonate of sodium and tartaric acid. 58 914 DISEASES OF URETHRA AND URINARY FISTULA. Posterior Catheterization is a name employed by Volkmann for a mode of treatment advocated by Yerguin, Hunter, Brainard, and Ranke, and which consists in opening the bladder above the pubis, and passing a catheter through the wound and into the urethra from its vesical extremity. The Endoscope__This consists of a somewhat conical metallic tube, straight for the urethra, and beaked like a vesical sound for the bladder, Avith an eye-piece, an illuminating apparatus, and an arrangement of mirrors, by which a strong light can be thrown upon Avhatever touches the end of the tube. This mode of exploring the internal cavities of the body appears to have suggested itself to Borrini, in the beginning of this century, and subse- Fig. 503. Desormeaux's endoscope. quently to Segalas, Bombolzini, Fisher (of Boston), and Avery, but was first practically introduced to the notice of the profession by Desormeaux ; modi- fications of the instrument have since been proposed by Cruise, Warwick, Wales, and others, simplifying the apparatus, and permitting the employment of sunlight instead of artificial illumination. Though changes of color in the urethral mucous membrane are readily recognized with the endoscope, it has not been found to add much to the information which can be acquired by careful exploration with the sound or catheter, and has proved less useful in practice than was at first anticipated. Malformations of the Urethra. The urethra may be partially or completely occluded, or may be partially deficient, an abnormal opening existing on its upper or lower surface. AVhen the opening is above, the deformity is called epispadias, and when below, hypospadias. MALFORMATIONS OF THE URETHRA. 915 Partial Occlusion, or Congenital Narrowing of the Urethra, occurs at or near the external meatus; the treatment consists in restoring the calibre of the part by an incision Avith a probe-pointed bistoury, recontraction being prevented by the subsequent use of a bougie, or, as advised by Weber, by dissecting the skin from around the orifice, and then splitting and everting the mucous membrane which is subsequently attached by several points of suture, as in Ricord's mode of amputating tbe penis. Complete Occlusion of the Urethra produces retention of urine which usually proves fatal within a few hours of birth: if the condition should be recognized during life, the occluding membrane, Avhich is usually but a few lines in thickness, should be divided with a sharp bistoury or punc- tured with a trocar and canula, the opening being maintained by the occa- sional passage of a bougie. Should the point of occlusion be so far back as to render it impossible to reach it from the meatus, it would, I think, be the surgeon's duty to open the urethra behind the seat of obstruction, if this could be done from the perineum, or to puncture the bladder by one of the operations which have already been described. Epispadias, or Deficiency in the Roof of the Urethra, may be complete or partial. Complete epispadias is seldom met with except in connection with exstrophy of the bladder ; the latter deformity having been remedied in the Avay already described, the epispadias may be relieved by a plastic opera- tion, as has been done by J. Wood (see page 892). Partial epispadias is but a lesser degree of the same deformity, the abnormal opening extending from near the pubes to the end of the penis; it may be treated in a similar manner, by turning doAvn a narrow flap from the hypogastric region, and covering it in Avith a bridge of skin dissected from the scrotum. This opera- tion, Avhich originated Avith Nekton in 1So2, has been since repeated, both by himself, by Follin, and by J. Wood, Avith good results ; it is the operation after Avhich was modelled Richard's method of treating exstrophy of the bladder (see page fS'JO). Hypospadias, or Deficiency in the Floor of the Urethra, is a compara- tively common affection. The abnormal opening, which is usually much smaller than that of epispadias, is commonly found at the base of the franuni, more rarely at the point of junction of the penis and scrotum, and occasionally, it is said, in the perineum. Complete hypospadias, associated with cleft scrotum, constitutes one form of hermaphrodism, so called. When the opening is placed far back, the deformity, beside causing in- convenience in micturition, in- terferes with the ejaculation of semen, and thus renders the pa- tient practically sterile; under these circumstances the malfor- mation (which is usually unim- portant) may call for surgical treatment, which consists in endeavoring to restore Avith knife or trocar the natural passage from the meatus to the urethra above the hypospadiac orifice—the latter being subsequently closed by a Hypospadias Duplay's method. 916 DISEASES OF URETHRA AND URINARY FISTULA. plastic operation such as will be described under the head of urethral fistula, or in making a neAv urethra by one of the ingenious operations devised by Bouisson, Moutet, Anger, and Duplay, of France ; J. Wood, of London; and Gouley, of New York. Of these, the best are, I think, Wood's and Du- play's—the former consisting in inverting a flap from the loAver suiface of the penis and scrotum, and covering it in Avith a saddle-shaped flap taken from the prepuce, and the latter in inA'erting flaps from the lower surface of the penis and covering them in Avith others taken from the sides of the organ, a dorsal incision being made if necessary to relieve tension (Fig. o04). In cases of glandular hypospadias Avith great contraction of the orifice, I have employed Avith much advantage Weber's operation for partial occlusion of the urethra. Prolapsus of the Urethra. This is said by Guersant to be a not unfrequent affection in female chil- dren. The prolapsus, which results from straining efforts in coughing or in defecation, forms a rose-colored tumor at the urinary meatus, apparently pro- ceeding from the interior of the canal, but, having in its centre an opening Avhich admits the catheter and thus reveals the nature of the affection. If unrelieved, the prolapsus leads to vulvitis, and gives rise to a burning and smarting sensation in the act of micturition. The treatment recommended by Guersant is excision Avith curved scissors, hemorrhage after the operation being checked by the application of the perchloride of iron or ice. The use of the galvanic or actual cautery is advised by Skene, of Brooklyn. Cha- morro, a Spanish surgeon, records a case occurring in an adult and at first mistaken for prolapsus of the Avomb. Rest in bed and the use of astringents rendered reduction possible. Streubel and Blum have also observed the affection in adults. Urethrocele. In this affection, which is only met with in females, the Avail of the urethra becomes much thickened, and forms a pouch Avhich projects betAveen the labia, allowing the retention of a considerable quantity of urine, and eventually lead- ing to cystitis and ulceration of the bladder. The treatment recommended by Bozeman, avIio has given a good account of the affection, consists in tapping tbe cystocele at its most dependent point. Skene mentions a case cured by dilatation of the urethra and the injection of nitrate of silver. Gillette re- lieved his patient by denuding the anterior vaginal wall and bringing the edges of the wound together Avith stitches, wliile Lawson Tait was equally successful by cutting away the base of the sac, dissecting out its mucous lining, and then bringing together the edges of the vaginal Avound. Urethritis. Inflammation of the Urethra may arise from injury, from gastric or intes- tinal disorder, from exposure to cold, from the contact of irritating injections, from an acid or ammoniacal condition of the urine (as in cases of long-stand- ing stricture or prostatic enlargement), from onanism, from prolonged or violent coitus, or from contact Avith the menstrual fluid or Avith leucorrhoeal or gonorrhoeal discharges. Whatever its origin, its course and symptoms are the same, and it requires the same treatment. This has already been de- scribed at page 423. SPASM OF THE URETHRA. 917 Spasai of the Urethra. Spasm, or, as it is usually called, Spasmodic Stricture of the Urethra, rarely occurs except as a complication in cases of permanent or organic stricture, or in those of inflammation of the urethra. I do not mean to deny the frequent existence of muscular contraction in a healthy urethra, which is indeed often felt closing around a catheter or bougie, the canal, as it were, grasping the instrument; but it is \Tery seldom, indeed (except in the cases mentioned), that this contraction is sufficient to materially hinder the flow of urine, or to impede the entrance of a catheter. The chief causes of spasm, beside organic stricture and urethral inflamma- tion, one or both of Avhich are present, in the large majority of instances, are (1) the irritation caused by the impaction of a calculus, by an acid or ammo- niacal condition of the urine, or by certain substances Avhich are eliminated by the kidneys, as the oil of turpentine, Spanish fly, and some varieties of wine or other liquor; (2) voluntary neglect to empty the bladder at the right time ; (3) exposure to cold; (4) immoderate indulgence in coitus; (5) diseases of or operations on the loAver boAvel; and (G) disorders of the digestive appa- ratus or of the nervous system. To the latter cause is to be referred the urethral spasm, sometimes culminating in temporary retention, Avhich occurs in the course of fevers, or after severe traumatic injuries or surgical opera- tions. Usually an attack of spasmodic retention is traceable to a combination of causes; thus it not unfrequently happens that a patient with slight organic stricture, or slight urethral or prostatic inflammation, dining out or joining some party of pleasure, and indulging more freely than usual in the delights of the table, perhaps also neglecting to obey the call of nature at the proper time, finds at length, when an opportunity to empty the bladder is presented, that the power of micturition is gone. Slight spasm may occur at any part of the canal, but the common seat of the affection is at the membranous por- tion, from the action of the compressor urethras muscles. The symptoms of spasm of the urethra are the sudden occurrence of great diminution in the size of the stream, with great pain and straining in the act of urination, which is often accompanied Avith a feeling of Aveight and fulness in the perineum, and Avith irritation of the lips of the meatus, showing that Avith the spasm there exists a certain degree of urethral and prostatic inflam- mation. The treatment varies according as there is or is not complete retention. In the latter case, relaxation of the spasm may usually be induced by the administration of an enema of laudanum, and by placing the patient in a Avarm bath, a full dose of castor oil being given as soon as the bladder is relieAed. Another remedy Avhich has acquired a good deal of reputation in these cases, is the muriated tincture of iron, given in doses of ten or twenty minims every quarter of" an hour. The introduction of lumps of ice into the rectum is recommended by Cazenave and Teevan. The recurrence of spasm must be obviated by seeking for and removing the cause, and by attention to the state of tbe general health. When there is great acidity of the urine, alkalies may be administered, such as the bicarbonate of sodium, or the liquor potassae, in combination with tincture of hyoscyamus and spirit of nitrous ether. If, as is usually the case, there is some permanent constriction of the urethra, this must be remedied by the systematic use of bougies. In a case of complete retention of urine from spasm of the urethra, it is, I think, better to resort at once to the catheter. Apart from the patient's suffering, Avhich is extreme, there is positive risk in alloAving the bladder to remain distended; atony of this organ, or cystitis, with all its consequences, 918 DISEASES OF URETHRA AND URINARY FISTULA. may result, or rupture of the urethra, or even of the bkdder itself, may fol- low, leading to urinary extravasation, or even to fatal peritonitis. A rather small catheter—No. 11 or 12 (French)1—should be employed; and a gum- elastic is commonly preferable to a metallic instrument, as producing less pain. If catheterization fail, the patient should be put into a hot bath, opium administered, and (if there be much inflammation) leeches applied to the perineum, Avhen the bladder will either relieve itself, or it will be found that the instrument can be readily' introduced. Severer measures, such as opening the urethra in the perineum, or puncture of the bladder, can only be required when the spasm is a mere complication of tight organic stricture, or of decided enlargement of the prostate. Brodie and Thompson have each recorded a case in which urethral spasm occurred periodically, and ultimately disappeared under the use of quinia. Coxgestia'e Stricture. The term is ordinarily, but incorrectly, applied to the temporary interfer- ence Avith the flow of urine which is due to inflammatory swelling of the prostate and adjacent parts. It is, in fact, a condition of subacute prosta- titis, a disease which, as already mentioned, seriously impedes micturition, and occasionally produces absolute retention (p. 901). It is not unfrequently observed as a complication of gonorrhoea, caused by exposure to cold, or by imprudence of various kinds. (See p. 426.) When occurring in cases of organic stricture or enlarged prostate, spasm is often superadded^ The treat- ment consists in the administration of laxatives, with laudanum enemata, and the hot bath. Leeches to the perineum will often be of service. If the urine be unduly acid, alkalies may be given, and strict attention should be paid to the state of the patient's general health. If gonorrhoea be present, this must be treated in the way described in previous pages, and benefit will often be derived, under these circumstances, from the occasional introduction of a bougie. The catheter may be required if absolute retention should occur. Stricture of the Urethra. Stricture of the urethra, or, as it is often called, in contradistinction to the temporary forms of obstruction last mentioned, Permanent or Organic Stric- ture, may result from long-continued urethritis (whether gonorrhoeal or other- wise), from mechanical injury ( Traumatic Stricture), or from the contraction Avhich attends the healing of chancroidal or other ulcers. The congenital defect which has been already described as Partial Occlusion of the Urethra, is sometimes not detected until adult life, Avhen it may, for all practical pur- poses, be regarded as a form of organic stricture. Age — Traumatic stricture may occur at any age. I have seen one case in a boy of 11, avIio died from urinary extravasation following the giving Avay of the urethra behind the seat of stricture. This case, Avhich Avas one ofkreat interest, has been fully reported by Dr. Charles C. Lee, of New York.2 CThe other forms of stricture, of which the gonorrhoeal is by far the most common, are rarely, if ever, met with before the age of puberty ; and, as several years usually elapse betAveen the occurrence of the gonorrhoea and that of the "stric- ture to which it gives rise, the latter is most commonly observed for the first time in men from 25 to 40 years of age. 1 The numbers given in this chapter refer to the French scale, or " Charriere- fibere." 2 American Journ. of Med. Sciences, July, 18G2. p. 108. STRICTURE OF THE URETHRA. 919 Locality.—The seat of stricture is, in the large majority of cases (over tAvo-thirds), at the sub-pubic curvature of the urethra. This has been con- clusively established by the laborious and careful investigations of Sir Henry Tliompson. The most common position is at the posterior or bulbous part of the spongy portion of the canal (Fig. f>05), the liability of the urethra to con- striction diminishing as it is traced backAvards. The next most frequent seat Fig. 505. Fig. 506. Section of urethra, showing very narrow stric- Strictures near the orifice of the urethra. ture, and dilated and reticulated membranous and (Thompson.) prostatic portions behind it. (Thompson.) of stricture is at, or within two and a half inches of, the meatus, and after this comes the central part of the spongy portion. Stricture in the posterior part of the membranous portion is very rare, Avhile in the prostatic portion it probably never occurs, though the contrary has been maintained by very eminent authorities. Number.—Usually—in more than three-fourths of all cases—there is but one stricture, but occasionally tAvo or three distinct constrictions are found in the same urethra, and cases are described in which there are said to have been still larger numbers. When several strictures coexist, one is almost invariably found at the sub-pubic curA'e. Morbid Anatomy__The tissue chiefly affected is the submucous areolar tissue, which, as the result of the inflammatory process, becomes the seat of lymph-formation, partial organization following, and gluing together the mucous and submucous tissues, and often involving the substance of the corpus spongiosum. The contraction Avhich ensues diminishes the calibre of the canal, often throAving the lining membrane of the urethra into folds or ridges, and at the same time lessens the natural elasticity of the part, and, of course, seriously impedes the exercise of its functions. Another form of stricture is described by some writers, as consisting in the deposit of a pseudo-membranous substance on the mucous membrane itself. Such a con- dition, if it exist at all, must be extremely rare. 920 DISEASES OF URETHRA AND URINARY FISTULA. Classification.—Strictures are variously classified, according to—1, their anatomical character; 2, the degree of contraction which they cause; and, 3, the symptoms which they present. 1. Classification according to Anatomical Character__(1.) A linear, bridle, pack-thread, or valvular stricture is one in wliich the obstruction is produced by a thick fold of mucous membrane perforated in the centre, or forming a crescentic septum at one side only of the canal, or passing across from one side to the other in the form of an isolated band or bands. These bands or frama are, according to Erichsen, probably formed artificially, by the perforation of a crescentic mucous fold with the point of a catheter. (2.) An annular stricture resembles the variety last described, except in the circumstance that the canal is obstructed for a greater extent, the appear- ance being that wliich would be produced by tying a string or tape around the urethra. (3.) Indurated annular stricture is the name given by Thompson to that form of constriction in Avhich the tissues around the canal are indurated to the depth of from half a line to a line. The contraction is usually greatest at the central portion of the stricture, giving the part an hour-glass appearance. The induration is commonly most dense at the floor of the urethra. (4.) Irregular or tortuous strictures embrace all the more complicated forms of the disease. 2. Classification according to Degree of Contraction__A Aery important classification of strictures, as regards their treatment, is into permeable and impermeable. In one sense of the word, every stricture is permeable; that is to say, no stricture is so tight but that a drop or tAvo of urine will occasion- ally find its way through ;l but that every stricture which alloAvs the passage of urine is, as has been asserted, necessarily permeable to a catheter or bou- gie, if used Avith sufficient skill and patience, I cannot admit. Doubtless one surgeon will succeed where another fails, but from all that I have seen, either in my OAvn practice or in that of others, I am prepared to fully indorse the statement of Prof. Bumstead, that no surgeon of any considerable experience can honestly maintain that he has never seen an " impassable stricture." Liston and Syme, avIio were the great advocates of the doctrine that no stricture was impermeable, Ave re both foiled in their later years in the at- tempt to pass an instrument, and eAren Sir Henry Thompson, avIio, in his clinical lectures, published in 1868, declared of the "operation for imper- meable stricture" (perineal section), that he had never had occasion to per- form it, and doubted if the necessity for it ever existed—in the third edition of the same Avork (1873) acknowledges that the general rule of permeability admits of a few exceptions, and confesses that he has thrice had occasion to perform the operation in question. 3. Classification according to Symptoms__Strictures are further classified, according to their symptoms, into the simple stricture, the irritable stricture, and the contractile or recurrent stricture. The significance of these terms will appear in the sequel. Symptoms of Stricture__One of the earliest symptoms of stricture, in many cases, is the presence of a slight gleety discharge ; there is, besides, pain in micturition, referred to the part of the urethra behind the stricture, and the calls to empty the bladder recur with increased frequency. The stream is diminished in size, and often altered in form, being curiously forked 1 Obliteration of the urethra may result from severe laceration ot the part, the urine all flowing through a fistulous opening in the perineum; but such a condition is not, properly speaking, a stricture. URETHRAL FEVER. 921 or divided. As a consequence of the small size of the stream, a longer time is required to empty the bladder, and the involuntary straining which at- tends the act often leads to great irritation of the rectum, with perhaps piles or prolapsus, and, in extreme cases, a discharge of the rectal contents Avhen- ever urination is attempted. Retention of urine may occur at any moment, from spasm or congestion, or from the occlusion of the narrow passage by a pellet of mucus or a calculous concretion, but more usually the stream grad- ually lessens until the urine escapes in drops, the bladder slowly becoming distended, until the condition described as retention with overflow is estab- lished. The retained urine undergoes decomposition, becoming ammoniacal, and producing cystitis with deposit of phosphatic matter. Hematuria is an occasional symptom of stricture, the blood being usually of urethral, but sometimes of vesical origin. Ulceration of the bkdder, or of the urethra behind the point of stricture, not unfrequently takes place, and, under these circumstances, rupture of the part may result from the straining efforts of the patient, leading to peritonitis or urinary extravasation. In other cases the ureters and pelves of the kidneys become dilated, and chronic renal disease1 supervenes. Abscesses often occur in the perineum, and more rarely in con- nection with the anterior portions of the urethra, leading to the formation of urinary fistube. There is, usually, not much constitutional disturbance in the early stages of stricture ; cases are. hoAvever, occasionally met with, in which grave ner- vous symptoms, with general depression, follow upon very trivial causes— such as the passage of a catheter, slight exposure to cold, etc. These symp- toms, which are grouped together under the name of urethral fever, are chiefly, but not exclusively, met Avith in cases of irritable stricture, so called, in Avhich catheterization produces great and persisting pain. In the advanced stages of stricture, the constitution ahvays suffers, the digestion being im- paired, and the patient becoming emaciated and feeble. When the kidneys are seriously affected, convulsions or coma may ensue. Urethral Fever is a not infrequent sequel of operations on the urethra, and may even occur after the simple introduction of a catheter. This affec- tion is said by Thompson to be most common among the inhabitants of warm climates. It is characterized by the occurrence of rigors (occasionally attended by syncope), Avith headache and vomiting, folloAved by febrile reaction. The symptoms, which sometimes return periodically, like the paroxvsins of intermittent fever, may immediately folloAV the introduction of the catheter, but are usually delayed until after the first subsequent act of micturition, and thus appear to be due to the contact of urine with the tender, and perhaps abraded, surface of the urethra. The affection rarely causes death, though it may do so, particularly in cases complicated by the existence of renal disease, possibly, as suggested by Thompson, from the sudden arrest of the function of the kidney. Urethral fever is occasionally folloAved by inflammation and suppuration of the joints, or of the muscular or areolar tissues, and, indeed, is in many respects analogous to gonorrhoeal rheumatism. It is, I believe, like that affection, a mild form of pyemia. (See page 430.) 1 The peculiar form of renal disease which is so often met with in cases of stricture and other obstructive diseases of the urinary organs as to have been called "surgical kidney," is described by Dr. Dickinson as disseminated sn/i/iin-ation of the kidney, a condition closely resembling the renal manifestation of general pyaemia. lie proposes the name uriseptic as applicable to this form of renal suppuration, believing that it results from the absorption of ammoniacal and putrid urine. Dr. Goodbart is dis- posed to look upon the surgical kidney as, in some instances at least, an erysipelatous affection. 922 DISEASES OF URETHRA AND URINARY FISTULA. It is maintained by Sedillot, Beltz, and other writers, that the occurrence of urethral fever is due to the absorption of urine, but this is at least not proved, while the fact that (1) the affection may and does occur in cases in which there is not the slightest reason to believe that any laceration of the urethra exists, and that (2), on the other hand, it does not occur in cases of urinary extravasation or infiltration (as after lithotomy), would seem to justify a contrary opinion. The treatment of urethral fever consists in the administration of nutritious food and stimulants, Avith tonics, especially quinia, and opium. The patient should be kept in bed, and great caution should be exercised in the employ- ment of instruments. As a prophylactic, in patients predisposed to attacks of urethral or (as Holt calls it) stricture fever, quinia and opium may be given at regular intervals after each introduction of the catheter. Diagnosis of Stricture__This is made by exploration Avith a sound or catheter, and may be aided in some cases by the use of the endoscope. When the existence of stricture is suspected, the surgeon should introduce a medium-sized catheter—No. 13 or 14 of the French scale—and if, on several trials, the instrument is invariably arrested at the same point in the mem- branous or spongy portion of the urethra, the fact that there is a stricture may be considered as established. It is important, in this exploration, to use a catheter of sufficient size, for a small one may lead to error on the one hand, by catching in a lacuna, or, on the other, by passing readily through the stricture, if this be not Aery tight. To ascertain the degree of contrac- tion Avhich exists, the surgeon may desire the patient to make water, Avhen the size of the stream will afford some information upon this point. It often happens, however, that the patient is unable, from a nervous feeling, to uri- nate Avhen asked to do so, and the surgeon must then try in succession smaller and smaller catheters, until one is found Avhich enters the constricted part of the urethra. In seeking for the mouth of the stricture, it is Avell to have some regular course of proceeding; the catheter is not to be thrust, blindly in various directions, but should be first carried along the roof the urethra, and in the median line, then to either side, and finally along the floor of the canal. By means of the bougie a boule, the surgeon can ascertain, not only the position and tightness of the stricture, but its extent as well. Formerly wax bougies Avere employed, with the notion that, by pressing the instrument against the stricture, a mould might be obtained that Avould sIioav its form and direction ; but this mode of exploration has not proved very satisfactory, and is rarely employed at the present day. Treatment of Stricture. The Constitutional Treatment of stricture should never be neglected. The diet should be regulated, and the digestive functions brought into a good con- dition. Cystitis, if present, should be treated in the Avay already described, and the general health maintained by the administration of tonics, and by attention to the hygienic state of the patient. Rest in bed for a few days is often a valuable preliminary to instrumental treatment, by relieving the con- gestion of the parts, and diminishing the tendency to spasm. II. Lee believes that many strictures are of syphilitic origin, and for such recommends the administration of mercury. The Local Treatment embraces the application of various methods, Avhich may be classified under the five heads of dilata- tion, rupture, the use of caustics, and internal and external incision. The use of caustics in the treatment of stricture is rarely resorted to at the pros- TREATMENT OF STRICTURE BY DILATATION. 923 ent day, having been properly superseded by other and safer methods. The articles which have been chiefly employed are the nitrate of silver and the potassa fusa, the cauterizing agent being applied by means of an instrument resembling a catheter with a cup-like depression at its beak, or being simply fixed on the end of a Avax bougie. Amussat has recently advocated a modi- fication of this mode of treatment, consisting in the employment of the galvanic cautery applied to the strictured part by means of suitable electrodes. I shall consider the treatment of stricture under the heads of permeable stricture, impermeable stricture, and stricture complicated with retention of urine. I. Treatment of Permeable Stricture. This may be conducted by means of—1, gradual dilatation ; 2, continuous dilatation ; 3, rapid dilatation, or rupture ; 4, internal urethrotomy ; and 5, external perineal urethrotomy with a guide (Syme's operation). 1. Gradual Dilatation is by far the best mode of treatment in any instance in which it is applicable, and should be given a fair trial in every case of permeable stricture. An instrument (usually a flexible one) of suf- ficient size to enter and be fairly grasped by the stricture, should be employed Avithout using such force as to cause pain or lead to hemorrhage ; such an instrument having been carried through the stricture and passed into the bladder, may be allowed to remain for a few seconds, Avhen it should be gently Avithdrawn.1 After a feAV days, it may be passed again and followed by a larger instrument, this process being continued until the urethra has, in the course of a fortnight or so, been dilated sufficiently to receive a No. 20 or 22 French catheter, which will be found, in ordinary cases, as large as the canal can accommodate.2 The dilatation must be subsequently maintained by the introduction of the catheter at gradually lengthening intervals. The mode in wliich gradual dilatation effects the cure of a stricture, is probably by inducing absorption of the imperfectly organized lymph which infiltrates the submucous tissue. 'This plan of treatment will be found satisfactory in the majority of cases of gonorrhoeal stricture. The great requisites for success are gentle manipulation and patience : no violence is to be used, lest a false passage be made ; but the instrument is to be gently engaged in the mouth of the stricture, and held there Avith the slightest pressure for a few minutes, when it will ordinarily slip through ; if not, it should be withdraAvn, and^ a smaller one substituted. The dilatation must also be very gradual ; if a No. 10 has been passed at one visit, it will be quite sufficient to get in a No. 11 or 12 at the next, and no advantage can be derived from attempting to progress more rapidly; for, by so doing, an attack of urethral fever may not improb- ably be induced, Avhich, besides endangering the patient's life, necessitates an abandonment for the time of all treatment for the relief of the stricture. False Passages result from the employment of too much force, particularly in the use of small metallic instruments ; the usual situation of false passages 1 Bardinet recommends that the instrument should be constantly moved backwards and forwards so as to effect an " internal massage" of the stricture—a mode of treat- ment which I cannot approve. 2 Dr. Otis, of New York, and some other surgeons, believe that the dilatation ot the urethra should be carried to a much greater extent, and Dr. Otis has devised an ingenious urethrometer for determining what he considers the normal calibre ot the tube; I hope that I may not be considered as hopelessly wedded to conservatism, when I express the opinion that a stricture-patient who can pass a No. 21 or ^ catheter without suffering had better rest and be thankful. 921 DISEASES OF URETHRA AND URINARY FISTULA. Fig. 507. is at the lower part of the urethra, and to one or other side. At the moment of the instrument's deviating from the proper channel, the patient feels a sharp pain, and is usually conscious of something having given Avay ; the surgeon at the same time perceives that the instrument has slipped from the urethra, by the grating sensation which is produced ; and upon placing the finger in the rectum, probably feels the instrument in close proximity to tbe intes- tinal Avail; if a catheter has been used, blood is pumped through it at every motion, and, whatever instrument has been employed, rather profuse hemor- rhage may folloAV its Avithdrawal. Should the sur- geon be so unfortunate as to make a false passage, he should, if possible, introduce a catheter into the bladder, by keeping its point closely to the roof of the urethra, leaving it in place for a few days, until the laceration has had time to heal. Even if this cannot be done, there is, however, not much risk of urinary extravasation occurring, doubtless on account of the false passage running in the opposite direction to that of the outfioAving stream. Old false passages often give a great deal of trouble in the treatment of strictures by dilatation, the catheter tending con- stantly to slip into the Avrong channel. This may be obviated by using a well-curved instrument, and by keeping its point aAvay from the orifice of the false passage, the position of which is soon ascer- tained ; assistance may be also derived by tilting up the beak of the instrument by pressure with the finger introduced into the rectum. False passages. (Druitt.) 2. Continuous Dilatation__This requires the confinement of the patient to bed ; it is effected by introducing a catheter, which is then secured in the bladder, and replaced in the course of a couple of days by a larger one, and so on until sufficient dilatation has been accomplished. This is an efficient mode of treatment for cases in Avhich catheterization gives great pain (^irritable strictures), or in Avhich the stricture manifests a tendency to recontract after ordinary dilatation (contractile or recurrent strictures). It may also be properly employed when, from the existence of false passages or other circumstances, special difficulty has been experienced in the first intro- duction of the instrument. In the employment of continuous dilatation flexible catheters are invariably to be preferred. Under the name of the " multiple-wedge treatment," Dr. J. S. Coleman, of Augusta, Georgia, recom- mends the introduction of several small bougies, side by side, as an efficient means of practising continuous dilatation. 3. Rapid Dilatation or Rupture__The methods Avhich are included under these heads may be properly classed together, as the differences in their modes of action is one of degree rather than of kind. Desault, Buchanan, Ilutton, Maisonneuve, and Wakley, endeavored to effect rapid dilation of urethral strictures by introducing first a narroAv sound or catheter as a guide, and then sliding over it tubes of gradually increasing sizes. Wakley's instru- ment, Avhich is probably the best of this kind, consists of a small silver catheter which is first introduced into the bladder, a steel rod being then screAved into its outer extremity, so as to form an unerring guide over which the dilating TREATMENT OF STRICTURE BY RUPTURE. 925 tubes of gum-elastic or silver are subsequently passed. Fluid pressure,1 effected with a dilator constructed of silk and catgut, and capable of disten- sion by means of a syringe, Avas long ago employed by Arnott, and has been more recently resorted to by Steurer, of NeAv York, Avhile the expanding properties of the laminaria digitata have been utilized by Reeves, Newman, and others; but, upon the Avhole, the best means of effecting rapid dilatation is by using instruments consisting of tAvo or more blades, Avhich can be made to diverge Avhen in the urethra by a screAV arrangement in the handle, or by introducing betAveen them plungers, which acton the principle of the Avedge. Luxmoor (in 1*12), Civiale, Leroy d'Etiolles, Perreve, Lyon, Pancoast, Thebaud, Yoillemier, B. Wills Richardson, and others, have devised ingenious instruments for carrying out this object, but I shall only describe tAvo, viz., Sir H. Thompson's instrument for " over-distending," and Mr. Holt's for " splitting" strictures. Thompson's instrument consists of tAAro blades, Avhich are joined at either end, and Avhich can be separated at an intermediate point by turning a screw Fig. 508. Thompson's stricture expander. in the handle; an index serves to show the extent to which expansion has been carried, the figures corresponding to the numbers of the English catheter scale. The distending force is to be applied rather slowly, so as to overstretch rather than rupture the morbid tissues, and when the instrument is Avithdrawn, a full-sized gum catheter is passed, and alloAved to remain tAventy-four hours. Dilatation is subsequently maintained by the occasional introduction of a large sound. Holt's instrument (a modification of Perreve's), in its present improved form consists of two blades joined at their loAver extremity, and fixed in a Fig. 509. Holt's instrument for splitting strictures. handle containing a screAV which can be set so as to limit the amount of ex- pansion. A guiding rod (made IioIIoav so as to serve for a catheter, and furnished Avith a stylet to keep it free from clots) passes between the blades, and when the instrument is introduced, a dilating tube, or plunger, of the required size, is slipped OA*er the guide and quickly thrust down in such a Avay as to split or rupture the stricture ; the plunger is next rotated upon the guiding rod, to insure separation of the split, when the Avhole instrument is removed, and the Avater drawn off with a full-sized catheter; no instrument is left in the bladder in ordinary cases, but a catheter is passed every other day for a Aveek, and afterAvards at longer intervals. The patient should go to bed after the operation, and take two grains of quinia with ten minims of 1 Coze, of Strasbourg, employs fluid pressure, by bringing the weight of a column of water to bear directly upon the face of the stricture by means of an apparatus similar to the ordinary Weber's or Thudichum's douche. A similar plan is employed by Dr. Hadden and Dr. Golding, of New York. 926 DISEASES OF URETHRA AND URINARY FISTULA. laudanum, every four hours until six doses have been taken. Mr. Holt be- lieves that by tiiis instrument the submucous tissue is split, but the mucous membrane of the urethra itself uninjured ; but that such is not ahvays the case, is shoAvn by the fact that the operation is occasionally folloAved by rather free bleeding. My own experience with Holt's method is limited, but, so far as it goes, is favorable. I regard it as an excellent mode of treatment in cases of dense cartilaginous stricture of the sub-pubic region, as Avell as in those of the irritable and contractile varieties. It is, however, not free from risk, urethral fever and death having occasionally followed its employment. Until within a few years, the application of either of these methods Avas necessarily delayed until the stricture had been dilated sufficiently to admit the instrument, Avhich could not be made of a smaller size than a No. 8 or 9 French catheter; but it is noAv possible, by resorting to certain ingenious modern contrivances, to employ the over-distension or rupture treatment at once, for any stricture which is permeable to the smallest filiform bougie. One method, originally suggested, I believe, by Prof. Van Buren, of New York, and Avidely popularized by Dr. Gouley, of the same city, consists in obliquely perforating the extremity of the instrument which is to be used, so as to make an " eye" by Avhich it can be threaded over a delicate Avhalebone bougie, previously introduced ; Avhile in the other plan, which is attributed by Van Buren to Maisonneuve, and which has been extensively employed by Bumstead, the surgeon makes use of an ordinary filiform gum bougie pro- vided Avith a metallic cap, which can be screAved on to the extremity of whatever instrument is to be employed; the bougie being introduced, the instrument is attached to its end, and is thus readily guided tlirough the stricture, the bougie itself passing on and becoming coiled up in the bladder. 4. Internal Urethrotomy__This mode of treatment, which was employed by Allies and Physick, in the last century, and by John and Charles Bell, in the early part of this century, is particularly applicable to strictures in the anterior part of the urethra, but may also be used for those situated in the sub-pubic region—though for such, the treatment by rupture is, I think, preferable. For strictures at or near the external meatus,1 a probe-pointed bistoury guided by a small, straight staff, or grooved'director, will answer every purpose, but for strictures in other localities more compli- cated instruments are required. These, Avhich are called urethrotomes, Avhat- ever their exact form (and a great many have been invented by different surgeons), consist essentially in a sound or catheter carrying a concealed blade, which can be made to project by means of a spring in the handle, and which is designed to cut from before backwards, from behind forwards, or in both directions. Fig. 510. Civiale's urethrotome. Urethrotomy from Behind Forwards, with such an instrument as Civiale's (Fig. 510), is, upon the whole, the safest method, but requires previous 1 For strictures at the meatus, B. Wills Richardson employs an operation devised many years ago by Colles, of Dublin, and very analogous to that more recently recom- mended by Weber in cases of congenital occlusion of the part. (See page 915.) URETHROTOMY. 927 dilatation of the stricture, up to the calibre of a No. 8 or 9 French catheter: it is particularly applicable to strictures in the penile portion of the urethra. Civiale's instrument has been ingeniously modified by S. W. Gross, and by Kinloch, of Charleston. Urethrotomy from Before Backwards can only be safely performed by first introducing a guide through the stricture. Many urethrotomes of this kind are noAv before the profession, including those of Maisonneuve, Wood, Thomp- son, Trelat, F. N. Otis, Hill, Durham, Teevan, Mastin, Giberson, and Pritch- ett. These instruments vary in their details, but all act by first securing the introduction of a guide upon Avhich is subsequently passed the blade AA°hich divides the stricture. Some combine cutting with dilatation, Avhile others allow the surgeon, if he think proper, to enlarge the incision as the urethro- tome is AvithdraAvn. "Whatever method be employed, the incision should, I think, be made on the lower and not the upper side of the stricture ; a flexible catheter should be kept in the bladder for tAventy-four hours, and dilatation subsequently maintained by the occasional passage of a sound. Internal urethrotomy may be performed in the same classes of cases as Holt's opera- tion ; but the latter is, I think, to be preferred for strictures Fig. 511. behind the scrotum, the former being reserved for those situated anteriorly. In the after-treat ment of these cases, Otis employs dry cold applied by Petitgand's method of " mediate irrigation" (p. 56). 5. External Perineal Urethrotomy with a Guide, or the Operation by External Division or Ex- ternal Incision (Syme's Method), is very commonly con- fused1 Avith the old operation of perineal section, Avhich is, hoAvever, only applicable to cases of impermeable stricture, Avhereas, a prerequisite for this method (which Avas intro- duced by Prof. Syme in 1844),2 is that a staff shall be passed through the stricture into the bladder. Syme's staff varies in size from that of a No. 5, to that of a No. 12 French catheter, and is grooved at the lower third on its convex surface ; at the point where the grooved portion joins the rest of the shaft, there is a distinct shoulder, t Syme's staff,forex- , . , . , , x . r ,. . . ' ternal division of ure- which is made to rest against the face ot the stricture, and thrai stricture. thus guide the surgeon in his incisions. The operation is thus performed : the patient, being etherized, is secured in the lithotomy po- sition, and the staff introduced (in the case of a very tight stricture, by either of the methods described at page 92f>);3 the surgeon then makes an incision 1 A good deal of this confusion is, I think, owing to the fact that Prof. Syme reported as examples of his own operation, several cases, in Avhicli, having failed to introduce his staff, he cut into the perineum, guiding the subsequent course of the instrument by placing his finger in the wound. By so doing he really converted the operations into old-fashioned perineal sections, the only difference being that he cut down upon a small staff instead of a large one, and then slipped the same small staff through the stricture, instead of substituting a grooved director. 2 A similar procedure had been previously resorted to, and Avas described by Desault as one variety of the " boutonnitre," but to Syme is due the credit of making the ope- ration generally known, and of indicating the circumstances under which it should be employed. 3 In order to avoid the entrance of the staff into a false passage, Prof. Gouley pro- ceeds as follows : The urethra being filled with olive oil, an attempt is made to intro- duce a probe-pointed whalebone guide, the point of which is rendered temporarily spiral by immersing it in boiling water, twisting it around a small staff, and suddenly 928 DISEASES OF URETHRA AND URINARY FISTULA. about an inch and a half in length,1 exactly in the median line of the peri- neum, and feeling for the staff, introduces the knife, with its back towards the rectum, into the urethra behind the stricture, which is then divided by cutting in the groove of the instrument from behind forAvards. A broad grooved director is then slipped into the bladder, and upon this, as a guide, a No. 13 or 11 catheter introduced and secured in the usual AAray ; the instru- ment is retained for a couple of days, after Avhich a sound must be occasion- ally passed to prevent recontraction ; the perineal wound usually heals Avithout difficulty. Syme subsequently gave up the introduction of a catheter through the urethra, substituting a short perineal tube, so as to afford a free outlet for the contents of the bladder, Avhile Yan Buren, Gouley, and other American surgeons, have gone still further and have dispensed with the catheter alto- gether. The results of this operation are, on the Avhole, very satisfactory ; 219 cases, collected by Thompson, sIioav a mortality of less than 7 per cent., wliich is a small death-rate in vieAv of the nature of the cases in which it is ordinarily performed. The operation by external division is particularly indicated in cases of dense and cartilaginous stricture (particularly when of traumatic origin), and of irritable or contractile stricture, Avhen complicated by the existence of per- ineal fistule. In cases, however, in Avhich there is no fistula, Holt's opera- tion is, I think, usually preferable. Syme's method Avas also recommended by its distinguished author for the treatment of strictures in the anterior part of the urethra, but for such cases internal urethrotomy seems to me a better method. II. Treatment of Impermeable Stricture. Cases are occasionally met with in Avhich, from traumatic causes, the urethral canal is at some part totally obliterated, the urine escaping altogether through a fistula behind the point of injury ; beside these cases, there are others Avhich are more properly called strictures, in which, though a few drops of urine make their Avay through the meatus, yet no instrument, not even a filiform bougie—can be introduced. For such cases Boyer, and afterwards Mayor, recommended forced catheterization (a proceeding Avhich Avas attended Avitli the gravest risks, and is now happily almost entirely abandoned), wliile Stafford proposed to cut through the impassable stricture with a •' lancetted catheter." This plan might perhaps be adopted if a stricture in the anterior part of the urethra Avere so tight as to forbid the safer operation of internal urethrotomy. Such a case must, however, be extremely rare. The applica- tion of electricity by means of an electrode pressed against the face of the stricture has been occasionally employed Avith advantage, and might be tried if the patient objected to more radical measures. There remain to be described the Operation for Impermeable Stricture, Perineal Section, or, as it is more accurately called by Prof. Gouley, External Perineal Urethrotomy without a Guide, and the operation recently recom- cooling it. If the point of the guide becomes engaged in a lacuna, it is slightly Avith- drawn and carried onward with a rotatory movement. If it enters a false passage, it is retained in. situ with the left band, while another is passed by its side, this pro- ceeding being repeated until tbe false passage is filled up, when at last one guide enters the bladder ; the others are then withdrawn, and an "eyed catheter staff" threaded over that which is retained, in the way described at page 926. 1 H. Dick suggested subcutaneous division of the stricture, the introduction of the knife being guided by the use of a staff provided with bulbs which could be felt through the tissues of the perineum, and modifications of the subcutaneous method have been recently employed by Mastin, of Mobile, and by Teevan, of London. PERINEAL SECTION. 929 mended by Mr. Cock. The first is often spoken of as the boutonniere or button-hole incision; but that name appears, from the writings of Desault, to have been indiscriminately applied by French surgeons to any or all opera- tions which had for their object the establishment of an opening from the perineum into the bladder, and thus would include (beside the ordinary per- ineal section) the " external division" o£ Prof. Syme, Cock's operation in which the urethra is opened behind the stricture, and even the now obsolete procedure of puncturing the bladder through the perineum. 1. External Perineal Urethrotomy without a Guide__The first formal operation of external urethrotomy for the relief of stricture, unaccompanied by retention, appears to have been performed about the year 1652, by an English surgeon, named Molins, upon a patient not too respectable, referred to by Wiseman, who gives an account of the case, as " an old forni- cator." The urethra had been opened behind the stricture, on account of retention of urine, some time previously, but this not satisfying the patient, Mr. Molins placed him in the lithotomy position, and, giving one testicle in charge to his servant and the other to Wiseman, " Avith his knife divided the scrotum in the middle, . . . and cutting into the urethra, slit it the whole length to the incision in perineo." This rather heroic procedure appears to have been followed by no unpleasant consequences, though it was not success- ful in curing the perineal fistula. The operation of perineal section was sub- sequently resorted to by various surgeons, chiefly, hoAvever, in cases of reten- tion, but does not appear to have been generally recognized as a legitimate mode of treating stricture unaccompanied by that complication, until the publication of papers by Arnott, in 1823, and Jameson, of Baltimore, in 1821, followed some years later by Mr. Guthrie's well-known work on the "Anatomy and Diseases of the Urinary and Sexual Organs." The latter surgeon recommended that the urethra should be opened behind the stricture, which Avas then to be divided by cutting forwards upon the point of a catheter or sound previously introduced, but most operators have, in all essential par- ticulars, followed the practice of Jameson and Arnott, cutting directly upon the point of the sound, and then cautiously dissecting backwards in the median line. F. Jordan has modified Guthrie's procedure by opening the urethra through the rectum, and then endeavoring to pass a flexible catheter through the stricture from behind forwards. External perineal urethrotomy without a guide may be thus performed: The patient being etherized and secured in the lithotomy position, a full-sized catheter, or, AArhich is better, a staff grooved on its convexity is passed down until its beak rests upon the face of the stricture, taking care that it does not enter a false passage. The staff is then confided to an assistant, who holds it steadily in one position, while the surgeon makes an incision from an inch and a half to two inches in length, exactly in the median line of the perineum. This incision should go through the skin and superficial fascia, and should reach to within about half an inch of the anus. Ike surgeon next feels for the groove of the staff and cuts into it, thus fairly opening the urethra in front of the stricture. The sides of the canal (the mucous surface of which is easily recognized) are now held apart with tenacula, forceps, or loops of thread—one passed through each margin of the urethra, as advised by Avery—and the part may be still further exposed by turning out the end of the sound through the wound, and thus drawing the urethra forwards, as recently recommended by Wheelhouse, of Leeds. In most instances it will be found possible to slip a small grooved director, a probe, or even a fine whalebone bougie, through the stricture, the mouth of which is thus brought into view ; in which case all that remains to be done is to slit up the contracted tissues upon the 59 930 DISEASES OF URETHRA AND URINARY FISTULA. guide which has been introduced,1 pass a broad director into the bladder, and upon this a full-sized catheter, which may be left in place for about forty-eight hours.2 If the opening in the stricture cannot be found, the surgeon must cautiously dissect backAvards, with very light touches of the knife, and keep- ing strictly in the median line, until the dilated portion of the urethra behind the stricture is laid open. This, of course, is the only plan which can be fol- lowed in the rare cases, already referred to, of traumatic obliteration of the urethra. The after-treatment consists in the occasional passage of a sound to prevent recontraction. Mastin, of Mobile, after cutting into the healthy urethra in front of the stricture, divides the latter by a subcutaneous incision, and closes the external wound by means of hare-lip pins, so as to, if possible, obtain primary union. The operation Avhich has been described, is certainly a much more difficult one than that of Prof. Syme, and appears to have been more often followed by death ; yet, in view of the otherwise hopeless nature of the cases in which it is performed, it must be considered to giAe, upon the whole, very satisfac- tory results. Of 35 cases collected by Boeckel, in which the operation was performed by French or German surgeons, 8 terminated fatally, giving a mortality of nearly 23 per cent.; but in the hands of American surgeons, the results, according to Prof. Gouley, have been much better. Indeed, the ope- ration, if carefully performed, is not in itself very dangerous, and in the majority of fatal cases death has resulted from previously existing disease o ' the bladder and kidneys. Perineal section, which has, in this country, always been a favorite mode of treating obstinate strictures, is adapted to precisely the same classes of cases as Syme's method, except that, to justify the former operation, the stricture must have resisted all attempts to introduce an instru- ment. The operation is also indicated in some cases of stricture accompanied by retention, in cases of ruptured urethra in which catheterization cannot be accomplished (see page 377), and in some cases of traumatic obliteration of the urethra—though it is a question Avhether it might not often be better under these circumstances to make no attempt to restore the continuity of the canal, but to simply dilate the fistulous orifice which always exists behind the point of occlusion, or to make a direct opening into the posterior part of the urethra, in the way recommended. 2. Tapping the Urethra at the Apex of the Prostate, unas- sisted by a Guide Staff) is the name given by Mr. Cock, of Guy's Hos- pital, to a variety of the old " boutonniere" operation which Avas frequently practised by Wiseman and others for the relief of urinary retention, but Avhich Mr. Cock recommends in cases of impassable stricture, even when not thus complicated. The operation consists in opening the urethra behind the stricture, very much in the way it was done by Guthrie, in his mode of per- forming perineal section ; but, whereas Guthrie insisted (and I think with reason) on the propriety of always completing the operation by dividing the stricture itself, Mr. Cock urgently advises that the stricture should not be touched, but that the patient should rather be allowed to recover with a perineal fistula. The following are Mr. Cock's directions for the performance of this opera- tion : The patient being in the lithotomy position, the left forefinger of the 1 Having secured the entrance of a filiform bougie, Otis passes the other end of the instrument forwards, through the anterior portion of the urethra, and then screwing on a Maisonneuve's urethrotome, completes the operation by internal section of the stricture at its upper side. 2 This is considered unnecessary by Van Buren, Gouley, and many other American surgeons. RETENTION OF URINE FROM STRICTURE. 931 operator is placed in the rectum, Avith its tip at the apex of the prostate, the relations of Avhich should be carefully ascertained. A double-edged knife is then plunged steadily but boldly into the median line of the perineum, and carried in a direction tOAvards the tip of the left forefinger Avhich lies in the rectum, Avhile, at the same time, bykn upAvard and downward movement, the incision is enlarged in the median line to any extent that is considered de- Fig. 512. Tapping the urethra in the perineum. (Bryant.) sirable. The lower extremity of the wound reaches to Avithin about half an inch of the anus. The knife is pressed steadily onwards tOAvards the apex of the prostate, until its point can be felt in close proximity to the tip of the left forefinger, and is then made to pierce the urethra, by advancing it obliquely either to the right or left. The finger is still kept in the rectum, Avhile the knife is withdraAvn, and a probe-pointed director introduced through the wound into the urethra, and passed into the bladder. The finger is then Avithdrawn, and the director held in the left hand, while a canula or female catheter is slid along its groove into the bladder, where it is retained for a few days. This operation, which I consider a very excellent one in cases of urinary retention, seems to me inferior to the perineal section (either by Arnott's and Jameson's, or by Guthrie's method), for cases of stricture in which that com- plication does not exist. III. Treatmext of Stricture Complicated with Retention of Urine. When permanent narrowing of the urethra exists, a very slight cause may at any moment lead to complete retention (see page 921). Under such cir- cumstances, the sufferings of the patient are very great, and it becomes neces- sary to adopt prompt and efficient means to evacuate the bladder. The best course to be pursued is, I think, at once to etherize the patient, and when full relaxation has been obtained, to ascertain the exact locality of the stricture, by the introduction of a No. 13 or 14 catheter, and then attempt to pass a small flexible or metallic instrument, trying Ararious sizes in succession, and taking every precaution not to produce laceration of the urethra. If a catheter cannot be passed, perhaps a small bougie may be made to enter the stricture, and it will often happen that Avhen this is withdraAvn, after remaining a few minutes, a small stream of urine will folloAV. The same end may also be at- 932 DISEASES OF URETHRA AND URINARY FISTULA. tained, in some instances, by pressing for a feAV minutes with a sound against the face of the stricture. Maenamara, of Dublin, believes that there is in the urethra a vermicular movement towards the bladder, and maintains that if a small catheter can be fixed in a stricture, it will in the course of an hour or so make its own way through the obstruction. If a filiform bougie can be introduced into the bladder, a catheter can readily be made to follow, in the Avay described at page 926, when the urine can be drawn off, and the surgeon may at once proceed to treat the stricture by either rupture or internal urethrotomy. Sir Henry Thompson has devised, for use in these cases, a probe-pointed catheter, the beak of which is as slender as the most delicate metallic probe. The instrument is doubtless an efficient one in skilful hands, but seems to me less adapted for general employment than the filiform bougie used in the way which has been described. Dr. F. N. Otis employs a probe-pointed " dilating catheter," with a " testing syringe," Avhich by withdrawing a small quantity of urine shows conclusively when the instrument has reached the bladder. This catheter may be guided through a very close stricture by threading it over a filiform bougie of extra length. If, after patient trial for half an hour or so, no instrument can be intro- duced, or if prolonged but fruitless attempts at catheterization have been already made by another surgeon, the patient should be placed in a hot bath until faintness is induced, and then put to bed, and wrapped in blankets, with hot fomentations to the pubes and perineum. He should be brought thoroughly under the influence of opium, or, if this drug be for any reason contra-indicated, may take the muriated tincture of iron in the Avay directed at page 917. Under this treatment the bladder will, in the large majority of instances, relieve itself in the course of a few hours, but should it not do so, the patient must again be etherized, and the attempt to afford instrumental relief care- fully reneAved. If the surgeon's efforts are still unsuccessful, more decided measures must be adopted. No precise rule can be given as to the length of time during which delay is justifiable in these cases, nor can the surgeon judge accurately of the degree of vesical distension by the size of the tumor which the bladder forms in the supra-pubic region ; for, in cases of long- standing stricture, the organ is often thickened and contracted, and may be dangerously distended by an amount of urine which, under other circum- stances, Avould be insignificant. The dangers of delay are very great, and I believe exceed those entailed by a skilfully performed operation. Apart from the risk of rupture of the bladder or urethra, serious injury cannot but be inflicted upon the ureters and kidneys, by the damming up, even for a feAV hours, of the urinary secretion. The operations which may be employed for the relief of retention dependent upon organic stricture, are forced catheterization, perineal section, tapping the urethra behind the stricture (Cock's method), and tapping the bladder— through the rectum, above the pubis, or through the pubic symphysis. The first method (forced catheterization) is now, happily, seldom resorted to; it is very uncertain, and extremely dangerous—and should, in my judgment, be utterly banished from practice. The operative procedures employed in all the other methods mentioned have already been described, and it only remains to indicate the particular cases which call for one mode of treatment rather than for another. If swelling or other signs of inflammation in the perineum lead the surgeon to suppose that ulceration or rupture of the urethra may have already occurred, and that urinary extravasation is therefore imminent, if, indeed, it has not actually taken place, one or other of the perineal opera- tions should be preferred, and the choice between these should, I think, rest STRICTURE OF THE FEMALE URETHRA. 933 upon the origin of the stricture, Avhether gonorrhoeal or traumatic. For the former, Cock's operation may be resorted to, as being easier, and, under these circumstances, quite as satisfactory as the perineal section ; for, by diverting the course of the urine for a short time, the stricture Avill, in all probability, become quite amenable to dilatation, or to one of the other methods used in the treatment of permeable stricture. If, however, the stricture be of trau- matic origin, it is, I think, better to perform perineal section ; for this form of the disease is ahvays very intractable, and it is, therefore, better to employ a radical remedy at the outset. If, on the contrary, there be no reason to fear urinary extravasation, it is, 1 think, better, in most instances, to employ the aspirator above the pubis, or, if this instrument be not at band, to resort to puncture of the bladder through the rectum—which is usually, in these cases, an easy and safe ope- ration ; after a few days, the stricture can be dealt Avith by either dilatation, rupture, internal urethrotomy, or external division, as may be thought proper. If, from the size of the prostate or the contracted state of the bladder, the rectal puncture should be considered undesirable, the next best course Avould be to open the urethra behind the seat of stricture; or, if the disease Avere of traumatic origin, the perineal section might be preferred, for the reasons already mentioned. Ruptures of the Bladder and Urethra are among the gravest sequehe of retention of urine from organic stricture. Rupture of the Bladder (which is very rare) may give rise to peritonitis, or, if the rent be at a part uncovered by the peritoneum, to extravasation of urine Avithin the pelvis ; in either case the accident is usually, though not invariably, folloAved by death, three out of eight cases referred to by Gouley being reported as recoveries. Rupture of the Urethra almost invariably occurs at the membranous part of the canal, the urine Avhich is extraAasated then making its way into the tissues of the perineum, scrotum, groin, and anterior abdominal parietes, and more rarely passing backAvards into the tissues of the ischio-rectal fossa? and buttocks. The treatment of these accidents has already been described at pages 375 and 377. Stricture of the Female Urethra is a very rare affection. It may result from gonorrhoea, or from the cicatrization of a chancre or chancroid; but is more apt to be caused by the inflammation following traumatic injuries, particularly from the use of forceps, or the pressure of the foetal head in child- birth. The seat of the stricture is usually at or very near the meatus. The treatment consists in dilatation, aided, if necessary, by a slight incision Avith a probe-pointed knife. In a case of stricture of the female urethra compli- cated with retention, in Avhich catheterization proved impossible, Curling resorted to puncture of the bladder through the vagina. Dr. R. NeAvman reports several cases cured by the use of electricity. Introduction of the Female Catheter___The female catheter is shorter and less curved than the instrument used for the male urethra, and should be provided with rings, at its open extremity, to prevent the possibility of its slipping into the bladder. The catheter should be introduced Avithout any exposure of the person, and this may be most conveniently done Avhile the patient is in bed, with the thighs flexed and somewhat separated from each other. The surgeon stands on the patient's left side, and passing his left hand beneath the flexed limb, introduces his forefinger between the nymphce, bringing it from behind forAvards until it touches the space betAveen the en- trance of the vagina and the orifice of the urethra, the prominence of Avhich is easily recognized by the touch ; the catheter is then introduced with the right 934 DISEASES OF URETHRA AND URINARY FISTULA. hand above the flexed limb, and, guided upon the left forefinger, slips without difficulty into the bladder. The whole operation is done under the cover of the bedclothes. In cases of malformation or obstruction, the introduction of the catheter may prove more difficult, and may even be impracticable without the exposure of the part; should retention occur under such circumstances, no false sense of modesty should prevent the adoption of whatever course may be necessary for the patient's relief. Tumors and Fissure of the Urethra. The older Avriters attributed most cases of urinary obstruction to the exist- ence of tumors of the urethra, which they called caruncles or carnosittes; but in the light of modern pathology, true tumors of this part must be con- sidered very rare. In many instances, Avhat have been called tumors, are Fig. 513. Papillary tumor of the female urethra. (Boivin.) merely clusters of prominent vascular granulations, which, as in other mucous membranes, occasionally result from long-continued inflammation. True urethral tumors are, however, occasionally met with, belonging chiefly to the papillary and fibro-cellular varieties. The papillary groAvths are principally seen near the meatus, and are much less common in the male than in the female sex, Avhile the fibro-cellular or polypoid tumors are chiefly limited to the prostatic part of the male urethra. Tuberculous and cancerous deposits, also, are occasionally seen in the urethra; but are usually secondary to similar formations in the kidney, bladder, or prostate. The treatment of the vascular papillary growths which are seen near the meatus, and Avhich alone are likely to be recognized during life, consists in excision, ligation, the appli- cation of caustics (of which the best, according to Dr. Edis, are chromic and carbolic acids), or the use of the actual or galvanic cautery. The latter is the safest remedy for the vascular tumors of the female urethra, excision URINARY FISTULA IN THE MALE. 935 being, in this locality, attended with some risk of hemorrhage. If the hot iron is used, the surrounding parts should be protected with a wooden spa- tula. Should spasmodic contraction of the urethra persist after removal of the growth, forcible dilatation (as recommended by Richet) may be resorted to, and the same plan may be adopted, as advised by Spiegelberg, in the treatment offissure of the female urethra, a condition analogous to the fissure, or painful ulcer, of the rectum (see pages 823, 897). Urinary Fistula in the Male. Urethral Fistula—Fistulous communications between the male urethra and the external surface of the body are not unfrequently met with in cases of long-standing stricture. There may be one or several external openings, and these may be situated in the perineum, scrotum, or lower surface of the penis, or even in the thighs, buttocks, or abdominal wall. Fig. 514. Urinary fistulae in the male. (Liston.) The treatment must be directed in the first place to the cure of the stric- ture, for the abnormal openings cannot be expected to heal while any obstruc- tion to the natural course of the urine remains. Simple dilatation Avill in many cases be sufficient, and it often happens that, when the normal calibre of the urethra has been restored, the fistula will heal of itself. If the stric- ture is very hard and cartilaginous, or peculiarly irritable, or if, though easily dilated, it constantly tends to recontract, it will usually be advisable to resort at once to external division (Syme's method), which promises better results under these circumstances than either rupture or internal urethrotomy. If the stricture be impermeable, the perineal section must be performed as a last resort. If the fistula still persists after the cure of the stricture, special means must be adopted for its treatment. It is often recommended to retain a ca- theter in the bladder, in these cases, so as to prevent any urine from escaping through the fistula ; but the plan very seldom succeeds, for the reason that a small quantity of urine invariably trickles alongside of the instrument, and thus defeats the object in view. It is much better to teach the patient to use a gum-elastic catheter for himself, when, if he can be induced to co-operate with the surgeon by not, under any circumstances, urinating except through the instrument, the fistula will probably heal Avithout difficulty under simple dressing. The special treatment of urethral fistulae varies according as they are seated in the perineal, scrotal, or penile portions of the urethra. 936 DISEASES OF URETHRA AND URINARY FISTULA. 1. Perineal Fistula—If of small size, a perineal fistula may be induced to heal by introducing a fine probe coated with nitrate of silver, or (Avhich is probably the most efficient means) by the application of the galvanic cautery. If there be several external openings, a good plan is to connect them together with an oakum thread, introduced by means of an eyed probe ; while, if this fail, it may be necessary to lay open the smaller sinuses by incision upon a grooved director. If the fistula be a large one, its edges may be touched with strong nitric acid, so as to make a superficial slough, which, when detached, will leave healthy granulating surfaces ; or the edges may be deeply pared, and brought together with metallic sutures. Voillemier and Guyon recom- mend that the fistula and surrounding tissue should be cut out by means of curved incisions meeting in front and behind. 2. Scrotal Fistula, on account of the lax condition of the parts, usually requires to be freely laid open, when it Avill probably heal by granulation ; or the edges may be deeply pared and the adjacent tissues dissected up, so as to form broad and thick flaps, Avhich are then to be accurately brought to- gether in the median line with deep and superficial sutures. 3. Penile Fistula is the most intractable form of urethral fistula, and can seldom be cured Avithout a plastic operation. In some cases, however, success may be obtained by touching the edges Avith nitric acid, and holding the granulating surfaces together Avith serre-fines, after the detachment of the slough. The contact of urine must be prevented by keeping a full-sized catheter in the bladder, or, which is usually better, by the frequent introduc- tion of a flexible instrument. Dieffenbach's lace-suture may also be applied Fig. 515. with advantage in some cases. The edges of the fistula are first blistered with the tincture of cantharides, and the cuticle scraped off with a scalpel. By repeated introductions of a small curved needle, a waxed silk thread is next carried subcutaneously around, but not across, the fistula, at a distance of about a quarter of an inch from its margin, Avhen, by drawing upon both ends of the thread, the opening is puckered up like the mouth of a purse, and secured with a knot. The suture may be removed after three or four days. E. Noble Smith has recently reported a case in Avhich a cure was effected by the application of a strong solution of nitrate of silver (3J-f^j) to the urethral as well as to the external orifice of the fistula. 4. Blind Urinary Fistula is the name given to suppurating tracks opening into the urethra, but having no external orifice. The treatment con- sists in laying open the sinus, and then proceeding as in the case of an ordi- nary urethral fistula. A similar affection is described by Skene, of Brooklyn, as occurring in Avomen, and as curable by dilating the canal and using astrin- gent injections. URACHAL FISTULA. 937 Urethroplasty___The simple urethroplasty operations occasionally re- quired in cases of perineal and scrotal fistula, have just been mentioned. More complicated procedures are, hoAvever, often needed in the treatment of fistulas in the penile portion of the urethra. 1. A good plan is to freshen the edges of the fistula, and dissect up long, bridge-like flaps, which are then stitched together over a slip of India-rubber, or, Avhich is better, a piece of thin lead ribbon (Fig. 515), so as to prevent the contact of urine. This operation is said to have originated with Dieffen- bach. 2. Alliot, Segalas, Nekton, and others, have succeeded in curing penile fistulas by dissecting up the integuments around the opening and sliding them over the latter, after freshening its edges. Fig. 516. Fie. 517. Urethroplasty : Dieffenbach's method. (Erichsen.) Urethroplasty; Le Gros Clark's method. (Erichsen.) 3. Astley Cooper operated by paring the edges of the fistula, so as to form a quadrilateral wound, Avhich Avas then closed with a flap of similar form, borrowed from the scrotum. 4. Le Gros Clark pares the edges of the fistula, and closes it by dissecting up flaps from each side and joining them in the middle line by means of the clamp or quilled suture. Somewhat similar operations are attributed to Rey- bard and Delorne. 5. R. F. Weir, folloAving Langenbeck and Szymanowski, has succeeded by inverting an oval flap from one side of the fistula, and pocketing it in a groove upon the other side. Whatever plan be adopted, it may, perhaps, be thought advisable to divert the course of the urine for a feAV days, by puncturing the bladder through the rectum, or, better, by opening the urethra in the perineum, as has been done by Segalas, Ricord, and Thompson. The results of all these operations are apt to be disappointing; 82 cases tabulated by Czerny gave in all but 35 recoveries, and in many of these the duration of treatment was more than a year. Urachal Fistula___It occasionally happens that the urachus remains patulous and allows a discharge of urine from the umbilicus. This rare con- dition, of Avhich I have seen but one example, has been effectually remedied by Gueniot by the application of ligatures and caustic so as to occlude the 938 DISEASES OF URETHRA AND URINARY FISTULA. umbilical opening. Jacoby has effected a cure by the use of the actual cautery, and A. Rose, of New York, by means of a plastic operation. Worster has in the same Avay cured a case of urachal fistula opening between the umbilicus and pubes. If the fistula be complicated by the existence of phimosis, this should be relieved first, when the urachal opening may close of itself, as in a case recorded by Charles. Vesico-rectal and Urethro-rectal Fistulae have already been considered (see page 819). Urinary Fistula in the Female. Of this there are fhre varieties, the urethro-vaginal, the vesico-vaginal, the vesico-utero-vaginal, the uretero-vaginal, and the vesico-uterinefistula. The locality of the fistula in each case is indicated by the name. The causes of these fistulae are direct injury, abscess, ulceration, and sloughing due to pres- sure, as from the child's head in labor—the latter being by far the most fre- quent origin of the affection. The consequences of this condition are extremely annoying to the patient; incontinence of urine is almost constantly present, leading to excoriation of the genital organs and thighs, and giving rise to an ammoniacal odor which renders the patient an object of loathing to herself, if not to all around her. The diagnosis can be made by placing the patient on her elbows and knees, and exposing the part by drawing away the opposite wall of the vagina with a Sims's or Bozeman's duck-billed speculum (Fig. 518); if the fistula be very small, it may elude detection unless the bladder is injected, which may be done with simple water, milk, or a weak infusion of madder or indigo. The consideration of the treatment of the vesico-vaginal and other varieties of urinary fistula met with in the female sex, belongs rather to the depart- ment of Gynaecology than to that of General Surgery, Fig. 518. and I shall, therefore, content myself with indicating the principles upon which the various modern opera- tions for the relief of these affections are founded, refer- ring the reader for more detailed information to the excellent Avorks of Simpson, Sims, BroAvn, Emmet, Byford, Thomas, Agnew, and other writers on these subjects. Until within a few years, these affections were generally considered incurable, and it is chiefly through the labors of American surgeons, that the ope- rative treatment of vaginal fistulae, from being the opprobrium of our art, has been made one of the most successful procedures in the whole range of surgical practice. Without wishing to make invidious distinc- tions, I may refer particularly to the early labors of Hay ward, of Massachusetts, and Mettauer, of Virginia, and to the brilliant successes more recently obtained by Marion Sims, who, in 1852, as justly remarked by Duck-buied speculum. Thomas, combined the essentials of success, and placed the operation at the disposal of the profession. Since this time the subject has been illustrated both at home and abroad, by Boze- man, Emmet, Schuppert, Briggs, Agnew, Simpson, BroAvn, Bryant* Wells, Kidd, Simon, Ulrich, Neugebauer, and many other surgeons. If a urethro-vaginal or vesico-vaginal fistula be very small, an attempt may be made to effect its closure by the application of the actual or galvanic cau- tery, or by touching the edges with nitric acid and holding them together OPERATIONS FOR URINARY VAGINAL FISTULJE. 939 with serre-fines, a plan which has been recently recommended in some cases by Spencer Wells. The large majority of fistuk, however, require an opera- tion, Avhich essentially consists in paring the edges of the opening, and ap- proximating the raw surfaces (preferably in a transverse direction) by means of sutures, which are left in place until firm union has occurred. This plan is more generally applicable than any of the flap operations Avhich have been suggested, though these may be occasionally useful in particular cases. Operations for Urinary Vaginal Fistulae—The points which require special consideration are—1. The position of the patient; 2. The mode of exposing the fistula; 3. Paring the edges ; -1. Introduction of the sutures ; 5. Fastening the sutures ; 6. Use of the catheter during the after- treatment ; and 7. The time at Avhich the sutures should be removed. The patient should be prepared for the operation by attending to the state of the general health, by subduing local inflammation, and by dividing any cicatri- cial bands that might interiere with the success of the treatment. A dose of castor oil should be administered the night before, and an enema given on the morning of the operation, Avhile to avoid the suffering, both physical and mental, to which this Avould otherwise necessarily give rise, the patient should invariably be anaesthetized, unless there be some special reason to the con- trary. 1. Position of the Patient__The best is, I think, a modification of that known as the knee-elboAv position, the patient being supported upon inflows or on a Avell-padded double-inclined plane, Avith the hips elevated, and the head and shoulders depressed, the thighs widely separated, and held apart by assistants; Sims and Emmet, however, prefer a semi-prone position, the patient lying partly on the left side Avith the thighs flexed—the right rather more than the left—and the breast resting upon the table, while Simon adopts the supine position, with the hips and thighs much raised, and Wells recommends the ordinary lithotomy position, with the hands and feet fastened together with bandages or straps. 2. Exposure of the Fistula__This may be done with an ordinary Sims's speculum, held by an assistant, or by means of Emmet's modification of that instrument, if the semi-prone position is chosen, or by a similar modification described by Wells, if the patient be placed either on her back or in the position here recommended. These modifications of Sims's speculum consist in the adaptation of a fenestrated blade, which fits over the buttock or sacrum of the patient, and thus keeps the instrument in place without the aid of an assistant. A bright light is neces- sary for the operation, the best illumination be- ing afforded by placing the operating table near a high window ; if this cannot be obtained, an Argand lamp and reflector may be substi- tuted. Emmet's speculum. 3. Paring the Edges__This may be done with either kniA'es or scis- sors, according to the fancy of the operator ; it is convenient to have a double- edged knife curved on the flat, and others with the blades bent at an angle with the shaft (Fig. 520). The sides of the fistula may be steadied by means of suitable forceps, or one or more hooks Avith long handles, while the paring 940 DISEASES OF URETHRA AND URINARY FISTULA. is effected by transfixing the part with the knife, and cutting first in one, and then in the opposite direction, so that a complete ring is denuded. In doing Fig. 520. Knife for vesico-vaginal fistula. this, some surgeons cut perpendicularly to the plane of the vesico-vaginal septum, Avhile others bevel the edges by cutting in an oblique direction, so as to spare the mucous membrane of the bladder. Langenbeck again, and, more recently, Collis, of Dublin, have advised that the edges of the fistula should Fig. 521. Operation for vesico-vaginal fistula ; sutures in position. (Si: be split, so as to obtain a broad raw surface without cutting away any tissue whatever. Provided that a broad surface be obtained for adhesion, it proba- bly makes little difference which particular plan is adopted. Before proceed- OPERATION FOR VESICO-VAGINAL FISTULA. 941 ing to the next step of the operation, all bleeding should be checked by torsion, by pressure Avith a piece of sponge mounted on a handle or " sponge-holder," or by throAving in a stream of cold water with a syringe. 4. Introduction of the Sutures—The material generally chosen for the suture, in this country, is, in accordance with the practice of Sims and Bozeman, silver Avire ; and this seems to me, upon the Avhole, preferable to the other substances used for the purpose. Simon, hoAvever, employs a silken, and Ulrich, of Alenna, a hempen suture ; while AVells considers, and probably with good reason, the choice of material much less important than bas been commonly supposed. Wutzer employed the harelip pin and twisted suture, and the same plan with various modifications has been since adopted by Metzler, of Prague, Mastin, of Mobile, and Watson, of Edinburgh. The sutures, Avhether of silk or metal, may be conveniently introduced with short Avell-curved needles held by suitable forceps, or with needles eyed near the point, and mounted in handles like the ordinary naevus needle. Sometimes the silk or wire may be threaded upon tAvo needles, each of Avhich is intro- duced from the vesical surface of the fistula ; or an eyed needle, threaded, may be passed through one margin, and a notched needle, unthreaded, through the other—the loop of the thread being then caught in the notch and thus drawn tlirough ; or, again, the surgeon may adopt a plan similar to that of Mr. Avery, in the operation for cleft palate (see p. 739). Dr. Joseph Bell employs steel points Avelded to the wire, so as to leave no projecting shoulder and to require no threading. Special needles have been devised for this ope- ration by Druitt, Startin, and others, but I am not aware that they possess any superiority over the simpler implements above recommended. The pas- sage of the needle from within outwards may be aided by steadying the part to be transfixed with a blunt hook bent at an angle to its shaft, and, Avhen Avire is used, advantage may be derived from drawing it over a notched " feeder," Avhich prevents it from cutting through the margin of the fistula. When the edges have been bevelled or split, the sutures should be passed so as not to encroach upon the vesical mucous membrane, but this may be in- cluded when the fistula has been pared perpendicularly to the septum. The sutures should be passed about half an inch from the free margin of the fistula, and should be about a sixth of an inch apart. The fistula should, if possible, be closed in a transverse direction, so as to form a cicatrix at right angles to the long axis of the vagina. A single set of sutures may be used, or a deep and superficial set, according to the fancy Fig. 522. of the operator. 5. Fastening the Sutures__If of silk, the sutures are to be tied in an ordinary surgeon's knot, all the knots being made on the same side of the fistula; wire sutures may be conveniently clamped with perforated shot, or Fig. 523. Bozeraan's button suture. Coghill's wire twister. 942 DISEASES OF URETHRA AND URINARY FISTULA. tAvisted with the fingers, or, if the fistula be high up, with the "wire twister" devised by Coghill (Fig. 522); or the ends on either side may be passed through a metallic plate and secured with shot (as in Sims's earlier operations); or Bozeman's ingenious modification, knoAvn as the " button suture," may be substituted (Fig. 523); or the surgeon may employ one of the many shields and splints, AA'hich have been devised by Simpson, BroAvn, Agnew, and others. In the majority of cases, however, the simple inter- rupted suture will, I think, be found more satisfactory than any other. As a test of the accurate closure of the fistula, an attempt may be made to pass a probe between the stitches, and the bladder may be injected with milk or colored water. 6. The Catheter__It is by the large majority of writers thought very important to introduce a catheter—Sims's " sigmoid" instrument (Fig. 453) is the best—immediately after the operation, and to keep it in place during the after-treatment. Simon, however, has discarded the catheter altogether, except in cases of retention, Avhen he introduces the instrument at intervals of three or four hours ; while Wells introduces at first a small vulcanite catheter, but removes it as soon as it causes any irritation or discomfort. In this country, the principal advocates of the disuse of the catheter are Dr. Schuppert, of New Orleans, and Dr. Briggs, of Nashville. If the catheter be used, great care must be taken not to let it become clogged with mucus. 7. Removal of the Sutures__This may he done while the patient is in the semi-prone position. Silk sutures should be Avithdrawn about the 6th or 7th day, and Avire sutures from the 8th to the 14th; it is better to retain them unnecessarily than to remove them prematurely. The bowels should be locked up with opium for about two weeks, and cleanliness insured by daily syringing of the vagina. If the urine be ammo- niacal, the bladder may be washed out through a double catheter. Modifications Required in Special Cases__AVhen the fistula is placed in the upper part of the vesico-vaginal septum, care must be taken not to implicate the ureters in the operation. Neglect of this precaution may lead to failure, from the ureter opening into the vagina above the cicatrix, or even to death, from occlusion of the ureter and consequent uraemia. For uretero-vaginal fistulas, Parvin turns the displaced dis- tal extremity of the ureter into the bladder, and then closes the vaginal opening, while Landau recommends that an attempt should be made to pass a catheter from the bladder through the ureter, the opening in which is then to be closed over the instrument; or, if this cannot be done, that the loAver part of the ureter should be slit into the bladder, so as to convert the case into one of ordinary vesico-vaginal fistula. In cases of vesico-utero-vaginal fistula, the anterior lip of the uterus, or possibly the posterior lip, must be utilized in closing the opening : in the latter case, the patient is rendered sterile, and the menses escape through the urethra. In cases of vesico-uterine fis- tula, the anterior lip of the uterus must be slit up until the opening is exposed, when its edges may be freshened and united with sutures. In cases of very great deficiency of the vesico-vaginal septum, the ope- ration of transverse obliteration of the vagina (Fig. 525), as employed by Simon and Bozeman, may be Fig. 524. Operation for vesico- uterine fistula. (Thomas TRANSVERSE OBLITERATION OF VAGINA. 943 necessary : this consists in paring the anterior lip of the fistula, and attaching it to the previously denuded posterior wall of the vagina, so as to completely close the orifice of this canal; the menses subsequently escape through the urethra, but the patient is rendered sterile and unfitted for sexual congress. Hence, when applicable, a better plan, also suggested by Bozeman, is to Fig. 525. Transverse obliteration of the vagina. (Simon.) endeavor to lessen the antero-posterior diameter of the fistula, by daily drag- ging down the neck of the uterus, with forceps, for some Aveeks prior to the operation, which is then performed as in an ordinary case of vesicoutero- vaginal fistula. AVhen the floor of the urethra is completely destroyed as well as the vesico-vaginal septum, it may be necessary to pare, or split, and unite the labia, as in the operation of episiorraphy (p. 072), so as to close the vulva, except at its anterior portion, Avhere an opening must be left for the escape of the urine and menses, incontinence being prevented by the adapta- tion of a suitable truss. This operation, which I have myself resorted to with advantage, may be supplemented, as suggested by Maunder, by tapping the vagina through the rectum and introducing a tube, so as to insure a free exit to the urine until the union of the raw surfaces is complete.1 1 In the above pages I have drawn freely from the excellent Treatise on the Diseases of Women, by Prof. T. G. Thomas, of New York, and from a valuable paper on the treatment of vaginal fistula, by Mr. T. Spencer Wells, in St. Thomas's Hosp. Reports. N.S., vol. i., 1870. 944 DISEASES OF THE GENERATIVE ORGANS. CHAPTER XLVII. DISEASES OF THE GENERATIVE ORGANS. DISEASES OF THE MALE GENITALS. Malformations op the Penis and Scrotum. Congenital Adhesion.—The penis is sometimes bound down to the scrotum by a web of skin extending from the lower surface of the organ to the raphe ; the treatment consists in dividing the web, and bringing the edges of the wound together in a longitudinal direction (as successfully done by Bouisson), or, if this be impracticable on account of the shortness of the attachments, in carefully dissecting the penis from its abnormal position and raising it towards the belly, the gap in the scrotum being then filled Avith a flap borrowed from the groin or thigh, as suggested by Holmes. Incurvation of the Penis (with hypospadias) is occasionally met with, and may seriously interfere with procreation : the treatment may con- sist (1) in subcutaneous division of the contracted tissue, as practised by Bouisson; (2) in excising a wedge-shaped piece from the dorsum of the organ by transverse incisions, and bringing the sides of the wounds together so as to raise the glans penis, as advised by Physick, Pancoast, and Gross ; (3) in amputating the head of the organ, and enlarging the hypospadic ori- fice, as suggested by Holmes, or (4) in splicing the contracted part as inge- niously suggested by Dr. Gouley, of New York. Dr. R. F. Weir, also of New York, has, in two cases in which this condition was complicated by congeni- tal adhesion to the scrotum, successfully resorted to a modification of Bouis- son's method, while Dr. E. Bradley, of the same city, has operated by making V-shaped incisions on the loAver surface of the organ, which was then strapped up against the abdomen Avhile cicatrization occurred. Fissure, or Cleft of the Scrotum, occurring in connection with malformation of the penis and complete hypospadias, constitutes a variety of so-called hermaphrodism ; the cleft scrotum represents the labia majora, and the deformed penis the clitoris, and if the testes be retained within the abdo- men the resemblance to the female organs is tolerably complete. These cases seldom admit of operative interference, but the surgeon may be called upon to express an opinion as to the sex of the child, and to advise as to the mode in which it shall be brought up. The diagnosis of sex can usually, but by no means always, be made by simultaneous rectal and vesical explora- tion ; if no trace of a uterus be found, and if the supposed vagina open directly into the bladder, the probability is that the subject belongs to the male sex. In a case of doubt, it would probably be judicious, as advised by Holmes, to bring the child up as a boy. Phimosis. Phimosis may be either congenital or acquired. This condition consists in an elongation of the prepuce, Avith contraction of its orifice, preventing the foreskin from being drawn back so as to expose the glans penis. TREATMENT OF PHIMOSIS. 945 Congenital Phimosis__In congenital cases the contraction is most marked in the inner or mucous layer of the prepuce, which adheres more or less closely to the suiface of the glans,1 while the skin of the part is compara- tively lax. Phimosis is often the source of great inconvenience, if not of positive disease. In childhood, it may form an impediment to the flow of urine, leading to irritation of the urethra and bladder, and giving rise to symptoms of vesical calculus, and, sometimes, to reflex, nervous phenomena, paralysis, etc. In adult life, it may similarly interfere with the discharge of semen, and thus render the patient practically sterile, while, by preventing the retraction of the prepuce, it causes an accumulation of smegma, producing great irrita- tion of the part, and exposing the patient to repeated attacks of balano- posthitis. Phimosis, moreover, apparently renders its subject more liable to the various forms of venereal infection, and becomes a serious complication when venereal diseases are acquired. It also, in the opinion of Hey, Holmes, and others, predisposes to the development of malignant disease of the part. Acquired Phimosis may result from thickening of the prepuce, fol- 1 owing gonorrhceal or chancroidal inflammation, or may be dependent upon the existence of fissures or excoriations of the part. In some instances, phimosis is complicated with a condition of solid oedema of the prepuce, con- stituting a state of hypertrophy, which, like the analogous hypertrophy of the clitoris, seems, occasionally, to be due to constitutional syphilis. Treatment of Phimosis.—In some cases it is sufficient to divide the mucous layer of the prepuce, Avhich is, as has been mentioned, the part chiefly affected in congenital phimosis, but in many instances it will be necessary to adopt severer measures, Avhich may be classified under the heads of incision, excision, and circumcision. 1. Division of the Mucous Layer of the Prepuce may be ac- complished in several Avays :— (1.) Sudden dilatation or rupture of the mucous layer may be effected by introducing the blades of an ordinary pair of dressing forceps between the prepuce and glans penis, one on either side, and then quickly withdrawing the instrument with its blades widely separated; the foreskin is then draAvn back, and kept retracted for about forty-eight hours. This plan is said to have originated with Hutton, of Dublin, and has been, lately, highly com- mended by Cruise, of the same place, avIio has devised a special instrument for the operation. A three-bladed forceps is employed for the same purpose by French surgeons. Erichsen recommends, in cases of acquired phimosis depending upon fis- sures of the preputial orifice, gradual dilatation, effected by means of a tAvo- bladed urethral dilator, such as is used in the operation of lithectasy in the female. (2.) The surgeon may employ a small pair of scissors, the loAver blade of which is probe-pointed, introducing this blade between the prepuce and glans, and thrusting the other or sharp-pointed blade between the layers of the pre- puce. The contracted mucous layer can now be divided at a single stroke, the foreskin being then retracted, as in the previous method. This mode of • According to B6kai, adhesion of the inner layer of the prepuce to the glans penis is a normal condition during early infancy. It may give rise to many of the symp- toms Avhich are ordinarily attributed to true phimosis, but may be distinguished by the readiness with which the foreskin can be drawn back, showing that its orifice is not really contracted. 60 946 DISEASES OF THE GENERATIVE ORGANS. operating appears to have originated with Dr. Edward Peace, of this city, formerly one of the surgeons to the Pennsylvania Hospital. (3.) Faure's method consists in forcibly draAving backward the skin of the penis, and dividing the mucous layer of the prepuce, which is thus made tense, by a succession of notches with a pair of probe-pointed scissors. 2. Incision___This may be done either at the upper or lower surface of the penis ; probe-pointed scissors may be used, or the surgeon may introduce a grooved director, and upon this a sharp-pointed curved bistoury, which is then made to transfix the prepuce and cut from within outAvards, scissors being employed, if necessary, to complete the division of the mucous membrane. Another plan is to dispense with the director, guarding the point of the bis- toury with a small piece of Avax until it has reached the desired point, Avhen it is made to transfix and cut its Avay out as before. If the incision be made below, the froenum, if too short, may be at the same time divided. This method is attended Avith the disadvantage of leaving a wing-like projection of preputial tissue on either side of the penis, constituting an unseemly defor- mity, and, if, as often happens, the prepuce subsequently becomes thickened and hypertrophied, interfering with coitus. 3. Excision__The prepuce having been divided Avith a bistoury along the dorsum of the penis, as in the operation by incision, the flaps on either side may be seized with forceps and cut off in an oblique direction, so as to make an oval Avound; the mucous membrane is then attached to the skin with silk or lead sutures, and the part covered with a cold Avater-dressing. This operation gives a very good result, and is, I think, particularly applicable to Fie. 526. Circumcision. (Ericlisen.) those cases in which the prepuce is in a state of solid oedema and hypertrophy. Other plans are to excise the framum, together with a V-snaPed portion of the prepuce, as in the operations of Taxil and Jobert (de Lamballe), or to remove with scissors a semilunar flap, as in the method of Lisfranc. PARAPHIMOSIS. 947 4. Circumcision is, I think, ordinarily the best mode of treatment. The prepuce should be draAvn forAvards, so that the portion which corre- sponds, in the ordinary condition, to the line of the corona glandis shall be entirely in front of the penis ; a pair of narroAv-bladed forceps is then applied in an oblique direction (so as not to encroach too much upon the framum), and firmly held by an assistant, while the surgeon Avith knife or scissors removes the part of the prepuce which is in front; Avhen the instrument is removed, it will be found that more of the skin has been taken aAvay than of the mucous membrane, and it is, therefore, usually necessary to slit this along the dorsum of the penis—when the corners of the flaps thus formed may be excised, and the operation completed by uniting the skin and mucous membrane with silk or lead sutures, or with serrefines. This operation is commonly attended Avith some little hemorrhage, which, if sutures are used, can be conveniently cheeked by transfixing each of the bleeding vessels with one of the stitches; under other circumstances, ligatures may be required. An ingenious modifi- cation of this operation is that Avhich was introduced by Ricord, who has devised for the purpose a fenestrated forceps, tlirough which the suture threads may be introduced before the prepuce is cut off; the forceps being removed, the mucous membrane is, if necessary, slit along the dorsum, and each thread dhided in the middle, so as to form a suture on either side. No operation for phimosis should, as a rule, be performed in any case com- plicated with chancroid, lest the Avhole Avound should become inoculated. In order to prevent the occurrence of painful erections after these operations, Dr. Otis, of New York, recommends the use of dry cold applied by means of Petitgand's method of mediate irrigation (p. 56). Paraphimosis. This is the name given to the condition in which the prepuce has been draAvn up above the corona glandis and cannot be replaced. The glans soon becomes swollen and oedematous, from the constriction exercised by the pre- putial orifice, and, if relief be not afforded, ulceration or sloughing may occur. Paraphimosis is chiefly met Avith in boys, but may occur at any age if the prepuce be contracted. The treatment consists in effecting reduction, which may be sometimes aided by preliminary scarifications, or by the application of the cold douche or of ice. Reduction may usually be accomplished by the sur- FiS- 52?- geon's fingers, combining traction upon the prepuce with compression of the glans, which should be Avell oiled and covered Avith a small rag, to prevent the fingers from slipping. The surgeon first com- presses the glans firmly for five or ten minutes with the fingers of the right hand, so as to squeeze the blood out of the part, and then encircling the prepuce Avith the left hand, as shown in Fig. 527, gradually draws the part into its normal place, aiding the manoeuvre by trying to insert the right thumb-nail beneath the edge of the prepu- tial orifice. Other plans are to compress the glans by surrounding it Avith a tape or strip of adhesive plaster, or by applying broad-bladed forceps; or to raise the pre- putial ring upon a director, while the glans Reduction of paraphimosis. (Phillips.) 948 DISEASES OF THE GENERATIVE ORGANS. is pushed up beneath the instrument. If these means fail, a small bistoury must be introduced flatAvise beneath the edge of the preputial orifice, Avhich lies at the bottom of the groove behind the sAvollen glans, and then turned with its edge upwards so as to nick the constricting tissues at one or more points of their circumference; the tension being thus relieved, reduction can be accomplished without difficulty. Inflammatory Affections of the Penis and Scrotum. Diffuse Inflammation of the Areolar Tissue of the Penis and Scrotum may result from erysipelas or urinary extravasation, or may occur as a sequela of certain fevers—particularly variola and scarlatina. The parts become greatly swollen, constituting the condition often spoken of as inflammatory oedema, and gangrene is apt to ensue. The treatment consists in making free incisions, and in elevating the parts and applying Avarm fomentations; quinia and iron may be given in pretty large doses, while the strength of the patient is kept up by the administration of concentrated food and stimulants. Gangrene of the Penis is a serious affection Avhich may result from either phimosis or paraphimosis, as it may, likeAvise, from traumatic causes, such as the introduction of the organ into a ring, the impaction of a calculus in the urethra, Avounds of the cavernous bodies, etc. Gangrene of this part has also been observed as the result of phagedaenic ulceration, of phlebitis of the dorsal vein, and of urinary extravasation; and has been seen in the course of low fevers. Usually the prepuce only is affected; but occasionally the skin of the whole penis or even the entire organ may be implicated. AVhen either the prepuce or the glans is threatened with gangrene, no time should be lost in slitting up the former, so as to relieve the part from tension. AVhen gangrene has actually occurred, little can be done beyond supporting the strength of the patient, and facilitating the separation of the sloughs as they become detached. Demarquay speaks favorably of the actual cautery as a means of preventing the spread of the disease. The affection may prove directly fatal, through simple exhaustion, through the development of pyamiia, or through the occurrence of secondary hemorrhage; or may indirectly cause death, according to Demarquay, by the patient falling into a state of ma- rasmus, caused by the impairment of the generative poAvers. In other cases, in spite of the loss of considerable portions of the penis, the procreative pow- ers of the patient have not been at all diminished. Herpetic and Aphthous Ulcerations on the penis are chiefly in- teresting on account of the probability of their being mistaken for chancroids (see p. 433). The treatment consists in the use of astringent applications, such as the oxide of zinc in powder, or lotions of borax, and in attention to the state of the general health. Thrombosis of the Corpus Cavernosum__Prescott Hewett has described two cases in Avhich, in persons of a gouty tendency, spontaneous thrombosis occurred in patches in the cavernous body of the penis. The chief interest attaching to the affection is its liability to be mistaken for syphilis or cancer, from either of wliich however it may be distinguished by its essentially chronic character, and by the fact that the inguinal glands are not involved. No treatment is required. Since the publication of Hewett's paper, similar cases have been described by Van Buren and Keyes, and by STRUCTURAL CHANGES IN THE PENIS AND SCROTUM. 949 HoAvard Marsh. Thrombosis of the dorsal vein of the penis has been ob- served by Lucas. Balanitis and Posthitis have already been considered (see p. 428). Structural Changes in the Penis and Scrotum. Hypertrophy of the Prepuce may result from long-continued irri- tation of the part, or may be due to a condition of Elephantiasis Arabum (see pp. 469, 505)—in Avhich case the subcutaneous tissues of the penis are commonly affected in a similar manner, as may be also the scrotum. The treatment consists in the excision of the enlarged prepuce and of a V-shaped piece from the dorsum of the glans penis, the sides of the wound being brought together Avith stitches. 528. Hypertrophy of the Corpora Cavernosa has been observed in one case recorded by J. G. Kerr, of Canton. The affection does not appear to admit of operative treatment. Hypertrophy or Elephantiasis of the Scrotum is chiefly seen in warm climates. The disease anatomically resembles what has been de- scribed as the fibro-cellular outgrowth (p. 469), and can only be removed by excision. When of moderate dimensions, the hypertrophied scrotum can be removed with little risk; but when, as not unfrequently happens, the part forms a pendulous tumor Aveighing from 40 to 80 or even 165 pounds (as in a case mentioned by Van Buren and Keyes), the operation becomes one of a formidable nature. To diminish the loss of blood, Avhich is always consid- erable, the tumor should be elevated above the rest of the body for some hours before the operation, as advised by Brett and O'Ferrall, and the neck of the tumor may he compressed with a clamp, as recommended by Fayrer, or with a running noose, as ingeniously suggested by Dr. Mac tier. If a hernia be present, this should first be fully reduced. The operation may be performed by introducing a director down to the penis, Avhich lies at the bottom of a sinus, deeply buried in the mass, and upon the director a catlin, wliich is made to transfix the superincumbent tissues and cut its way outAvards. The penis is now carefully dissected out and held up towards the abdomen, Avhen incisions are made on each side so as to expose the testes, which are similarly dissected out and turned up until the operation is completed. The tunica? vaginales, if diseased, are to be cut away, and then the whole mass separated by cutting across its Hypertrophy;r elephantiasis of the scrotum, m base close to the perineum. Hemor- ft Hindoo. (Titiey.) 950 - DISEASES OF THE GENERATIVE ORGANS. rhage is next to be suppressed, 50 or 60 ligatures being sometimes required for this purpose, and the wound is then to be simply dressed with oiled lint and alloAved to heal by granulation. The testes and penis quickly become covered, and cicatrization is usually completed in from six Aveeks to two months. If, in the case of a very large tumor, it is found that the dissection of the testes would prolong the operation beyond from three to five minutes, Fayrer advises that the attempt to save these organs should be abandoned, and the Avhole mass swept away as quickly as possible. Of 28 patients operated on by Fayrer, 22 recovered and 6 died, one from shock, and the other 5 from pyamiia. Dr. Kerr, of Canton, has modified this opera- tion by covering in the testes with flaps taken from the sides of the scrotum. Vegetations or Warts on the penis, Venereal Warts, as they are often, though incorrectly, called, have already been referred to (see p. 199). Vascular Tumors, or Angeiomata of the penis are occasionally met Avith, and may be treated by excision, the application of caustics, the establishment of a seton (Reeves), or e\Ten, as in a remarkable case reported by Parona, by amputation of the organ. The same surgeon has successfully employed injections of* chloral in a case of varix of the dorsal vein of the penis. Malignant Diseases of the Penis—The penis may be the seat of either epithelioma or scirrhus, the former, which is the more common affec- tion, ordinarily beginning in the pre- Fig. 529. puce, while scirrhus usually originates in the body of the penis, in the de- pression behind the corona glandis. Both of these forms of disease appear to be more common in the subjects of congenital phimosis than in those who are not thus affected, which is of itself a sufficient reason to induce the sur- geon to recommend circumcision in all cases of preputial contraction. Epi- thelioma of the penis may possibly be mistaken for exuberant vegetations or for chancre. From the former it may be distinguished by the indurated and infiltrated condition of the parts, Avhich is characteristic of the malignant af- fection, and from the latter by the history and course of the disease, the comparatively late implication of the inguinal lymphatic glands, and the ne- gative effect of antisyphilitic treatment. Treatment—In the case of epithelioma, if the nature of the affection be recognized before the glans has become involved, it may be possible to re- move the Avhole mass of disease by circumcision ; but at a later period amputation of the penis is the only resource Avhich offers a prospect of benefit, and the same operation is required Avhen the groAvth is of a scirrhous char- acter. Epithelioma of the penis. (From a patient in the Episcopal Hospital ) Amputation of the Penis, if performed at an early period, before the lymphatic glands have become involved, is quite a successful proceeding, EPITHELIOMA OF THE SCROTUM. 951 and often gives a long respite from the disease, if indeed it does not effect a permanent cure. The operation may be performed with either the Avire loop and galvanic cautery, the ecraseur, or the knife. The disadvantage Avhich attends the use of the ecraseur, is that the contraction which ensues in heal- ing is apt to diminish the calibre of the urethra, and thus lead to difficulty in micturition ; to avoid this, it has been recommended to introduce a flexible catheter, cut through this with the chain of the instrument, and leave the remnant in place during the process of cicatrization ; but it is not ahvays very easy to sever the catheter in this manner, and, unless great care be exercised, its end may escape from the surgeon's grasp and slip into the bladder. Upon the Avliole, the operation Avith the knife seems to be preferable under ordinary circumstances, though if it be necessary to amputate the organ very high up, the ecraseur may answer a better purpose. Thiersch and Dr. C.Johnston, of Baltimore, have thus successfully removed the entire organ, connecting the divided urethra with an artificial opening in the perineum. To prevent hemorrhage, in the use of the knife, a tape may be tied tightly around the root of the penis, and an assistant should grasp the part Avith his fingers to prevent the stump from being retracted beneath the pubis, or, as advised by Tyrrell, the penis may be transfixed with a large acupressure pin, behind which the tape is applied, the pin itself being left in place for several days, and until all risk of bleeding has passed by. The surgeon takes the glans, wrapped in lint, in his left hand, and draws the organ forAvards, so as to put its integument on the stretch ; he then cuts off the part to be removed Avith a sharp knife, either at a single stroke, or, Avhich I think better, divides first the cavernous bodies, and then alloAVs the organ to retract before sever- ing the urethra, Avhich is thus left rather longer than the rest of the penis. Bleeding is next to be checked, about five ligatures usually being required, Avhen the operation should be completed according to Ricord's plan, by split- ting the projecting portion of the urethra at three or four points and everting its mucous membrane, which is then attached to the skin by means of the interrupted suture. Another plan, suggested by "Watson, of Edinburgh, is to make a slit in the integument of the penis, and to pass the projecting ure- thra through this slit, so as effectually to prevent the occurrence of contrac- tion during the healing process. Unless the amputation be done very near the root of the organ, the pro- creative powers of the individual do not seem to be impaired by the operation. Non-malignant Tumors of the penis are occasionally met with, and may be removed Avithout infringing upon the integrity of the rest of the organ. Epithelioma of the Scrotum is chiefly observed in chimney-SAveepers,1 av hence it has been called chimney-sweeper's or soot cancer; it appears to be produced by the irritation caused by the con- tact of soot, beginning as a scaly or incrusted wart which soon ulcerates, and perhaps ultimately involv- ing the whole scrotum, the testis, and the inguinal and pelvic lymphatic glands. The treatment consists in complete excision of the groAvth, at as early a period as possible. 1 In the only cases seen by the late J. C. Warren, of Boston, hoAvever, the patients were not chimney-SAveepers. Fig. 530. Epithelioma of the scrotum. (Curling.) 952 DISEASES OF THE GENERATIVE ORGANS. Malformations and Malpositions of the Testes. Complete Absence of one or both Testes has occasionally been observed, but a more common condition is an Arrest in the Normal Descent of the Organ, the gland remaining in the abdominal cavity or in some part of the inguinal canal. In other cases a testis may pass through the femoral ring, may be found in the perineum, or, though lodged in the scrotum, may be inverted, so that the epididymis is placed in front of the body of the organ. Retained testes are liable to become inflamed, and are peculiarly predisposed to struc- tural degeneration. It would appear also, from the researches of Godard and Curling, that a retained testis either secretes no fluid, or that its secretion is destitute of spermatozoa ; hence a monorchid, or person with one undescended testis, depends for his procreative power upon the single gland which has reached the scrotum, while a cryptorchid, or person with both testes retained, though capable of coition, is necessarily sterile. Treatment___The treatment of malpositions of the testis is in most cases limited to palliative measures. If the gland be still within the abdomen at the end of the first year of life, Curling advises the application of a truss to insure its permanent retention. When the testis is above the external ring, it requires no treatment, unless it becomes inflamed, or is the seat of struc- tural degeneration. When at or just outside of the external ring, the gland is liable to slip backAvards and forAvards, and causes a good deal of pain Avhen pinched in the inguinal canal. Under such circumstances a truss should be used, the pad being applied if possible between the testis and ring ; if this cannot be done, the gland may be pushed into the canal and held there with a truss provided with a suitable obturator, as advised by Curling, or a truss with a concave or ring pad to receive the gland, may be employed, as recom- mended by J. Wood. If a testicle Avhich is retained in the inguinal canal becomes inflamed, the affection may at first sight be mistaken for strangulated hernia, but may com- monly be distinguished in the way described at page 793. The treatment consists in the application of leeches, folloAved by ice or hot fomentations, as most agreeable to the patient, with the internal administration of laxatives and saline diaphoretics. If the gland be subject to repeated attacks of in- flammation, the question of excision may properly be considered; the opera- tion is usually successful, but is attended Avith a certain amount of risk, from the proximity of the peritoneum. Excision is always required in case of structural degeneration of a retained testicle, and may also be practised Avhen the organ is situated in the perineum, in Avhich position it is constantly ex- posed to injury. Inversion of the Testicle is chiefly interesting when accompanied with hydrocele, the fluid then being found behind the organ, instead of in front of it, as is usually the case. H. Lee has recorded a curious instance of Temporary Disappearance of the Testicle, the organ having slipped up through the inguinal rinn-, which Avas dilated by the presence of a hernia. The patient was directed to go without the truss for a few days, when the missing gland reappeared. Dr. Humphry refers to a case in Avhich the organ similarly vanished durin"- the act of masturbation, but in this instance the disappearance was unfortunately permanent. Orchitis. Orchitis, or Inflammation of the Testicle, may result from traumatic causes, from rheumatism, from mumps, or from the spread of gonorrhoeal or other in- ORCHITIS. 953 Fig. 531. flammation from the urethra. In the latter cases the epididymis is commonly the part primarily affected, constituting the affection knoAvn as Epididymitis, Hernia Humoralis, or Swelled Testicle, Avhich has already been described at page 42G. The symptoms of orchitis are those of inflammation in gene- ral, the pain being very intense, and often radiating up the course of the spermatic cord. There is usually effusion into the tunica vaginalis (acute hydrocele), and there is often a great deal of constitutional disturbance. The treatment is essentially the same, no matter Avhat may be the origin of the affection. When the symptoms are very acute, I know of nothing which will afford such rapid relief as the puncture of the tunica albuginea, in the way recommended by Vidal (de Cassis) and H. Smith. In less acute eases, it may be sufficient to confine the patient to bed, and to keep the scrotum ele- vated and covered Avith cold lead-water and laudanum. Laxatives and ano- dyne diaphoretics, folloAved at a later period by quinia, may be administered internally. In chronic cases, in Avhich the enlargement of the organ continues after the subsidence of all acute symptoms, strapping of the testicle may be resorted to Avith advantage. This may be done with simple adhesiAre plaster, or Avith the plaster of am- moniac and mercury if there be any suspicion of a syphi- litic taint. Strapping the Testicle___The scrotum having been carefully Avashed and shaved, the surgeon draAvs the skin of the affected side upwards, so that the part which covers the testicle is tensely stretched over the organ. A strip of plaster is then applied circularly above the gland and drawn pretty closely, so as to isolate the part and prevent the other strips from slipping. These are noAv applied, in an imbricated manner, alternately in a longitudinal and transverse direction, until the Avhole organ is covered in and firmly and evenly compressed, no one strip, however, being draAvn so tightly as to pro- duce excoriation. When properly applied, the effect of strapping in promoting absorption, and thus reducing the size of the part, is very striking. The dressing commonly requires renewal every day or every other day, and upon each occasion the scrotum should be Avell Avashed Avith Castile soap and Avater, so as to keep the skin in a healthy condition. Abscess and Hernia of the Testicle—Abscess is an occasional sequel of orchitis, the pus being usually formed in the tissues of the scrotum rather than in the testicle itself, but sometimes originating beneath the tunica albuginea, in the proper gland struc- ture. In the former case the affection is of but little consequence, the abscess healing Avithout difficulty after the evacuation of its contents ; but when the testicle itself is the seat of suppuration, a fistulous opening is apt to remain, through Avhich a portion of the seminiferous tubules may protrude, in the form of a vascular, fungoid mass. The treatment of this Hernia of the Testis, as it is called, consists in the topical use of stimulating astringents, such as the red oxide of mercury, with pressure—which maybe applied with adhesive Hernia of the testicle. (Curling.) Strapping the testicle. (Velpeau.) Fig. 532. 954 DISEASES OF THE GENERATIVE ORGANS. strips, or, better, as recommended by Syme, by making elliptical incisions around the protruding mass and loosening the surrounding integument, Avhich is then united over the protrusion Avith sutures—thus making the skin of the part exercise the requisite compression. If one testicle only be affected, and the patient's health begins to fail under the long continuance of the disease, castration may occasionally be justifiable. Neuralgia of the Testis. The seat of pain may be the epididymis, the body of the testicle itself, or the spermatic cord. The part is usually extremely sensitive to the touch, and there may be slight SAvelling Avithout any evidence of positive disease. The pain is often of a paroxysmal character. The affection is sometimes associated Avith an irritable condition of the urethra, and Avith the occurrence of involuntary seminal discharges. In other cases it depends upon the exis- tence of varicocele, or may be sympathetically excited by hemorrhoids. Often, however, neuralgia of the testicle exists Avithout any apparent cause. The treatment consists in removing any source of irritation that can be dis- covered, and, in cases of obscure origin, in the administration of tonics and antispasmodics, and in the topical use of sedatives and anodynes. Galvanism has occasionally proved serviceable in these cases. Castration has been recommended, and is often desired by the patient. It is, hoAvever, an unjus- tifiable operation under these circumstances, as being totally uncalled for in cases of local origin, and only capable of affording temporary relief, if any, in those of a constitutional nature. Hydrocele and Hematocele. Hydrocele of the Tunica Vaginalis, or simply Hydrocele, consists in a col- lection of serous fluid in the tunica vaginalis. Several varieties of the disease are described by surgical Avriters, as the congenital, the acquired, and the encysted hydrocele. Inguinal hydrocele is a name used by Holthouse for hydrocele occurring in connection with an undescended testis. Congenital Hydrocele results from an imperfect closure of the com- munication between the tunica vaginalis and the peritoneal cavity. This form of hydrocele is observed in infants, and may be recognized by the fluid flow- ing back into the abdominal cavity Avhen the scrotum is elevated or com- pressed. Congenital hydrocele usually undergoes a spontaneous cure by the closure of the vaginal process of peritoneum; if, as often happens, the hydro- cele be accompanied Avith hernia, a truss should be Avorn to prevent the descent of the intestine. Should a congenital hydrocele not disappear spon- taneously, discutient remedies, such as a lotion containing muriate of am- monia, or the tincture of iodine (diluted), may be applied to the scrotum, or acupuncture may be tried, or the fluid may be evacuated Avith an exploring trocar and canula, and a little alcohol injected while compression is maintained upon the inguinal canal. This plan, which is recommended by Richard, is, however, necessarily attended with some risk of peritonitis. Acquired Hydrocele may originate in an attack of orchitis, which, as has been mentioned, is usually accompanied with effusion into the tunica vaginalis, but more commonly begins as a chronic affection, sometimes follow- ing a bloAv, but often being assignable to no particular cause. It may occur at any age, but is probably most common in infants, and in adults about the middle period of life. HYDROCELE. 955 The symptoms are SAvelling, beginning at the loAver part of the scrotum, and attended with a sensation of Aveight and dragging, but rarely Avith pain. The sAvelling is at first (usually) soft, fluctuating, and elastic, but ultimately becomes tense and hard, and assumes a pear-like shape which is very charac- teristic. The size varies from that of a lien's egg to that of a large orange, sometimes even exceeding the latter measurement. As the SAvelling creeps up the cord to the external abdominal ring, it covers over and partially con- ceals the penis. The diagnosis can usually be made Avithout difficulty, by noting the pyri- form character of the tumor, and by observing that the SAvelling of hydrocele is translucent Avhen examined by transmitted light. For this test the patient should be in a dark room, and the surgeon should grasp the neck of the hydrocele with one hand, so as to put the integument on the stretch, while the edge of the other hand is applied to the convexity of the swelling so as to shade it from side rays ; a lighted candle or lamp being then held by an assistant close behind the tumor, this will in the large majority of cases be found translucent. This test may, hoAvever, occasionally fail, either from the dark color of the contained liquid, or from the thickness of the superincumbent tissues, Avhile on the other hand a solid tumor may occasionally be translucent, as in a case of round-celled sarcoma, recorded by Lucke, and in one of hernia (in a child), mentioned by HoAvse; hence in some circumstances an explora- tory puncture or incision may be required to reveal the true nature of the affec- tion. For the diagnosis from hernia, see page 793. The fluid of a hydrocele varies in quantity in different cases, the amount being usually from six ounces to a pint, but occasionally reaching to several quarts ; it is commonly of a straw color and limpid, and is albuminous, coagulating sometimes into a solid mass Avhen heated; in other instances it is of a dark broAvn color, from the admixture of blood, and it then usually con- tains cholestearine. It is occasionally of a milky or chylous character, and contains leucocytes and fatty matter. In some rare cases it coagulates spon- taneously. Tbe tunica vaginalis, or Sac of the Hydrocele, and its other coverings, are usually thinned by distension, but otherAvise normal; in some cases, hoAvever, the sac is thickened—becoming the seat of a pseudo-mem- branous formation which may send prolongations across the cavity in the form of bands or septa—or more rarely undergoes calcification ; in these cases the resulting pressure may cause atrophy of the testicle, but in most instances this organ is normal or slightly enlarged. The position of the testis, in hydrocele, is almost ahvays at the loAver and posterior part of the scrotum, but it may occasionally be in front (from congenital inversion of the organ), or its position may be altered by the formation of adhesions between the op- posing surfaces of the tunica vaginalis. The position of the testis should ahvays be, if possible, ascertained (by examination with transmitted light) before resorting to operation. The two tunicse vaginales are affected Avith about equal frequency, and double hydrocele is occasionally observed ; in this case the existence of a communication with the abdominal cavity may always be suspected. The treatment of acquired hydrocele may be either palliative or radical. In infants and young children, a cure may often be effected by the application of discutients, or by acupuncture, as in the congenital form of the affection ; and, even in adults, a single tapping (which constitutes the palliative mode of treatment), Avill occasionally afford permanent relief, though, more commonly, the effusion returns after each tapping, the hydrocele re-acquiring its original size in the course of a feAV months. Occasionally the intervals between the successive returns of the disease become gradually longer, until, after repeated tappings, the affection ultimately disappears. 956 DISEASES OF THE GENERATIVE ORGANS. Tapping for hydrocele ; a, introduction of trocar ; b, position of canula. (Erichsen.) Tapping a Hydrocele, or the Palliative Operation, is attended with very little risk, though, in aged subjects, death may occasionally follow from the occurrence of diffuse inflammation of the connective tissue of the part. The surgeon, having determined the position of the testicle, grasps the hydro- cele with his left hand so as to make the skin tense, and choosing a point which is at the opposite side from the gland, and free from subcutaneous veins, introduces, with a quick plung- ing motion, a small trocar and canula, at about the junction of the middle and loAver thirds of the scrotum. The instrument should be at first thrust directly backAvards, but as soon as the point has entered the sac should be inclined in an upAvard direction (Fig. 533), so as to avoid Avounding the testicle—an accident Avhich, though rarely folloAved by any evil result, should, if possible, be avoided. The trocar is then withdraAvn, Avhen the fluid escapes through the canula, and is caught in any convenient receptacle. The operation is attended with very little pain, and the patient, need not therefore be etherized; he may be placed in the recumbent position, or, Avhich I prefer, if the hydrocele is not a very large one, may sit on the edge of a high chair, or stand, leaning against a table. The surgeon should ex- amine bis trocar before using it, to make sure that it has a good point, and that it fits and slips easily in the canula; from neglect of this precaution, I haA-e seen a surgeon introduce his instrument, and then find that the trocar could Avith great difficulty be extricated from the canula, into which it was firmly rusted. After the Avithdrawal of the canula, a piece of sticking-plaster may be put over the puncture, but no further after-treatment is required. Bradley, of Manchester, recommends that the part should be tightly strapped after tapping, and believes that thus re-accumulation may be prevented. The palliative treatment may be properly employed if the patient cannot spare the requisite time from his ordinary avocations to undergo the operation for the radical cure, and in the case of very old or feeble men Avho might illy support the risk of the operation. Simple tapping may also be employed once or twice as a preliminary to the radical treatment, which is most apt to succeed when the disease is in a chronic condition. Radical Treatment of Hydrocele__Various operations are per- formed Avith a vieAv of effecting a permanent cure of hydrocele, those most worthy of mention being the methods by injection, by the formation of a seton, by incision, and by excision of the tunica vaginalis. 1. Injection___The fluid of the hydrocele having been evacuated Avith the trocar and canula, some irritating substance may be injected through the lat- ter, so as to excite inflammation in the tunica A-aginalis. The modus ope- randi of injections, in cases of hydrocele, appears to be in most cases the formation of inflammatory lymph, wliich glues together more or less com- pletely the opposing surfaces of the sac; in some instances, however, no adhe- sions have been found on dissection, and the cure has appeared, therefore, to be due to some intangible change in the tunica vaginalis itself. The injec- tion treatment is very rarely followed by suppuration. Various substances have been employed for the injection of hydrocele, the best being the tincture HYDROCELE. 957 of iodine, as originally suggested by Sir J. Ranald Martin. Some surgeons use the tincture largely diluted, allowing the injected fluid to Aoav out again through the canula before the latter is withdraAvn ; but Syme's plan, which I have ahvays followed, and which, Avhen properly carried out, almost never fails, is to inject a small quantity of the pure tincture (f'5j to iij, according to the size of the SAvelling), and alloAv it to remain in the sac. The injection may be made Avith an ordinary penis syringe ; or, which is more convenient, a gum-elastic bag with a nozzle and stopcock ; and it is better to use a pla- tinum canula instead of one made of silver, as the latter metal may be cor- roded by contact with the iodine. After the injection, the canula should be cautiously withdrawn, so as to preA-ent the escape of the fluid, which should then be diffused over the whole surface of the sac by giving the part a shake. A good deal of pain usually folloAvs the operation, and the scrotum com- monly SAvells to its original size in the course of a few days, the swelling then gradually subsiding until the cure is complete. In this stage of the treatment, the progress of the cure may be hastened by systematically strap- ping the part with adhesive plaster. The patient should be confined to bed, or at least to a lounge, for tAvo or three days ; but after that may resume his ordinary occupations. 2. The Seton.—Should the injection treatment fail (which, I may repeat, will very seldom happen if the surgeon use the pure tincture of iodine, and allow it to remain in the sac), the next best plan is to establish a seton. This may conveniently be done by replacing the trocar in the canula, after eAacuating the contents of the sac, and then making a counter-puncture from within outAvards ; the trocar is now withdrawn, and an eyed-probe, carrying two or three strands of silk, passed through the canula, Avhich is finally re- moved, leaving the threads in place. The ends are then loosely knotted and the patient sent to bed. The threads may, in most instances, be remoA'ed the next day, or the day after; but occasionally must be left a week or even longer, to produce the required amount of inflammation. Furneaux Jordan recommends that, to increase the irritation, the threads should be moistened with iodine liniment. The use of wire was recommended by Simpson, with the expectation that it would be less apt to excite troublesome suppuration than the seton made Avith silk. The experience of surgeons generally has, however, shoAvn that such is not the case, Avhile it has been found that the wire seton is by no means a certain remedy. 3. Incision___This consists in laying open the sac and stuffing the Avound Avith lint, so as to induce suppuration. Though an efficient mode of treat- ment, this is in most cases unnecessarily severe, and is not entirely free from risk. It is particularly adapted to cases in Avhich the thickness of the sac prevents the diagnosis from being made by the examination with transmitted light; if such a case be really one of hydrocele, the incision Avill suffice for its cure, while, if it turn out to be one of solid tumor, the Avound can be util- ized for the operation of castration. 4. Excision___This consists in laying open the sac, and carefully dissect- ing out the tunica vaginalis. If the operation succeeds, the cure is necessa- rily permanent ; but the procedure is a dangerous one, and should be kept as a last resort for cases that resist all other modes of treatment. Encysted Hydrocele (Spermatocele).—In this affection the fluid is not contained, properly speaking, in the tunica vaginalis, but in an independent cyst projecting from the surface of the testicle, or more commonly from the epididymis. In the latter case, the fluid of the cyst differs from that of an ordinary hydrocele in being watery or milky, and in containing spermatozoa ; and the name spermatocele is therefore properly applied to these, which be- 958 DISEASES OF THE GENERATIVE ORGANS. long to the class of seminal cysts (see p. 465). Those comparatively rare specimens of encysted hydrocele, however, in which the cyst projects from the body of the testis, cannot be so classed, as they do not appear to contain sper- matozoa—their fluid being of a serous character like that of the common hydrocele. This variety, as pointed out by Osborn, appears to originate in dilatation of the so-called " hydatid of Morgani," a remnant of the Miillerian duct of foetal life. The diagnosis of the encysted from the other forms of hydrocele, can usually be made by observing the position of the testis in rela- tion to the sac, Avhich, in the encysted variety of the disease, commonly pro- jects from the surface of, but does not surround, the gland. The treatment is the same as for the ordinary acquired hydrocele. Fibrous or Fibroid-cartilaginous bodies are sometimes found in the sac of a hydrocele ; they resemble in structure the rice-like bodies found in synovial bursie, and, if recognized during life, may be removed by a simple incision. Hydrocele of the Spermatic Cord__Three varieties are described by systematic writers, viz.: (1) the simple hydrocele of the cord, which con- sists in an accumulation of serous fluid in the cavity wliich often persists in the funicular portion of the \Taginal process of the peritoneum ; (2) the encysted hydrocele of the cord, in which the fluid is contained in an indepen- dent cyst developed in this situation ; and (3) the diffused hydrocele of the cord, a rare affection, referred to by Pott and Scarpa, Avhich appears to con- sist in an cedematous infiltration of the areolar tissue of the part. For the diagnosis of hydrocele of the cord from hernia, see page 792. The treatment of the simple and encysted varieties, consists in tapping, followed, if necessary, by the injection of iodine, or the formation of a seton. For the diffused hydro- cele—if any treatment Avere required—the external use of iodine or other sorbefacients might be resorted to. Hydrocele of the Seminal Vesicle is the name applied by N. R. Smith to a cyst developed in connection with the organ referred to ; it is a rare affection and may be mistaken for a distended bladder, but the diagnosis can be readily made by the use of a catheter and by the introduction of a finger into the rectum. The treatment consists in evacuating the contents of the cyst by tapping through the rectum, as in cases of urinary retention. (See page 908.) Hematocele.—Of this there are three varieties, viz.: (1) hematocele of the tunica vaginalis, consisting in an effusion of blood into this sac, and often supervening upon an ordinary hydrocele; (2) encysted hematocele, in which the blood is effused into the sac of an encysted hydrocele; and (3) hematocele of the cord, in Avhich the effusion occupies a position correspond- ing to that of a hydrocele of this part. Hamiatocele may result from traumatic causes—such as a blow or squeeze, or possibly the Avound of a small vessel inflicted in the operation for hydrocele—or may originate spontaneously from the rupture of a spermatic vein. In the spontaneous cases, Avhich are com- paratively rare, the hematocele sometimes attains a very large size, and the affection is, under these circumstances, attended with considerable danger. The blood of a hematocele is at first of course fluid, and may continue in this state for many years ; in other cases, it undergoes partial coagulation, the clots sometimes assuming a laminated arrangement like that seen in the sac of an aneurism ; or the blood corpuscles may become disintegrated, when the fluid of the hamiatocele has a dark and grumous appearance, and often con- VARICOCELE. 959 tains cholestearine ; if decomposition of the blood occurs, suppuration of the sac may ensue, and perhaps lead to fatal consequences. The symptoms are much the same as those of hydrocele, except that the part is not translucent when examined by transmitted light. The diagnosis, in the early stages of the affection, can commonly be made by observing that the swelling occurs rapidly, and usually after a bloAv—and yet is obviously not due to orchitis—while the absence of translucency, and the existence of ecchymosis, serve to distinguish the affection from hydrocele. When hamia- tocele has passed into a chronic condition, the diagnosis is more difficult, and in many cases the disease has been mistaken for cancer, and vice versa. Humphry points out that the cancerous testis steadily increases in size, Avhile the growth of a hematocele is irregular, and the swelling sometimes even undergoes diminution. The diagnosis from hernia has already been given at page 793. Treatment___In many cases hematocele undergoes a spontaneous cure; the hemorrhage ceases, and absorption then gradually occurs as in the case of blood effused in other parts of the body. Hence, in the early stages of the affection, the treatment should be merely palliative, consisting in the enforce- ment of rest, with elevation of the scrotum, the application of cold, etc. After a feAV days, the patient may go about with a suspensory bandage. If, how- ever, the hematocele be in a chronic state, tapping may be resorted to, and will occasionally effect a cure; should the sac refill, its contents will probably be thinner and more serous than at first, and the case Avill thus gradually be- come assimilated to one of hydrocele, when it may be treated with iodine injections. If the hematocele contain a large proportion of coagulum, it will probably be necessary to lay the sac open and allow it to heal by granulation. This should not, hoAvever, be done during the early stages of the affection, particularly in a case of the spontaneous variety, lest dangerous or even fatal hemorrhage should take place from the ruptured vein, which is sometimes very much enlarged. Before either puncturing or incising a hsematocele, the surgeon should, if possible, determine the position of the testis ; this cannot be ascertained, as in the case of hydrocele, by examination with transmitted light, but much information may often be gained by tracing doAvn the cord, and by noting the sensations of the patient, who usually experiences a cha- racteristic, sickening pain Avhen pressure is made on the testicle. Varicocele. Varicocele, or Cirsocele (varicose enlargement of the veins of the spermatic cord) is a very common affection, existing, according to Humphry, in about ten per cent, of all male adults. The causes of varicocele are those of varix in general; the anatomical peculiarities of the spermatic veins render them particularly susceptible to the affection, which is chiefly seen in those of lax and feeble habit, and is often hereditary. Varicocele is much more frequently seen on the left side than on the right: this appears to be due to a combina- tion of causes, such as the position of the left testicle, which is usually more dependent than the right; the obstacle to the return of blood which exists on the left side, from the left spermatic vein joining the renal vein at a right angle, instead of opening directly into the vena cava, as is done by the riglit spermatic vein ; the comparative deficiency of valves in the left spermatic vein as compared with the right (first pointed out by Dr. J. H. Brinton, of this city); and the exposure of the left spermatic vein to pressure, from accu- mulations of fecal matter in the sigmoid flexure of the colon. Symptoms___Varicocele forms a pyramidal swelling in the scrotum, with its base downwards, and its apex extending upAvards towards the ingui- 960 DISEASES OF THE GENERATIVE ORGANS. nal canal. The swelling has a peculiar knotted and convoluted feel, and the sensation conveyed to the hand is often compared to that Avhich would be given by a bunch of earthworms. The tumor increases Avhen the patient stands or Avalks, and almost if not quite disappears Avhen he lies down. It is sometimes, but by no means ahvays, attended Avith a feeling of weight and even pain, Avhich is increased by exercise, and is apt to be Avorse in summer, when the scrotum is more relaxed and pendulous than at other seasons. Vari- cocele sometimes attains a considerable size, filling the scrotum and envelop- ing the testicle, which may undergo diminution in bulk from the pressure of the overlying veins. Rupture of a varicocele may occur from a blow or other injury, causing great effusion of blood ; Erichsen mentions a case of this kind in which, the tumor having been opened, the patient died from venous hemorrhage. The diagnosis of varicocele from hernia (the only affection Avith which it is likely to be confounded) has been given at page 793. Treatment___In the large majority of cases, no treatment whatever is required: the patient may wear an elastic suspensory bandage, to support the part and relieve the feeling of weight which sometimes accompanies the affec- tion, but even this apparatus is in many instances voluntarily throAvn aside. To lessen the capacity of the scrotum, its loAver part may be drawn through a soft metallic ring covered with leather, or one of vulcanized India-rubber; this plan, Avhich was suggested by Yvkrmald, Avould certainly be attended Avith less risk than that by Avhich it appears to have been suggested, viz., excision of the loAver portion of the scrotum, as recommended by Cooper and Briggs, and more recently by M. H. Henry, of New York, who has devised an inge- nious clamp for the prevention of hemorrhage during the operation, an object sought to be attained by Hutchison, of Brooklyn, by first transfixing the scrotum half a dozen times with a large acupressure needle. The hypodermic injection of ergotine is recommended by tAvo Italian surgeons, Drs. Bertarelli and Cittaglia, and is certainly Avorthy of further trial. But the best palli- ative remedy for varicocele is, I think, the application of a light truss, as recommended by Curling and Ravoth, so as to break the column of blood in the spermatic veins (Avithout compressing the artery), and thus remove the pressure from the dilated vessels. Radical Cure of Varicocele__In a few cases, more energetic mea- sures may be required ; a great many operations besides that of Cooper, above referred to, have been proposed for the radical cure of varicocele, the best, probably, being those of Ricord, Vidal (de Cassis), H. Lee, J. Wkod, and Annandale. (1.) Ricord's Method consists in introducing subcutaneously, in opposite directions but through the same apertures, two double ligatures, one beneath the spermatic veins (isolated from the vas deferens), and the other above them, so that there shall be a loop and two ends of ligature on each side ; the ends are then threaded through the corresponding loops, and attached to a light yoke provided with a screw, by daily turning wliich they are constantly drawn tight—thus effectually strangulating and ultimately cutting through the veins, from which the ligatures drop in the course of the second or third week. (2.) VidaTs Operation consists in passing a steel pin, perforated at both ends, below the veins and between them and the vas deferens, and through the same apertures a silver wire above the veins, and between them and the skin ; the wire is threaded through the perforations at each end of the pin, which is then rotated in such a way as to twist the wire and roll up and firmly com- SARCOCELE AND TUMORS OF THE TESTIS. 961 press the veins. The wire is twisted more and more tightly each day until the veins are cut through (usually at the beginning of the second week), when the pin and Avire are easily withdrawn together. Bradley has simplified this method by passing a long pin above and then below the veins, thus compress- ing them as in the "Aberdeen" method of acupressure. (3.) Lee's Method consists in passing two needles beneath the veins, and between them and the vas deferens, about an inch apart—pressure being then made by means of elastic bands passed over the extremities of the needles. The veins, which are thus acupressed at tAvo points, are next divided subcu- taneously betAveen the needles, which may be removed on the third or fourth day after the operation. Should the division of the veins be followed by bleeding, which may happen from some vessel being cut that was not included by the needles, the hemorrhage can be readily arrested by the introduction of a third needle—below the point of division if the bleeding be venous, and above, if it be of an arterial character. I have varied this operation by acu- pressing the veins between hare-lip pins and loops of silver wire passed subcutaneously. (4.) Wood's Method is an ingenious modification of Ricord's, in which the veins are surrounded subcutaneously with a metallic ligature ; the ends of the Fig. 534. .<■■& Wood's instrument for varicocele. ligature pass through and are secured to a light spring, by the action of Avhich the Avire is constantly drawn tight. A somewhat similar method is practised by Barwell. (5.) Annandale's Method consists in excising a portion of the enlarged vein, as practised by Marshall and Steele in cases of varix of the extremities; hemorrhage may be arrested by acupressure as in Lee's operation. This mode of treatment has also been successfully employed by Mr. Howse. Rigaud simply exposes the vein without removing any portion of it. These operations (of which Lee's seems to me upon the Avhole the best) are all attended with some risk, and can only be justifiable in exceptional Sarcocele and Tumors op the Testis. Sarcocele is a general term, commonly but rather unfortunately applied tc all solid enlargements of the testicle. Surgeons speak of several varieties of sarcocele, as the simple, the tuberculous or scrofulous, the syphilitic, the cystic, and the malignant. 61 962 DISEASES OF THE GENERATIVE ORGANS. Simple Sarcocele is the chronic enlargement of the testis which results from inflammation of the organ. The affected gland is moderately increased in size, smooth and rather hard to the touch, though Occasionally semi-fluc- tuating in parts, and someAvhat painful and tender; the cord also is, in most cases, thickened and indurated. When cut into, the testis is found to be infiltrated with lymph in various stages of organization or fatty degeneration, the latter condition giving the appearance of yeliOAvish spots Avhich are often mistaken for tubercle. Suppuration occurs in some cases, and may be fol- lowed by hernia of the testis. Simple or inflammatory sarcocele is often accompanied Avith effusion into the tunica vaginalis, constituting Hydro- sarcocele. The treatment consists in strapping the testicle, with the occasional application of a feAV leeches, and attention to the state of the general health ; hernia of the testis is to be treated as described at page 953. Tuberculous Sarcocele__A deposit of true tubercle in the testis is, I believe, a less common affection than is ordinarily supposed, many of the cases which are called tuberculous sarcocele being really instances of simple enlargement from chronic inflammation, occurring in persons of a scrofulous diathesis. True tubercle in the testis, according to CarsAvell, Curling, and Salleron, is first developed as an intra-tnbular affection, but, according to Rindfleisch, VircliOAv, and other modern German pathologists, originates pri- marily in the interstitial areolar tissue. Causes___The causes of tuberculous sarcocele are involved in some ob- scurity. It is ordinarily said to folloAV gonorrhoea or sexual excess, or to be due to some traumatic injury of the part; but, according to Salleron (avIio has published an elaborate memoir on the subject, based upon an analysis of 51 cases), the true tuberculous sarcocele never follows these affections, Avhich are common causes of the simple sarcocele, except as a coincidence. His theory is that tubercle is deposited in the testis in infancy, as a manifestation of the tuberculous diathesis, but that the affection is not called into activity until after the period of puberty, when the generative organs become subject to functional excitement. Symptoms.—Tuberculous sarcocele commonly begins in the epididymis, but ultimately involves the whole testis, forming a large, nodulated, and usually indolent mass. In some cases, hoAvever, the enlargement is uniform, smooth, and semi-elastic. In the nodulated variety of the disease, one or more of the nodules gradually inflame and become adherent to the skin, abscesses forming, and perhaps leading to the occurrence of fungous protrusions, or hernie of the testis, and the greater part of the gland thus being, in some instances, gradually extruded from the scrotum. Both testicles are usually successively involved. The vasa deferentia, vesicule seminales, and prostate, are often similarly affected, and the patient may present evidences of phthisis, or of scrofulous disease of the lymphatic glands or other organs. The affection may be com- plicated Avith hydrocele. Treatment—The treatment consists in attention to the state of the general health, in regulation of the diet, and in the administration of cod-liver oil, iron, iodine, etc. The patient should live as much as possible in the open air. The part should be supported in a Avell-fitting suspensory bandage, and ad- vantage may be derived from the occasional application of iodine, or of local sedatives if there be much cutaneous inflammation. Humphry recommends that, in very bad cases, the sinuses should be laid open, tbe scrofulous matter turned out, and the parts stimulated to healthy action by the application of nitrate of silver. Verneuil recommends the actual cautery. Castration can SARCOCELE AND TUMORS OF THE TESTIS. 963 be justifiable only Avhen the general health is evidently suffering from the drain caused by the local affection. Syphilitic Sarcocele, in both of its varieties, has already been de- scribed (p. 449). The treatment is that of syphilis in general—mercury being particularly applicable in the early or ''interstitial," and iodide of potassium in the late or " gummy," form of the disease. Cystic Sarcocele—This, which was called by Sir Astley Cooper the "• Hydatid Testis," belongs to the fibro-cystic variety of tumor (see p. 472). The cysts themselves originate, as shown by Curling, in dilata- Fig. 535. bular rather than pyriform, and its AArant of translucency when examined with transmitted light. From malignant sarcocele it may be distinguished by its sloAver growth, and the absence of glandular implication and of cachexia. In some instances, hoAveAer, the diagnosis can only be made by puncturing the growth with a trocar and canula—when, if the case be one of cystic sarcocele, a feAV drops of serous fluid will probably be evacuated by each puncture, from the successive opening of different cysts—or even by microscopical examina- tion after removal. Treatment.—This consists in castration, which may be performed as soon as the nature of the case has been ascertained. Congenital Dermoid Cyst__Another form of cystic disease of the testicle is the congenital dermoid cyst, Avhich usually contains bone, teeth, or hair, and is believed by many Avriters to be an example of the malformation known as "foetal inclusion." Cases of this affection, Avhich is one of great raritv, have been recorded by several surgeons, among others by Prof. Van Buren, of New York. In the case observed by this distinguished surgeon, the patient, a child 2^ years old, had been treated (for what Avas supposed to be a hydrocele) by the establishment of a seton, which led to much suppu- ration and the protrusion of a large fungous mass. The treatment consists in castration, unless, as occasionally happens, the growth be entirely external to the testicle, when excision of the tumor alone would be sufficient. Other Non-malignant Growths are occasionally found in the tes- ticle, as the fibrous, fibro-cellular, cartilaginous, etc. The diagnosis from 964 DISEASES OF THE GENERATIVE ORGANS. the simple and syphilitic forms of sarcocele, with which alone they are apt to be confounded, can be made by watching the effect of remedies, which, in the case of tumor, Avould of course be negative. The treatment consists in castration. Fatty tumors have been observed in the spermatic cord, from Avhich situation they may be removed by excision. Malignant Sarcocele, or Cancer of the Testis, is almost always of the encephaloid variety, though both scirrhous and melanotic growths have been occasionally met with in this organ. In malignant sarcocele, the body of the testis is usually first involved, and the organ, Avhen cut into, exhibits masses of medullary cancer, in various stages of growth or degeneration, often mingled with cysts or cartilaginous nodules. The affection may occur at any age, but is most common in youth and early adult life. The symptoms are the presence of a rapidly groAving solid tumor—its growth is much more rapid than that of any other form of sarcocele—the mass being smooth, and at first uniformly firm to the touch, but afterAvards soft, elastic, and semi-fluctuating in spots, Avith enlargement of the scrotal veins, and ultimately turgescence and thickening of the cord. The deep iliac and lumbar lymphatic glands are involved at an early stage of the dis- ease, the inguinal glands not being affected until a later period. The tunics of the testis become very much distended by the enlarging tumor, and ulti- mately give way—when the growth becomes adherent to the scrotum; ulceration then follows, and allows the protrusion of a fungous mass. This stage of the disease is comparatively seldom seen at the present day, be- cause the nature of the case is recognized, and castration resorted to, at an earlier period. The growth is attended with very little pain at any time, and the general health of the patient does not suffer in the early stage, though cachexia is ultimately developed. One testicle only is commonly affected. The diagnosis from other forms of sarcocele can usually be made by ob- serving the very rapid growth of the tumor, its unilateral character, the en- largement of the scrotal veins, and the Avant of benefit from treatment; but the diagnosis from cystic sarcocele is often impossible until after removal, and even then without careful microscopical examination. From opaque hydro- cele and from hematocele, malignant sarcocele may be distinguished by ob- serving its weight and the sense of fluctuation Avhich it affords in spots, and, if necessary, by an exploratory incision ; this is better than puncture with a trocar, because, as pointed out by Humphry, the quantity of blood which Aoavs through the canula from an encephaloid testicle may be so great as to lead to the supposition that the case is one of hematocele. The prognosis is very unfavorable, death commonly taking place within two years, from the implication of the deep-seated glands, and from the occur- rence of secondary deposits in the lungs and other viscera. The only treatment Avhich offers the slightest hope of benefit is castration, and this operation is, as a rule, justifiable only in the early stages of the affec- tion, before the pelvic and lumbar glands have become involved__a point wliich can be determined by careful palpation of the abdomen. Castration.—The operation of castration, or removal of a testicle is thus performed : The part having been shaved, and the patient etherized, the surgeon grasps the posterior part of the tumor with his left hand, so as to make the scrotum tense in front; a longitudinal incision is now made from opposite the position of the external abdominal ring to near the bottom of the scrotum, wliich is then peeled off, as it Avere, by a feAV strokes of the knife until the gland hangs merely by the spermatic cord. The division of the cord FUNCTIONAL DISORDERS OF MALE GENERATIVE ORGANS. 965 is the most important part of the operation; this may be conveniently done Avith the ecraseur, but may be equally well accomplished with the knife —bleeding in the latter case being prevented by previously ligating Fig. 536. or acupressing the cord en masse; or the cord may be firmly held by an assistant, and its arteries tied separately after division. The pre- cise point at Avhich the cord is divided is of no consequence in the excision of non-malignant groAvths, and hence the surgeon may, if it be found more convenient, secure the cord before completing the dis- section of the tumor. In castra- tion for malignant disease, how- ever, it is important to cut the cord at as high a point as possible, and in these cases it is therefore better to dissect out the testicle, and carry the dissection up to the abdominal ring—then transfixing the cord with a double ligature, tying it in tA\To halves, and divid- ing it a little lower down, in the Avay already described. It is sometimes recommended that an elliptical por- tion of the scrotum should be removed, if the tumor be large ; but the skin of this part shrinks so much after the operation, that sucn a course can rarely be necessary. The after-treatment consists in simply bringing the edges of the Avound together, Avith or without stitches, as may be preferred, and in applying cold water dressing. Division of spermatic cord in castration. (Erichsen.) Functioxal Disorders of the Male Generative Apparatus. Impotence may result from several different conditions, of Avhich some are, wliile others are not, remediable. 1. Malformation or Mutilation of the Genital Organs may cause impo- tence, occasionally curable by operation (see page 944), but more commonly irremediable. 2. Debility of the Nervous Centres, folloAving severe illnesses, or attendant upon diseases in which the general nutrition is impaired, may render the patient temporarily or permanently impotent. The treatment consists in the adoption of means to improve the general health, the exhibition of tonics, such as iron, quinia, strychnia, and phosphorus, sea-bathing, etc. 3. Traumatic or other Lesions of the Cerebro-Spinal Servous System— Impotence from this cause is commonly permanent; the treatment Avould be that of the particular affection to which the impotence was due. 4. Temporary, or rather imaginary, impotence may arise from Mental Per- turbation or Over-excitement. This condition is chiefly met Avith in first attempts at coitus, Avhether sanctioned or not by the matrimonial tie. The affection is, I believe, never permanent. 5. Morbid Excitability of the Genital Organs, attended with involuntary seminal emissions (spermatorrhoea), occasionally gives rise to impotence, and is a very intractable affection, simply because it is often impossible to prevent the continued activity of the causes to which it is originally due. The com- 966 DISEASES OF THE GENERATIVE ORGANS. monest cause of this condition is probably onanism ; though it may also arise from premature or excessive indulgence in venery—and is kept up by impure habits of thought or conversation, reading obscene books, or gloating over lascivious pictures—while in its milder forms it may originate from irritation of neighboring organs, as the bladder or rectum. Seminal Emissions are by no means necessarily a sign of disease ; indeed, during early manhood, an occasional discharge of spermatic fluid during sleep, is an almost unavoidable attendant upon virtuous celibacy ; but when the emissions occur in the day as Avell as at night, and are very frequently repeated, they certainly indicate an unnatural state of debility and irrita- bility of the sexual apparatus. In the worst cases the patient is rendered impotent, by the emission taking place without any or with such slight erec- tion that penetration is impossible. Spermatorrhoea, as this affection is called—rather unfortunately, for the seminal flux is a mere symptom—is chiefly met with betAveen the periods of puberty and early adult life, and is most common in young men of feeble frame and of sedentary habits. In advanced stages the patient's general health suffers, and he often falls into a state of great mental depression. At the same time, there can be no doubt that, in many cases, ill health and va- rious nervous affections, such as epilepsy or insanity, are attributed Avithout sufficient reason to morbid excitability of the genital organs and to onanism— Avhen in point of fact the supposed causes are really the effects ; physical debility often exists Avhere the sexual appetite is fully if not inordinately de- veloped, and an excitable disposition, or an ill-balanced mind, renders its possessor less able to resist temptation, and more apt to fall into habits at which the moral sense revolts, than he who is blessed Avith both a healthy body and a healthy mind. The frightful pictures drawn by Tissot, Alibert, and other Avriters, are no doubt strictly correct; but the unfortunate victims whose histories they narrate Avere not insane from onanism, they Avere onanists because they were insane. The diagnosis of spermatorrhea from chronic prostatitis (prostatorrhcea) is readily made by microscopic examination of the discharge (see page 901). The treatment, as far as the use of remedies is concerned, consists in di- minishing the irritability of the genital organs, and in improving the general condition of the patient. The food should be abundant, but Avholesome, and particular care should be taken not to overload the stomach at night; alco- holic stimulants and spices should, as a rule, be avoided. The patient should take plenty of exercise in the open air, walking being better than riding or driving, as the motion of the horse or carriage sometimes excites the venereal orgasm ; he should sleep on a hard mattress—lying on either side rather than on the back—and should not be too Avarmly covered. Tonics, especially iron, quinia, strychnia, phosphorus, and occasionally cantharides, may be ad- ministered with advantage, Avhile cold hip-baths, the cold douche or sliOAver- bath, and sea-bathing (if this can be procured) will also prove of service. Bromide of potassium may be given in a full dose at bedtime, and will often procure sound rest, undisturbed by seminal emissions ; the hydrate of chloral has been recently recommended for the same purpose, as has the monobromide of camphor, by Dr. J. L. Vogel. The application of nitrate of silver in sub- stance or solution (gr. xx-xl to f|j) to the prostatic and bulbous portions of the urethra, may be of service in eases in Avhich these parts are found by ex- ternal pressure to be morbidly sensitive; the application may be made with a porte-caustique or syringe-catheter (as in cases of chronic prostatitis), and may be repeated at intervals of ten days or two weeks. Cold, applied as re- commended by Winternitz (p. 902), may be of use in some cases. DISEASES OF THE FEMALE GENITALS. 967 The course of treatment above described is addressed to the morbidly irritable condition of the genital organs, and may be employed with every prospect of success, provided that the causes of that condition have ceased to act, or can be removed. In cases originating in irritation of neighboring parts—as from hemorrhoids, from the presence of ascarides, or from an ab- normal condition of the urine—this can be readily done ; but when the unnatural irritability of the generative apparatus is kept up by constant exci- tation of the part, whether physical or mental, the prognosis is less favorable, because the removal of the cause is more difficult. Chastity in thought as well as deed is necessary to insure recovery ; but to attain this grace requires a prolonged struggle with temptation, wliich needs all the patient's fortitude and resolution. The treatment in these cases must be more moral than physi- cal, and even Avhen a purely physical cause, such as onanism, is to be dealt with, surgery offers remedies of but doubtful efficacy ; the application of blis- ters to the penis, or the operation of circumcision, may be of use in compelling at least a suspension of a bad habit; but the benefit will be evanescent, unless the moral nature of the patient can be reached in the interval. In their despair at continual relapses, victims of onanism have, it is said, occasionally made Abelards of themselves, with the hope that they would thus effectually banish temptation ; and surgeons, even, have been induced to castrate their patients, in obedience to the earnest solicitations of the latter. The opera- tion has, however, in the large majority of cases, proved as unsuccessful as it is unphilosophical; there is no reason to believe that the testes are particu- larly at fault, and the disease is in all cases more of the mind than of the body ; moreover, the gain to the moral nature of the individual is not in cow- ardly fleeing from, but in manfully resisting, temptation. The benefit which has been apparently derived, in some instances, from this heroic mode of treatment, has been, in all probability, such merely as might have been ob- tained from any great and sudden shock to the nervous system. The surgeon is occasionally called upon for an opinion as to Avhether an individual, avIio has suffered from frequent seminal emissions, and avIio, per- haps, fears that he is in consequence impotent, may properly enter into matri- monial engagements. The question is rather a delicate one, and no rule can, of course, be given which would be of universal application ; but it may pro- bably be safely said that, though, if undertaken merely with the selfish hope of effecting a cure for himself, without regard for the happiness of his partner, marriage will, in all probability, disappoint the man's expectations, yet the happy circumstances of a union founded on mutual preference and pure affec- tion, will offer the very best prospects of recovery. Sterility in the male may exist in connection with impotence, or inde- pendently. It most frequently arises from some local source of obstruction to the passage of the spermatozoa—as from induration and thickening of the globus minor as the result of epididymitis, or from urethral stricture—but may also depend upon retention of the testes within the abdominal cavity, upon absence of spermatozoa from the semen, or upon obscure changes in the chemical constitution of that fluid, the nature of which is not very well under- stood. The only hope of cure would be in the removal of any disease of the genito-urinary apparatus which might be detected. DISEASES OF THE FEMALE GENITALS. The limits of this volume will merely admit of a brief reference to those diseases of the Female Generative Apparatus which require operative, or dis- 968 DISEASES OF THE GENERATIVE ORGANS. tinctively surgical, treatment; nor is a more extended account of these affec- tions here necessary, for the Avhole subject properly belongs to the domain ot Gynecology, and is ably discussed in the numerous valuable Avorks on Diseases of Women which are now accessible to the student. Malforaiatioxs. The external genitals are subject to various malformations of very different degrees of severity. Imperforate Vulva__This, which is the slightest form of imperforate vagina, consists in a congenital occlusion of the vagina at or just in front of the nymphe. The septum is at first very delicate, and, if the condition is recognized soon after birth, can be readily ruptured by simply separating the parts with the thumbs, one placed upon each of the labia majora, or may be torn across with a probe or director, a strip of oiled lint being interposed to prevent reunion. At a later period a little dissection with the scalpel may be required, but the affection is always readily amenable to treatment. Adhesion of the Vulva is a condition precisely similar to the above, except that it is not congenital, but arises from adhesion of the opposing surfaces of mucous membrane, as the result of inflammatory action. The treatment con- sists in dissecting through the obstruction, and preventing its recurrence by the introduction of a tent. Imperforate Hymen__The hymen may be partially perforate, or completely imperforate. 1. Partially perforate hymen alloAvs the escape of the menstrual fluid, hut interferes with sexual intercourse—the thickness and rigidity of the membrane preventing penetration. In some instances pregnancy has occurred in spite of this obstacle, and the condition of parts has been first recognized from the effect of the dense hymen in hindering parturition, by arresting the passage of the fetal head. The treatment of partially perforate hymen consists simply in incising the part with a probe-pointed bistoury, dilatation being completed by means of a sponge-tent or bougie. 2. Imperforate hymen is a much more serious condition. If it were recog- nized before the age of puberty, it could be readily remedied by making a crucial incision, and by excising the flaps Avhich would thus be formed ; but unfortunately the malformation is seldom discovered until menstruation has repeatedly occurred, and until the vagina and uterus have become distended, sometimes to a great extent, by the accumulating secretion—forming a large, elastic, fluctuating tumor in the hypogastrium. The operation for the relief of this condition is easily and quickly performed, but is not unfrequently fol- lowed by serious and even fatal consequences. Death may result from endo- metritis and septicemia, due to decomposition of the uterine contents ; or from peritonitis, due to the escape of blood through a laceration of the Fallo- pian tubes, or even through their natural orifices, into the abdominal cavity. To prevent these accidents, it is recommended by Bernutz and Goupil that the hymen should be punctured with a small trocar and canula, a piece of tubing being attached to the latter, so that the contents of the uterus shall slowly drain aAvay. The puncture should be made eight or ten days after a menstrual period, and no pressure should be made upon the abdomen during the process of evacuation. Imperforate Vagina__This may vary in degree from the slight affec- tion already referred to as imperforate vulva, up to complete absence of the IMPERFORATE VAGINA. 969 vagina, accompanied, perhaps, with absence or imperfect development of the uterus. By simultaneous exploration with a sound in the bladder and a finger in the rectum, the thickness of tissue betAveen those parts can be estimated, and, if it be such as to render the existence of the uterus and upper part of the vagina tolerably certain, an effort may be properly made to reach the upper part of the tube during early childhood, Avhen operations on these organs are less dangerous than in adult life. If, hoAvever. the bladder and rectum be in such close contact as to render the existence of a uterus doubtful, it Avill be proper to wait until the period of puberty, Avhen the nature of the case will probably become more evident. In many instances the existence of malformation is not suspected until after puberty, when the attention of the patient and of her friends is aroused by the non-appearance of the menses, although the menstrual molimen may recur at regular intervals. The treatment to be pursued under such circumstances is a matter Avorthy of the gravest consideration. Any operation in such a case will be attended with considerable risk, and yet if the womb is becoming every month more and more distended Avith menstrual fluid, an operation is absolutely necessary —for while unrelieved the patient is in constant danger of peritonitis (from leakage backAvards through the Fallopian tubes), or even of rupture of the uterus. The treatment of imperforate vagina varies according to the condi- tion of the uterus. (1.) If the presence of an elastic fluctuating tumor in the region of the uterus, perceptible by rectal exploration and by abdominal palpation, shoAvs that there is an accumulation of menstrual fluid in the Avomb, there can be no question as to the propriety of an operation. It has been proposed to eva- cuate the uterine contents by puncture Avith a trocar and canula through the rectum, but, beside the risk of Avounding the peritoneum in such an operation, the relief Avould probably be but temporary, and re-accumulation Avould occur. Hence, it is better in such a case to attempt the formation of a vagina, by placing the patient in the lithotomy position, and, after making a small trans- verse incision, working cautiously upwards Avith the finger and handle of the knife in the septum betAveen the bowel and urethra (taking care not to open either of these), and guiding the dissection by keeping a sound in the bladder, and a finger in the rectum. When the sac containing the menstrual fluid is reached, it should be opened through a speculum with a small trocar, with the same precautions as in the case of imperforate hymen. The size of the newly-formed vagina must be subsequently maintained by the use of a bougie. In Amussat's method, Avhich is preferred in these cases by Bernutz and Goupil, the knife is dispensed with altogether, and the vagina formed by simply stretching the vulvar mucous membrane and pushing apart the rectum and urethra with the fingers ; the operation occupies several days, dilatation being maintained in the inteiwals betAveen the sittings by the introduction of tents. Le Fort has reported a remarkable case in which he formed a vagina by pass- ing a Aveak galvanic current through the parts every night for a month ; the negative pole Avas applied to the seat of occlusion and the positive pole to the AArall of the abdomen, and the current used Avas at no time so strong as to inconvenience the patient. (2.) If there be no uterine tumor, the course to be pursued is more doubt- ful. The menstrual molimen, it must be remembered, depends upon the ovaries, and not upon the uterus ; and a patient may suffer intensely at every monthly period, Avhile having no Avomb, or at least none capable of menstru- ating, and therefore no menstrual accumulation. If in a case of this kind it be ascertained by careful rectal exploration, conjoined with abdominal palpa- tion, that there is a Avell-formed Avomb—even though not distended—an operation such as was described in the last section might be justifiable, though 970 DISEASES OF THE GENERATIVE ORGANS. full of danger from the risk of opening the peritoneal cavity. If, however, it be found that there is no Avomb, or merely a rudimentary uterus (as in a case under my care at the Episcopal Hospital), no operation Avhatever should be performed. A good deal is sometimes said in these cases about fitting a young woman for matrimony, enabling her to be a wife, etc.—but, in point of fact, a Avoman to whom nature has denied a Avomb can never be adapted for marriage, though she may be fitted for prostitution. The surgeon's art may, indeed, enable her to be a man's mistress, but can never fit her to be his wife and the mother of his children. Prof. Gross speaks none to strongly when he says that, in such cases, " nothing is to be done . . . ; the woman is im- potent, and therefore disqualified for marriage." Non-Congenital Obliteration of the Vagina results from adhesion of the vaginal Avails after sloughing or severe inflammation ; it is most common in married women after labor, but may occur in young girls or children. The diagnosis from congenital absence of the \agina can be readily made by simultaneous rectal and vesical exploration, which will, in a case of non- congenital obliteration, reveal the existence of a dense septum, three-quarters of an inch or more in thickness—whereas, in a case of imperforate vagina, the instrument in the bladder and the finger in the rectum seem almost to be in apposition, and are evidently separated by a very thin layer of tissue. The treatment of the affection noAv under consideration consists in endeavoring to re-estabiish the canal, by cautious dissection between the urethra and rectum in the way already mentioned. The operation is attended with a great deal of danger, but is the only resource—and becomes imperatively necessary, when the uterus is distended by the menstrual accumulation. Double Vagina—In many cases this condition requires no treatment, and may be looked upon as merely a physiological curiosity. Should, how- ever, it become necessary to divide the vaginal septum, this may be readily effected with blunt pointed scissors, adhesion of the cut surfaces being pre- vented by the introduction of a strip of oiled lint, and cleanliness secured by the frequent use of detergent injections. Surgical Diseases of the Vulva. Hypertrophy of the Labia Majora is usually an inflammatory con- dition, depending, as in the case of the lips, upon the presence of a fissure or excoriation, and slowly disappearing when that is healed. Hypertrophy of the Labia Minora is occasionally met with, re- sembling anatomically what has been described as the " fibro-cellular out- growth." In warm climates this condition is comparatively common, and in some localities is said to be almost universal. The treatment, when the hypertrophy increases so much as to produce annoyance, consists in excision ; this operation is sometimes attended Avith a good deal of hemorrhage, Avhich may be conveniently arrested, as advised by Hutchinson, by transfixing the base of the labium with harelip pins and applying figure of 8 ligatures, so as to acupress the pedicle, as it were, en masse. Hypertrophy of the Clitoris is usually, I believe, the result of con- stitutional syphilis. The organ sometimes attains a very large size, and pro- duces a great deal of irritation, requiring excision, Avhich may be performed either with the knife or with the ecraseur. The bleeding in this operation SURGICAL DISEASES OF THE VAGINA. 971 may be quite profuse, and may possibly require the application of the actual cautery. Excision of the Clitoris, or Clitoridectomy, has been most unphilosophically proposed and practised as a remedy in cases of ejiilepsy and insanity. The operation has been forcibly and properly condemned by the almost unanimous voice of the profession. Vegetations, the so-called venereal warts, are often seen upon the vulva, and require extirpation with the knife or scissors. Tumors of various kinds are met Avith in the labia, the most common being the cystic tumor, though fatty, fibrous, and vascular groAvths are also met with in this situation. Tavo kinds of cyst are met with in the neighbor- hood of the labium ; one consists in a dilatation of Cowper's gland, and is curable by making a simple incision, and stuffing the cavity Avith lint, Avhile the other is a serous cyst, Avhich is developed in the labium itself, and some- times attains a very large size. The treatment of the latter consists in ex- cision, the operation requiring a rather troublesome dissection, and being attended Avith a good deal of bleeding, Avhich can, however, ahvays be checked by pressure and the use of a J bandage. Fibrous and fatty tumors of the labium also require excision, Avhile nevi in this part may be conveniently treated by ligation. Hydrocele of the Canal of Nuck is a rare affection, which Avas referred to in speaking of pudendal hernia (page 803). The treatment con- sists in the formation of a seton, or in the injection of iodine. Malignant Disease of the External Genitals may be primary— in Avhich case it is usually epitheliomatous—or secondary to cancer of the %-agina or uterus, either of the scirrhous or encephaloid variety. The vulva is also, sometimes, the seat of rodent ulcer. The sole treatment for any of these affections is excision, which is, however, only justifiable Avhen the dis- ease is so limited as to admit of complete extirpation. Vulvitis, in whatever way arising, presents the same symptoms, and de- mands the same treatment, as when of gonorrheal origin. (See page 428.) Noma Pudendi has already been referred to at page 392. Surgical Diseases, of the Vacixa. The Speculum is an instrument constantly required for exploration of the upper part of the vagina and the cervix uteri. For ordinary purposes, the best instruments are the simple cylindrical speculum, made of glass, coated like a mirror with quicksilver or tinfoil, and covered with India-rubber (Fig. 537), and the bivalve speculum, of Avhich the best form is that known as Cusco's (Fig. 538). For special cases, other instruments may be required, such as the duck-billed speculum (Fig. 518), either in its original form, or with the ingenious modifications of Emmet, Fallen, Thomas, Fryer, and others; Thomas's telescopic speculum; Ellis's expanding speculum; or the somewhat similar ingenious contrivances of Dr. Albert, H. Smith and Dr. J. S. Hough, of this city. Barnes highly commends Neugebauer's speculum, which combines the features of both the bivalve and the duck-billed instru- ments. The speculum should always be introduced (well warmed and oiled) under 972 DISEASES OF THE GENERATIVE ORGANS. cover of the patient's garments or bedclothes, without any exposure of the person. For ordinary examinations, the obstetric position on the left side Avill be satisfactory, but for the application of caustics, removal of polypi, etc., it will usually be more convenient to place the patient on her back, with the loAver limbs separated and supported upon chairs. The introduction of the Fig. 537. Fig. 538. Cylindrical speculum. Cusco's speculum. speculum may be conveniently effected by separating the vaginal walls with the fore and middle fingers of the left hand, and slipping in the instrument beneath and between them. Painful Ulcer or Fissure of the Vagina__This affection is closely analogous to the painful ulcer of the rectum or anus, and requires precisely similar treatment. (See page 823.) Polypoid Growths, belonging to the class of fibro-cellular tumors, are occasionally met with in the vagina, and may be treated by avulsion (if the pedicle is very small), ligation, the ecraseur, or the Avire loop and galvanic cautery. Cystic and other Tumors in the walls of the vagina are to be treated as similar affections of the vulva. Cancer of the vagina seldom admits of operative interference. Prolapsus of either the front or back wall of the vagina, may take place, constituting, in the former case, a variety of hernia of the bladder or urethra (cystocele, urethrocele), and, in the latter case, a similar condition of the rectum (rectocele). In most instances, sufficient relief may be afforded by the use of a suitable pessary or bandage, but occasionally a more radical measure may be required; this may, in a case of cystocele or rectocele, con- sist in denuding a circular strip of the vagina near its orifice, and bringing the sides together with sutures, so as to obtain adhesion of the labia majora for the lower three-fourths of their extent; or, if the case be complicated with prolapsus of the uterus, in denuding a longitudinal strip on either side of the vagina (or, which is better, a broad triangular space on the posterior wall of the canal), and then bringing the raw surfaces together, so as to reduce the calibre of the vagina through its entire length. The tormer operation is known SURGICAL DISEASES OF THE UTERUS. 973 as Episiorrhaphy, and the latter as Ely- Fig. 539. trorrhaphy. Episiorrhaphy has been modified by J. Bell by splitting instead of paring the labia, as in Langenbeck's and Collis's operations for vesico-vaginal fistula. Thomas has modified the ope- ration of elytrorraphy by separating the Thomas,8 clamp for elytrorrhaphy. layers of the vaginal Avail by a subcuta- neous, or rather submucous, procedure, then clamping the separated tissue with the instrument shoAvn in Fig. 539, and cutting off the part which pro- trudes. The treatment of urethrocele has already been referred to at pajre 916. Vaginismus is the name given by Sims to an affection which consists in a hyperesthetic condition of the nerves distributed to the vaginal mucous membrane at the position of the hymen, leading to a spasmodic contraction of the sphincter vagine muscle, Avhich renders coitus intensely painful, and, indeed, usually impossible, and thus practically makes the patient sterile. The spasm of the sphincter may be elicited by the slightest touch of the finger, or even of a camel's-hair brush. Vaginismus may be an idiopathic affection occurring in persons of a hysterical temperament, or may be due to some local cause, such as fissure of the vagina or rectum, papillary tumor of the meatus, inflammation of the womb or vagina, eczema or prurigo of the vulva, neuralgic tumors, etc. The treatment consists in removing the cause, if this can be ascertained, and in the administration of tonics, and the use of sedatives, iodo- form being specially recommended by Tarnier. Attempts may be made to relieve the spasm by the use of vaginal dilators, or, if necessary, by a resort to operative treatment. The simplest operation for vaginismus consists in sudden dilatation or partial rupture of the sphincter vagine muscle, effected by introducing the thumbs and forcibly separating them (the patient being etherized), as in Eecamier's and Van Buren's method of treating fissure of the anus. If this fail, the remains of the hymen may be excised, and the sphincter partially divided by a deep incision on either side of the perineal raphe (as recommended by Sims), or the pudic nerve may be cut—by direct incision, as originally recommended by Burns—or subcutaneously, as preferred by Simpson. These operations sometimes afford only temporary relief, and the constitutional treatment appropriate to neuralgia must therefore not be neglected after their employment. Surgical Diseases op the Uterus. Fibrous or Fibro-Muscular Tumors (Uterine Fibroids, Myomata). —These, Avhich are the most common of the uterine tumors, may occupy any portion of the structure of the womb. They may project on the outer sur- face of the organ beneath its peritoneal investment; may groAv inwards, filling the uterine cavity, and perhaps descending through the vagina and protruding betAveen the labia; or may be developed in the midst of the uterine Avail. They are classified according to their situation into subserous or sub-peritoneal; submucous; and interstitial or intermural fibroids. They are but loosely attached to the surrounding tissues, and sometimes attain a very large size. In the majority of cases palliative treatment only is required ; and it must always be remembered that uterine fibroids seem to disappear spontaneously in some instances; or may become detached, and may be expelled by the contractions of the womb. The most promising mode of treatment is, I think, the hypodermic use of ergot or ergotin, as recommended by Hilde- 974 DISEASES OF THE GENERATIVE ORGANS. brandt, Scanzoni, and Keating, of this city: my own experience Avith this remedy, though limited, confirms, as far as it goes, the favorable reports of those gentlemen. The following formula will be found satisfactory: R. Ext. ergot, fluid, fjiss ; Glycerine, f3j ; Aque, f' 5' j - M. Twenty minims to be injected once daily in the hypogastric region. In cases of submucous fibroids, excision or avulsion may be practised, a convenient instrument for the purpose being the "serrated scoop" devised by Thomas ; but if the groAvth be attached by a somewhat narrow pedicle (con- stituting the fibrous polypus of the uterus), it will usually be better to remove the tumor by means of the ecraseur, for the chain of wbich a wire rope may be substituted, as recommended by Braxton Hicks, or a steel wire, as pre- ferred by Kidd, of Dublin. The ecraseur may be applied by the aid of the ingenious "porte-chaine" of Dr. Marion Sims ; or the simpler form of instru- Fig. 540. Fibro-cellular uterine polypus with lung pedicle. (Boivin and Dug^s.) ment devised by Dr. Emmet, may be substituted : or a ligature may be first thrown around the pedicle with a double canula, and the chain of the ecra- seur subsequently drawn into place. The operation may be facilitated by seizing the part to be removed with shouldered tenacula which may then be •fixed in a handle, as suggested by Dr. A. H. Smith, of this city. In the case of interstitial growths, enucleation has been resorted to by Amussat, Atlee, Fordyce Barker, Thomas, and others. The operation con- POLYPI OF THE UTERUS. 975 Subserous uterine fibroids have, in a number of instances, been removed by abdominal section, the operation sometimes involving the extirpation of the entire uterus and both OA*aries (see page 813). This mode of treatment under any circumstances is replete with danger, and can only be justifiable in exceptional cases. The statistics of the procedure haAre been investigated by several writers, the most recent being Pozzi, Avho finds that 119 cases, including those collected by Routh, Keberle, Caternault, and Pean and Urdy, gave 77 deaths, a mortality of nearly 65 per cent. Dr. Sutton has removed a subserous fibroid through an incision in the posterior wall of the vagina, but the patient died in six hours. Drs. Kimball and Cutter have met with some success from the use of galvano- puneture in these cases. Fibro-cystic Tumors of the Uterus have been particularly studied in this country bA' C. C. Lee, Atlee, Peaslee, and Thomas. They have often been mistaken for ovarian cysts (see page 837). Only palliative treatment is as a rule to be recommended. Polypi of the Uterus usually belong to the fibro-cellular or myxo- matous varieties of tumor, and are often very vascular, and accompanied with an increased development of the glandular structures of the part. The hard or fibrous polypus, a variety of the uterine fibroid, has already been referred to. Polypi are usually attended by more or less profuse hemorrhage, which exhausts the patient and urgently demands surgical interference. The treatment consists in effecting the extrusion of the polypus from the uterus by drawing it doAvn with forceps, or, if this cannot be done, by dilating or 976 DISEASES OF THE GENERATIVE ORGANS. Pie. 542. Amputation of the neck of the uterus by means of the icrnseur. a. Shows the neck of the organ dragged to the vulva by means of forceps, c, d. The chain of the instru- ment passed around the part at its base. (Chassaignac.) incising the neck of the womb and administering ergot, and in then dealing Avith the growth by excision, avulsion, ligation, or the use of the ecraseur, in the way already mentioned (page 974). Dr. McClintock, of" Dublin, recommends the employment of a hemp saw; a loop of twisted cord is made to surround the base of the polypus, by aid of a double canula, the latter being then held by an assistant while the growth is cut through by draAving the cord backwards and forAvards as in using an ordinary chain saw. It may be occasionally necessary to attack the polypus while still within the uterus, but the ope- ration is under such circum- stances attended with great danger. Myeloid and Recur- rent Fibroid Tumors (Sarcomata) have been occa- sionally observed in the ute- rus ; the treatment would con- sist in excision, if the growth could be entirely extirpated without too much risk to the patient. Malignant Tumors of the Uterus may be either cancerous or epitheliomatous. Cancer of the uterus is usually of the encephaloid variety, though scirrhous and colloid growths are also met with in this organ ; the treatment should, in a very large majority of cases, be merely palliative, total extirpation being almost impossible, and partial excision, unless in very ex- ceptional instances, being worse than useless. Epithelioma commonly attacks the os and cervix uteri, and may appear in one of tAvo forms, viz., as the so- called "corroding ulcer," or as the "cauliflower excrescence." The treat- ment consists in amputation of the neck of the uterus, if the affection be recognized sufficiently early to allow of complete removal, or, if not seen until a later period, in cauterization of the surface of the growth Avith caustics or the hot iron, or in extirpation of as much as can be reached by means of the ecraseur or curette, a palliative measure Avhich has been employed with ad- A'antage by A. R. Simpson, Simon, Munde, Parry, Goodell, and others. Procidentia or Extreme Prolapsus of the Uterus may occa- sionally demand operative treatment; this consists in first amputating the neck of the organ (if it be much enlarged), and then performing an episior- raphy or elytrorraphy (p. 973), or a transverse obliteration of the vagina (p. 948\ This mode of treatment has been adopted in several cases by AMPUTATION OF THE CERVIX UTERI. 977 Dr. W. Goodell, of this city, with most gratifying results. Kolpoperineo- plasty is another operation for the same purpose, devised by Bischoff; it con- sists in dissecting up a tongue-shaped flap of mucous membrane from the posterior Avail of the vagina, and denuding a triangular space on either side ; the edges of the flap are then stitched to the anterior edges of the denuded spaces, and the wound closed beloAV with deep sutures, as in the operation for ruptured perineum. Amputation of the Cervix Uteri may be performed by the aid of cutting instruments, by means of the ecraseur (Fig. 542), or by the use of the wire loop and galvanic cautery. When the first method is resorted to, the part to be removed should be fully exposed by means of a duck-billed speculum ; the neck of the Avomb is then slit up on either side, and its lips successively excised with suitable scissors, the uterine mucous membrane being finally drawn forward (as advised by Sims), and attached to that of the vagina, by means of silver sutures. Dr. C. F. Clark, of Brooklyn, employs toothed scissors, dispensing with the preliminary slitting of the part, and leaving the stump to heal by granulation. The subjects of Lacerations of the Female Perineum, Vaginal Fistule, Ovarian Tumors, and Diseases of the Mammary Gland, have already been referred to in previous portions of the volume. 62 INDEX. ABDOMEN, injuries of, 366 operations on, 834 Abdominal abscesses, 845 aneurism, 559 muscles, rupture of, 367 organs, diseases of, 816 parietes, abscess of, 367 taxis, 807 tourniquet, 130 Abernetliy, ligation of external iliac ar- tery, 202, 562 ossification of muscle, 507 Abortion from injury to pregnant uterus, 378 Abortive treatment of gonorrhoea, 423 Abrasion, 40 Abscess, acute or pblegmonous, 380 chronic or cold, 383 disappearance of, by absorption, 382 hemorrhage into, 3S3 metastatic or multiple. See Pyaemia. residual, 384 after arthritis, 586 varieties of, 380 Abscess, abdominal, 845 of abdominal parietes, 367 alveolar, 727 of antrum, 729 areola of breast, 752 in auditory meatus, 690 biliary, 846 of bone, 568 breast, 752, 754 cornea, 651 fecal or stercoraceous, 847 of frontal sinus, 711 gum, 727 hepatic, 846 iliac, 644 ilio-pelvic, 847 intra-cranial, trephining for, 320 of larynx, 748 mammary, 752 mediastinal, 243, 358 of orbit, 687 ovarian, 817 palmar, 508 beneath pectoral muscle, 357 perineal, 426 perinephritic, 846 perityphlitic, 847 of prostate, 901 Abscess— psoas, 643 retro-pharyngeal, 743 spinal, 643 splenic, 846 subperiosteal, 564 of testis, 953 tongue, 723 urethral, 426 Abscission of staphyloma, 654 Absorbents, inflammation of. See Angeio- leucitis. Absorption, interstitial, 45, 46, 570 of spine. See Antero-posterior curvature. of bone after fracture, 234 lymph, 38 purulent. See Pyaemia. of pus, in abscesses, 382 Accommodation of ear, 699 eye, 675 Accumulator for making extension, 587 Acetabulum, fracture of, 243 perforation of, in hip disease, 590 Acetic acid in cancer, 493 Acorn-pointed bougies, 911 Acritochromacy. See Color-blindness. Acromion, fracture of, 249 Actual cautery, 84 Acupressure, 186 in amputation, 97 aneurism, 545 comparison of, with torsion and liga- ture, 189 modified, 188 repair of arteries after, 188 in secondary hemorrhage, 193 statistics of, 190 Acupuncturation, 84 in aneurism, 550 for radical cure of hernia, 768 in ununited fracture, 236 Adams, anchylosis of hip, 600 cicatrices, 48, 303 club-foot, 632 et seq. contraction of palmar fascia, 630 ectropion, 684 fracture of nose, 238 repair of tendons, 207 spinal disease, 644 Adapting power of ear, 699 Addison, T., keloid, 502 980 INDEX. Addison, W., origin of pus cell, 39 Adenitis, 506 Adenocele. See Glandular tumor. Adenoid tumor, 476. See Glandular tu- mor. vegetations of nose and pharynx, 704 Adenoma, 476. See Glandular tumor. Adhesion, union by, 141 secondary, 142 of vulva, 968 Adhesions in hernia, 764, 783 ovariotomy, 840 Adhesive plaster, 145 antiseptic, 150 A erteri version, 189 Age, influence of, on results of operations, 63 Agglutinative method for foreign bodies in ear, 341 AgneAV, C. R., diseases of eye, 649 et seq. Agnew, D. H., aneurism, 547 complicated luxation, 276 radical cure of hernia, 795 ruptured perineum, 379 Air in veins, 170 Air-passages, diseases of, 748 foreign bodies in, 346 Ala? nasi, restoration of, 708 Alanson, mode of amputating, 90 Albugo, 652 Albumen in blood, in inflammation, 36 Albuminous degeneration, 232 Alibert, keloid, 502 Alison, iodine injections for ovarian cysts, 839 Alison, R. H., chorea from syphilis, 449 Allarton, median lithotomy, 881, 882 Allbutt, hydrophobia, 155 Allen, G. 0., rupture of oesophagus, 354 Allen, H., foreign bodies in oesophagus, 355 osteo-myelitis of tibia, 567 syphilitic disease of skull, 451 Allen, H. R., taxis for hernia, 777 Allies, internal uvethtrotomy, 926 Allingham, colotomy, 810, 811 prolapsus of rectum, 833 Alliott, urethroplasty, 937 Allis. dislocation of hip, 290 ether inhaler, 77 fracture of femur, 258 hernia-knife, 782 Alopecia, syphilitic, 446, 448, 459 Alteratives in inflammation, 61 Alternating calculus, 852 Althof, canthoplasty, 649 Alveolar abscess, 727 cancer. See Colloid. sarcoma, 482 Amaurosis, 668 from extra-ocular causes, 674 Amber cataract, 661 Amblyopia. See Amaurosis. Ametropia, 676 Ammonia in chloroform poisoning, 75 in shock, 67 Amoebaform or amoeboid movement of cells, 37 Amputation, 89 causes of death after, 111 conditions requiring, 90 contractions of tendons after, 106 dressing stump after, 103 elongation of bone after, 105 hemorrhage (secondary) after, 105 history of, 89 instruments used in, 92 intermediate, 109 mortality after, 107 compared Avith excision, 605 operative procedures used in, 98 relative merits of, 102 position of surgeon in, 98, 100 primary or immediate, 109 quadruple, 102 results of, circumstances which influ- ence, 107 et seq. secondary or consecutive, 109 during shock, 136 simultaneous or synchronous, 102 statistics of, 108 et seq. stumps, affections of, after, 104 Amputation for aneurism, 92, 551 subclavian, 558 for arthritis, 588 burn, 301 cancer in bone, 579 caries, 571 deformity, 108, 109 dislocation, compound, 274 fracture, badly united, 233 compound, 229, 232 ununited, 236 frost-bite, 305 gunshot injury, 164 hemorrhage, secondary, 193 hospital gangrene, 395 joint wounds, 211 lacerated wounds, 148 necrosis, 575 onychia, 501 osteo-myelitis, 568 tetanus, 520 traumatic gangrene, 149 ulcer, 389 Amputation at ankle, 122 of arm, 116 cervix uteri, 977 at elbow-joint, 115 of fingers, 112 foot, 118, 123 forearm, 115 hand, 112, 114 at hip-joint, 127, 617 knee, 125 knee-joint, 124 of leg, 123 metatarsus, 119, 120 penis, 950 above shoulder, 118 at shoulder-joint, 116 sub-astragaloid, 120 IND EX. 981 Amputation— of thigh, 126 tarsus, 120 et seq. thumb, 114 toes, 118 at wrist-joint, 114 Amussat, colotomy, 810 imperforate vagina, 969 Amygdaline chancre, 444 Amygdaloid bubo, 443 Amyl, nitrite of, in chloroform poisoning, 75 in tetanus, 520 Amyloid degeneration, 232 Anaesthesia, history of, 73 local, 78, 79 A'arious modes of producing, 73, 76 et seq. Anaesthetics, 71 cases in Avhich they may be used, 72 in cataract operations, 663 death from, 75 in dislocations, 273 effects of, 74, 75 erotic dreams produced by, 79 in fractures, 221 precautions in use of, 74 results of operations, how influenced by, 72 in strangulated hernia, 778 Anatomical origin of cancer, 492 Anchyloblepharon, 6S5 Anchylosis, 596 continuous extension in, 597 of elbow, 600 false, 596 fibrous, 596 excision in, 598 of hip, 599 jaws, 737 from burns, 303 knee, 598, 600 passive motion in, 597 rupturing adhesions in, 597 of shoulder, 600 in spine disease, 642 of stapes to fenestra ovalis, 699 Andrews, detection of calculi, 856 painless operations, 140 Anel, operation for aneurism, 541 Aneurism or aneurisms, 532 amputation for, 92, 551 by anastomosis, 525 arterio-venous, 551 bruit of, 536 causes of, 533 cirsoid. See Arterial varix. death from, modes of, 539 diagnosis of, 537 diffused, 537 dissecting, 532 erosion of bones by, 536 fusiform, 532 after gunshot wounds, 168 hernial, 195 intra-cranial, from embolism, 534 Aneurism— miliary, in apoplexy, 534 orbital, 687 osteoid, 579 pressure-effects of, 536 pulsation in, 535 racemose See Aneurism by anasto- mosis. rupture of, 539 sac of, 534 sacculated, 532 secondary, 543 size of. 534 special. See the particular Arteries. spontaneous cure of, 538 structure of, 534 in stumps, 105 symptoms of, 535 terminations of, 538 thrill of, 536 traumatic, 194 after tenotomy, 635 treatment of, 539 by acupressure, 545 acupuncturation, 550 amputation, 551 caustic, 551 compression, 546 digital, 547 instrumental, 546 rapid, 547 flexion, 549 galvano-puneture, 550 injection of coagulating liquids, 550, 563 ligation, 540 on cardiac side, 541 distal side, 545 manipulation, 549 medical, 540 by " old operation," 540 strangulation, 550 of particular. See special Arteries. tubular, 532 varicose, 196 varieties of, 532 venous, 169 Aneurismal diathesis, 534 needle, 181 varix, 195 non-traumatic, 551 in stumps, 105 Angeioleucitis, 505 Angeioma, 477, 525 of penis, 949 Anger, displacement in fractured clavicle, 218 Angular displacement in fractures, 218 extension in dislocated hip, 294, 295 Animals, rabid, bites of. See Bites. Ankle, amputation at, 122 diseases and injuries of. See under Joints. dislocation of, 297 excision of, 211, 622 for gunshot injury, 166 982 INDEX. Ankle— fracture of, 268 weak, 636 Ankylosis. See Anchylosis. Annandale, excision of tongue, 726 varicocele, 961 varicose aneurism, 196 wounds of tendons, 208 Annular stricture of urethra, 920 Anodynes in inflammation, 58, 61 Antepyretic amputations, 109 Anterior splint, Smith's, 262, 263, 267 Anterior-posterior curvature of spine, 641 Anthrax. See Carbuncle. Antimony in inflammation, 60 Antiseptic adhesive plaster, 150 collodion, 146 ligatures, 97 treatment of wounds, 149 Antiseptics in inflammation, 58 Antrum, diseases of, 729 Antyllus, operation for aneurism, 540 Anus, artificial. See Fistula, fecal. fissure of, 823 fistula of. See Fistula in ano. malformations of, 812 malignant disease of, 818 neuralgia of, 833 pruritus of, 834 sacciform disease of, 833 ulcer of, painful, 823 tuberculous, 825 Aorta, aneurism of abdominal, 559 thoracic, 551 compressor for, 94, 130 ligation of, 201, 559 wounds of, 365 Aphakia, 676 Aphthous ulceration of penis, 948 Aplastic lymph, 37 Apnea, treatment of, 349 in wounds of neck, 344 Apoplexy of marrow, 566 Aqua Conradi, 647 Arachnitis, erysipelatous. See Erysipelas. traumatic, 313 Areola of breast, condition of, preceding mammary cancer, 752 diseases of, 751 Areolar tissue, diseases of, 505 syphilitic, 450 lesions of, in pyaemia, 410 Arlaud, disarticulation for osteo-myelitis, 568 Arlt, diseases of eye, 672 et seq. Arm, amputation of, 116 Armsby, radical cure of hernia, 768 Arnott, anaesthetics, effect of, on results of operations, 72 cold as an anaesthetic, 78 in cancer, 493 fluid pressure for dilatation of stric- ture, 925 fracture of axis, 331 Aromatic wine, 435 Arrow wounds. See Wounds. Arrows, caustic, in cancer, 494 in carbuncle, 396 Arsenic in cancer, 493 Arterial pyaemia. See Pyaemia. thrombosis, 172. /See Thrombosis. transfusion, 88 varix, 525 Arteriotomy, 87 Arterio-venous aneurism, 551 wounds, 195 Arteritis, 529 Artery or arteries, acupressure of. See Acupressure. aneurism of. See Aneurism, and spe- cial Arteries. constrictor for, 181 contraction and retraction of, 176 contusion of, 172 diseases of, 529 syphilitic, 450 forceps for, 96 hemorrhage from, 174 injuries of, 172 ligation of, 185 for inflammation, 59 joint-Avounds, 212 lines of incision for, 196 secondary hemorrhage after, 193 occlusion of, 529 gangrene after, 193 from injury, 172 remote consequences of, 194 in pyaemia, condition of, 410 ruptured, 172, 368 amputation for, 92 in dislocation, 274, 275 fracture, 227 wounds of, 173 in compound fractures, 229 in process of repair in, 176 rules for ligation in, 182 Artery or arteries of arm and forearm, aneurism of, 558 axillary, aneurism of, 558 ligation of, 200, 558 brachial aneurism, 558 ligation of, 200, 559 brachio-cephalic. See Artery, inno- minate. carotid, aneurism of, 554 internal, ligation of, 555 ligation of, 197, 554 cerebral disease after, 544, 555 in excision of upper jaw, 733 wounds of neck, 343 for neuralgia, 516 facial, ligation of, 198 femoral, common, acupressure of, 562 aneurism of, 561 ligation of, 203, 562 deep, aneurism of, 562 ligation of, 203 superficial, aneurism of, 562 diffused, 563 ligation of, 203, 562 INDEX. 983 Artery— gluteal, aneurism of, 560 ligation of, 201, 561 iliac, common, aneurism of, 559 ligation of, 201, 560 external, aneurism of, 561 ligation of, 202, 562 internal, aneurism of, 560 ligation of, 201, 561 innominate, aneurism of, 552 ligation of, 196, 556 intercostal, hemorrhage from, in chest wounds, 359, 361 injury of, in fractured ribs, 242 interosseous, ligation of, 201 intra-cranial, aneurism of, 555 intra-orbital, aneurism of, 555 ischiatic or sciatic, aneurism of, 560 ligation of, 201 of leg and foot, aneurisms of, 563 lingual, ligation of, 198 for malignant tumor of tongue, 727 mammary, internal, hemorrhage from, in chest wounds, 359, 361 obturator, relations of, in femoral her- nia, 799 occipital, ligation of, 198 peroneal, ligation of, 204 popliteal, aneurism of, 562 ligation and compression in, compared, 544, 548, 549 ligation of, 203 rupture of, in fractured knee, 228 pudic, aneurism of, 560 radial, ligation of, 201 sciatic. See Artery, ischiatic. subclavian, aneurism of, 555 ligation of, 198, 557, 558 intra-thoracic inflammation after, 544 temporal, ligation of, 198 thyroid, ligation of, 198 for bronchocele, 720 tibial, ligation of, 203 posterior, rupture of, in fracture of knee, 227 ulnar, ligation of, 201 vertebral, aneurism of, 555 ligation of, 198, 555 Arthritis, 583 acute, of infants, 586 amputation for, 588 causes of, 585 chronic rheumatic. See Arthritis, rheumatoid. excision for, 588 gelatinous, 583 excision for, 588 of hip-joint. See Hip disease. intervertebral joints, 645 residual abscess after, 586 rheumatoid, 594 of hip, diagnosis of, from fracture, 259 Arthritis— of sacro-iliac joint. See Sacro-iliac disease. suppuration in, 585, 587 tenotomy in, 586 traumatic, 210 Arthropathy from nerve lesion, 595 Articular changes in dislocation, 271 neuralgia, 603 Artificial anus. See Fistula, fecal. limb, adaptation of, 104 membrana tympani, 694 pupil, 660 respiration, 349 Ascites, diagnosis of, from ovarian tumor, 836 Aseptic traumatic fever, 51 Ashhurst, S., rupture of biceps, 207 Ashmead, amputation at hip-joint, 129 Asphyxia. See Apnea. Aspiration, 88 of aneurism, 540 continuous, 103 Assistants, duties of, in operations, 70 Asthenopia, 676 Astigmatism, 676 Astragalus, dislocation of, 297 excision of, 623 fracture of, 269 Astringents in inflammation, 58 Ataxia, locomotor, a cause of fracture, 214 Atheroma of arteries, 530 Atheromasia, 531 Atheromatous ulcer, 530 Atlee, J. L., ovariotomy, 841 et seq. Atlee, J. L., Jr., rupture of trachea, 345 Atlee, W. F., eructation in aortic aneurism, 536 hydrocele of hernial sac, 765 Atlee, W. L., arsenic in cancer, 493 ovarian tumors, 836 et seq. Atlo-axoid joint, arthritis of, 645 Atony of bladder, 898 Atrophic scirrhus of breast, 757 Atrophy, eccentric, 235 Auditory meatus. See Meatus. nerve, lesions of, 699 Aural polypi, 690 speculum, 689 Auricles, diseases of, 688 Auzias de Turenne, syphilization, 460 Avery, staphyloraphy, 739 urethrotomy, external, 929 Avulsion of limbs, 147 amputation for, 91 in reducing dislocations, 275, 277 nasal polypi, 705 toe-nail, 501 Axilla, dislocation of humerus into, 280 Axillary artery. See Artery. glands, management of in excision of breast, 760 Ayres, dislocation of cervical spine, 332 extroversion of bladder, 890 984 INDEX. BACCELLI, empyema, 363 Back, injuries of, 323 Bacteria in pyaemia, 410 Bailey, J. S., rupture of oesophagus, 354 Bailey, W. H., fat-embolism, 137 Baker, moles, 521) tracheal tubes, 353 Balanitis, 949 Balano-posthitis, 428 Balch, wound of heart, 365 Balfour, diversity of venereal diseases, 421 iodide of potassium in aneurism, 540 Ball, fracture of skull, 315 Balls, encysted, 169 Bandages, 79 for eye, 430, 647, 659 Bands, extending, in reducing dislocations, 274 internal strangulation by, 804 intrabursal, 510 membranous, in tympanum, 698 Bar at neck of bladder, 896 Barbadoes leg, 470, 505 Barker, E., extroversion of bladder, 891 Barometer, state of, influencing results of amputation, 107 Barren cysts, 463. See Cysts. Barth, rupture of heart, 358 Bartholow, oil of turpentine in hospital gangrene, 394 Barton, J. K., phagedaenic chancroid, 433 syphilis, 439 Barton, J. R., anchylosis, operations for, 599, 600 excision of lower jaw, 735 fractures, 231 el seq. recto-vaginal fistula, 820 Barwell, club-foot, 636 joint-diseases, 583 et seq. lateral curvature of spine, 627 naevus, 528 webbed fingers, 630 Basedow's disease. See Goitre, exoph- thalmic. Bassereau, syphilis, 421, 440, 442 Bastian, concussion of spinal cord, 325, 330 Battey's operation, 843 Baudens, amputation at knee-joint, 124 Bauer, hip-disease, 592, 593 recto-vesical lithotomy, 883 Bavarian dressing for fractures, 233 Bayard, fracture and exfoliation of cervical vertebra, 333, 645 Baynton, strapping ulcers, 387 Bayonet wounds. See Wounds. Beach, fracture of patella, 264 Beale, arteries, repair in wounded, 176 ophthalmoscope, 669 Beane, stricture of rectum, 816 Beans, interdental splint for fractured jaw, 240 Beck, rupture of trachea, 345 Beckett, rupture of heart, 358 B6clard, amputation at hip-joint, 128 Bed, fracture, 224 Bed-sores, 390 after spinal injuries, 329, 335 Beer, abscission of staphyloma, 654 Begg, quadruple amputation, 102 Belladonna in shock, 67 Bell, B., loose cartilages in joints, 603 venereal diseases, 421 Bell, C, air in veins, 171 cancerous cachexia, 485 Bell, G. H., erysipelas, 402 Bell, J., arteries, rules for ligating, 183 lithotomy, 869, 878 Bell, Jos., episiorraphy, 123 nerve-stretching, 206 Bellingham, aneurism, 540, 546 Bellocq, instrument for plugging posterior nares, 702 Bellows for artificial respiration, 349 Bending of bone, 209 Benique, catheter, 910 Bennett, E. H., fracture of costal cartilages, 242 Bennett, J. H., fibro-nucleated tumors, 480 Bent, excision of shoulder-joint, 610 Berger, rupture of trachea, 345 taxis for hernia, 777 Bernard, fracture of sacrum, 244 Bernutz and Goupil, imperforate hymen, 968 vagina, 968 Bertolet, repair of nerves, 206 Bevan, scald of glottis, 345 Bibron's antidote, 153 Biceps tendon, displacement of, 282 division of, 629 Bichloride of methylene as an anaesthetic 78 Biesiadeeki, chancroid and chancre, 453 Bifid uvula, 737 Bigelow, brain, iron bar in, 317 dislocation of hip, 288 et seq. voluntary, 271 excision of joints, 611, 613 exstrophy of bladder, 891 fracture of acetabulum, 243 cervix femoris, 257, 259 ununited, 236, 237, 610 litholapaxy, 863 lithotrity, 860 et seq. Y ligament, functions of, 288 Bigg's apparatus for bunion, 511 contracted knee, 598 Bilateral lithotomy, 879 Biliary abscess, 846 fistula, 373 Bill, arrow wounds, 152 carbolic acid for local anaesthesia, 79 Billings, trephining for epilepsy, 321, 322 Billroth, alveolar sarcoma, 482 arteries, repair of Avounded, 176 excision of knee, 620 fractures, union of, 222 gastroraphy, 373 inflammation, 36, 37 neuromata, 513 IND EX. 985 Billroth— pyaemia, 411 secondary fever, 50 suppuration, blue, 39 Birkett, amputation, causes of death after, 112 breast, diseases of, 751 et seq. fracture of acetabulum, 243 hernia, 761 et seq. scrotum, Avounds of, 378 Bistoury, 95 Bites of rabid animals, 154 snake, 153 Bivalve speculum, 971 Black, use of A-aginal suppositories in gon- orrhoea, 429 Black cataract, 661 Blackman, anchylosis of knee, 601 aneurism, 550 dislocations, 275, 276 fracture of patella, 265 resection of sacrum, 336 Bladder, absence of, 868 atony of, 898 complicating lithotrity, 868 bar at neck of, 896 calculus of. »See Calculus, vesical. cancer of, 896 catarrh of, 894 clots in, 897 diseases of, 888 malignant, complicating litho- trity, 868 structural, 895 exploration of. See Sounding. extroversion or exstrophy of, 888 fissure of neck of, 897 fistulae of. See Fistulae. foreign bodies in, 376 hemorrhage from, 897 hernia of, 766, 892 calculus in, 888 inflammation of. .See Cystitis. after spinal injuries, 327 injuries of, 375 inversion of, 892 irritability of, 894, 900 malformations of, 888 malpositions of, 892 missing the, in lithotomy, 875 neuralgia of, 900 paralysis of, 898 puncture of, 907, 908 for stricture, 933 rupture of, 375 from retention of urine, 933 sacculated, 895 complicating lithotrity, 868 spasm of, 900 in lithotomy, 876 stone in. See Calculus, vesical. tubercle of, 896 tumors of, 895 washing out the, after lithotrity, 865 wounds of, 376 Blake, affections of ear, 689 Blanchard, osteomalacia, 576 Blandin, harelip, 718 resection sound, 607 Blear-eye. See Ophthalmia tarsi. Bleeding piles, 825 Blennoirhagia. .See Gonorrhoea. Blennorrhoea, 422 of lachrymal sac. *See Mucocele. Blepharitis ciliaris, 681 Blepharospasm, 651 Blind fistula in ano, 820 urinary, 936 piles, 825 Blindness, neiwous, 668 Blisters in gonorrhoea, 425 indolent ulcers, 387 Blizard, compression of aneurism, 546 Blood calculi, 851 in inflammation, 35 loss of. *See Hemorrhage. in pyaemia, 410 transfusion of, 88, 178 in pyaemia, 414 Bloodless method of operating, Esmarch's, 93"" Bloodletting, 86, 87 in aneurism, 540 inflammation, 58, 59 lung wounds, 360 shock, 135 strangulated hernia, 778 Bloodvessels in inflammation, 35 injuries of, 169 in pyaemia, 410 Bloxam, dislocation tourniquet, 273, 294 Blue pus, 39 Bluhm, statistics of trephining, 322 Boeck, syphilization, 460 Boeckel, arrested development in joint disease, 605 external urethrotomy, 930 Boggie, hospital gangrene, 395 Boil. See Furuncle. Boinet, iodine injection for ovarian cysts, 839 Boisnot, dislocation of hip, 294 Bokai, adherent prepuce, 945 retropharyngeal abscess, 743 Boker, excision of lower jaAv for necrosis, 729 Bond, splint for fracture near elbow, 253 of radius, 256 Bone, abscess of, 568 absorption of, after fracture, 234 aneurism in, 579 atrophy of, 575 eccentric, 235 bending of, 209 cancer of, 578 caries of. See Caries. contusion of, 168, 208 cysts of, 577 death of. *See Necrosis. decalcification of, 565 diseases of, inflammatory, 563 non-inflammatory, 575 986 INDEX. Bone— eburnation of, 565 elongation of, after amputation, 105 excision in continuity of, 167 exfoliation of, 572 fracture of. See Fracture. gangrene of. See Necrosis. mephitic, 572, 573 hemorrhage from, 103 hydatids in, 578 hypertrophy of, 575 injuries of, 208 medullization of, 564 necrosis of. /See Necrosis. osteo-porosis of, 565 in pyaemia, 410 rarefaction of, 565 in rickets, 419 sclerosis of, 565 scrofula of, 417, 577 suppuration in, 566, 568 syphilitic affections of, 451, 577 transplantation of, 236 tubercle in, 577 tumors in, 577 pulsating, 579 ulceration of. See Caries. Bone-earth calculus, 850 Bone-nippers, 96 Bonnafont, inflammation of membrana tympani, 692 Bonnet, hip disease, 592 Bontflower, naevus, 529 Bony anchylosis, 596, 598, 599 Borborygmus in hernia, 765 Borelli, staphyloma, 655 Boucbon, 176 Bougie, Eustachian, 696 medicated, 425 oesophageal, 745 rectal, 816 urethral, 910 Bouisson, deformities of penis, 944 Bourdelot, direct pressure in aneurism, 546 Bourgeois, malignant pustule, 397 Bouton. >i Pneumatocele or pneumocele, 359, 363 Pneumonia from injuries of chest, 358 359 from wounds of throat, 344 Pneumothorax, 359, 362 Pocketing the pedicle in ovariotomy, 841 Poinsot, excision of astragalus, 623 Pointing of abscesses, 381 Poisoned wounds. See Wounds. Poland, calculus, 851 cancer of tonsil, 742 compound fracture of patella, 265 emphysema in chest wounds, 358 gastrotomy for foreign bodies, 375 rupture of ureter, 368 subclavian aneurism, 555 tetanus, 517 Politzer, diseases of the ear, 693 et seq. Pollock, caries, 571 death from blow on abdomen, 366 excision of scapula, 608 filopressure, 189 intestinal obstruction, 804, 806 rupture of diaphragm, 366 Polypus, 469 of bladder, 895 ear, 690 . frontal sinus, 711 Polypus of— larynx, 74S nasal, 704 naso-pharyngeal, 705 et seq. of rectum, 818 urethra, 934 uterus, 975 hard or fibrous, 974 vagina, 972 Ponfick, burns, 300, 301 Pooley, hemorrhoids, 831 tumor of tongue, 726 Porcher, dressing wounds, 145 Port-Avine stain, 526 Popliteal artery. See Artery. Porta, administration of ether, 77 Porte-moxa, 84 Porter, aneurism, 540, 548 Porter, C. B., absorption of bone after fracture, 234 excision of upper jaws, 734 Porter, G. H., modified acupressure, 188 sawing tibia in leg amputations, 124 Porter, J. H., intermittent hemorrhage, 192 ' Position in treatment of hemorrhage, 178 inflammation, 53 strangulated hernia, 778 Post, contraction of palmar fascia, 630 hospital gangrene, 394 Posterior catheterization, 914 nasal syringe, 703 Posthitis, 428, 949 Pott, disease of spine, 641, 644 fracture of fibula, 267 hydrocele of hernial sac, 765 intracranial suppuration, 320 Potter, color of blood in spinal injuries, Pouches, rectal, inflammation of, 833 Poultices, 58 vaginal, 429 Powell, hemorrhoids, 827 Pozzi, uterine fibroids, 975 Pregnancy, extra-uterine, 844 operations during, 64 Preparation of patients for operation, 68 Prepuce, division of, 945 elongation of. See Phimosis. excision of, 946 gangrene of, 436, 948 herpetic ulceration of, 433 hypertrophy of, 949 inflammation ol. See Balanitis. Pre-rectal lithotomy, 881 Presbyopia, 676 Presse-artere, 188 Pressure in aneurism. See Aneurism, treatment of, by compression. in cancer, 493 carbuncle, 396 reduction of dislocations, 2i4 hemorrhage, 179 inflammation, 59 ulcers, 388 Preventive treatment of calculus, 8;^ 1022 INDEX, Priapism in injuries of penis, 377 spine, 328 in vesical calculus, 855 Price, splint for excision of knee, 620 Primary amputation, 109 bubo, 437, 443, 506 syphilis, 439 union of wounds. See Adhesion, and First intention. Prince, fecal fistula, 373 grooved retractor for excisions, 607 Probang for oesophagus, 355 Probe, chemical, 163 drainage, 211 drum, or reverberating, 162 electric, 162 flexible, 163 jointed, 570 meerschaum, 162 Nelaton's, 162 uterine, 836 wire, 570 Probe-nippers, 162 Procidentia uteri, 976 Profunda artery. See Artery, femoral, deep. Projectiles, momentum of, 157 Prolabium, restoration of, 713 Prolapsus ani. See Prolapsus of rectum. of rectum, 831 operations for, 833 from vesical calculus, 855 tongue, 723 urethra, 916 vagina, 972 Proliferation of cells, 37 Proliferous cysts, 465, 466 of breast, 756 Prone position in affections of spine, 335, 644 and postural respiration, 350 Prostate, abscess of, 901 atrophy of, 909 bruising of, in lithotomy, 878 calculi of, 885, 909 cancer of, 909 cysts of, 909 division of, in bilateral lithotomy, 880 lateral lithotomy, 873, 875, 876 hemorrhage from, 897 hypertrophy of, 902 complicating lithotomy, 875 lithotrity, 868 incontinence of urine from, 903 retention of urine from, 903, 906 inflammation of. See Prostatitis. injuries of, 378 lesions of, in pyaemia, 409 puncture of bladder through, 907 tubercle of, 909 tumors of, 902 in lithotomy, 877 Prostatic calculi, 885, 909 catheters, 904 et seq. Prostatitis, 900, 901 Prostatorrhcea, 901 Prostration with excitement, 134 Provisional callus, 222 tourniquet. See Tourniquet. Pruritus of anus, 834 Pseudo-calculi, 851 Pseudo-paralysis, syphilitic, 452 Psoas abscess, 643 Psoriasis of conjunctiva, 650 Psychrophor, 902 Pterygium, 649 Ptosis, 684 Pubis, dislocation or diastasis of, 243, 279 dislocation of femur on, 293 fracture of, 243 puncture of bladder above, 908 Puche, chancroid, 432 Pudenda. See Genital organs, female. Pudendal hernia, 803 Pudic artery. See Artery. Pulleys, compound, in dislocations, 273, 294, 295 Pulpefaction of parts, 149 Pulpy degeneration of synovial membrane, 583 Pulsating bronchocele, 719 tumors, 479 in bone, 579 Pulsation of aneurism, 535 recurrent, 543 Pulse, venous, in chloroform anaesthesia, 75 Puncta lacrymalia, eversion or oblitera- tion of, 686 Puncturation, 87, 404 Puncture of bladder. See Bladder. intestine, 369, 778, 783, 809 Punctured wounds. See Wounds. Pupil, artificial, operations for, 660 contraction and dilatation of, 658 in injuries of head, 309, 311 spine, 328 Purgatives in hernia, 771, 778 inflammation, 60 Purple, injury of spine, 326 Purulent conjunctivitis or ophthalmia, 647 diathesis. ) o r> infection. } See Pv*mia- Purves, polypus knife-hook, 691 Pus, 38 absorption of, in abscesses, 382 pyaemia, 407 characters of, in caries, 570 cold abscesses, 384 corpuscles, origin of, 39 varieties of, 38 Pustular ophthalmia, 646 Pustule, malignant, 397 Putrid infection. See Pyaemia. Puzzle, Indian, for dislocations, 288 Pyaemia, 405 analogy of, with gonorrhoeal rheuma- tism and urethral fever, 412, 430, 921 with tubercle, 416 arterial, 408 INDEX. 1023 Pyaemia— causes of, 410 contagiousness of, 411 diagnosis of, 412 frequency of, in thigh amputations, 108 idiopathic or essential, 411 materies morbi of, 411 metastatic abscesses in, 408 morbid anatomy of, 409 pathology of, 406 prognosis of, 413 symptoms of, 417 treatment of, 413 trephining as a prophylactic against, 320 Pyaemic patches, 409 Pyarthrosis, 564, 583 Pyocyanine, 39 Pyogenic diathesis of fever. See Pyaemia. Pyonephrosis, 846 Pyrexia, paralytic, 328 QUADRUPLE amputation, 102 ligature for naevus, 527 Quesnay, white gangrene, 398 Quilled suture, 144 Quimby, amputation, 121 KABE, iliac and femoral aneurism, 562 Rabid animals, bites of, 154 Racemose aneurism. See Aneurism by anastomosis. Rachitis. See Rickets. adultorum. -See Osteomalacia. Rack for fractures of lower extremity, 268 Radcliffe, temperature in tetanus, 517 Radial artery. See Artery. Radiating incisions in ulcers, 387 Radical cure of hernia, 767 cases favorable for, 769 femoral, 806 inguinal, 794 umbilical, 787 ventral, 786 hydrocele, 956 varicocele, 960 Radius, dislocations of, 284 excision of, 167, 612 fractures of, 255 Railway spine, 329 Rainey, loose cartilages in joints, 602 Ramoneur, 356 Rankin, iodoform in ear disease, 697 syphilitic disease of eye, 449 Ranula, 724 acute, 723, 725 Rarefaction of bone, 565 Rasmussen, aspirator, 364 Rattlesnake poisoning, 153, 154 Reaction from shock, 67, 134, 136 Reade, syphilis of nervous system, 449 Ready method, Marshall Hall's, 350 Recamier, compression in cancer, 493 fissure of anus, 824 Reclination of cataract, 663 Rectal ovariotomy, 843 Rectangular flap amputation, 101 staff, 874, 881, 882 Rectilinear ecraseur, 830 Rectocele, 972 Recto-labial fistula, 820 Recto-urethral fistula, 819, 938 Recto-vaginal fistula, 819 Recto-vesical fistula, 819, 938 lithotomy, 883 Rectotomy, linear, 817 Rectum, abscess near, 821 bougies for, 816 cancer of, 817 encysted, 833 excision of, 818 exploration of, by hand, 816 fistulae of, 819 foreign bodies in, 376 hemorrhage from, 826 imperforate, 813 occlusion of, 813 polypus of, 818 pouches of, inflamed, 833 prolapsus of, 831. See Prolapsus. puncture of bladder through, 908 speculum for, 820 stricture of, 815 malignant, 817 simple or fibrous, 815 warty, 817 syphilitic lesions of, 448 tapping through, 838 tumors of, 818 ulcers of, 824 wounds of, 376 in lithotomy, 878 Recurrent bandage, 81 fibroid, 479 stricture. See Contractile stricture. tumors, 463, 479 Red corpuscles in inflammation, 35 Redness in inflammation, 42 Reducible hernia. See Hernia. Reduction of dislocations, 272 spinal, 334 fractures, 224 compound, 231 impacted and partial, 234 hernia, 767 strangulated, 777. See Taxis. in mass, 779 prolapsus of rectum, 832 Reef-knot, 97 Reeves, laminaria tents for stricture, 925 Reflex paralysis, 207 Refraction, 675 Regnoli, removal of tongue, 726 Reid, manipulation for hip dislocation, 291 Relaxation of membrana tympani, 692 Renal calculus, 851 nephrotomy for, 844 1024 IND EX. Renal— vessels, thrombosis of, in spinal in- juries, 32:5 Repair after excision, 605 of fractures, 221 wounds, 140 et seq. in arteries, 176, 177 nerves, 205 tendons, 207, 633 veins, 170 Resection. See Excision. osteo-plastic, of upper jaw, 706 of spine. -See Trephining. stomach, 845 Resection-sound, 607 Residual abscess. See Abscess. Resolution, 51 Respiration, artificial, 349 prone and postural, 350 Rest, in concussion of brain, 310 inflammation, 52 joint affections, 209, 210, 582, 586 spinal affections, 335, 644 Results of operations, circumstances which influence, 63 et seq. Retention cysts, 463 of urine, 898. See Urine. in gonorrhoea, 426 after lithotrity, 866 in spinal injuries, 327 Retina, concussion of, 339 diseases of, 672 tumors of, 673 Retinitis, 672 syphilitic, 446 Retraction of divided arteries, 176 muscles after amputation, 105 nipple, in cancer, 484, 758 Retractor, 98 grooved, for excisions, 607 Retro-peritoneal suppuration, 370 Retro-pharyngeal abscess, 743 Reverdin, facial carbuncle, 397 transplantation of cuticle, 388 Reversed spiral bandage, 80 Revulsion, 83. See Counter-irritation. Reynolds, erysipelas, 403 Rhagades, 445, 823 Rhett, gunshot wounds, 169 Rheumatic iritis, 657 ophthalmia, 656 Rheumatism, gonorrhoeal. See Gonor- rhoeal. Rheumatoid arthritis. See Arthritis. Rhineurynter for epistaxis, 702 Rhinolites, 707 Rhinoplasty, 707 Rhinorrhcea, 703 Rhinoscopy, 703 Ribbon,lead, 146 Ribs, changes in, in rickets, 420 dislocations of, 278 excision of, 609 fracture of, 241 necrosis of, 573 Richard, congenital hydrocele, 954 Richard— extroversion of bladder, 890 Richardson, B. W., bellows for trache- otomy, 354 excision of breast, 760 local anaesthesia, 78 painless operations, 140 styptic colloid, 146 tetanus, 518 Richardson, B. Wills, hemorrhoids, 830 hernia-knife, 782 Richardson, J. G., ranula, 725 Richardson, T. G., cystitis, 894 paracentesis thoracis, 364 radical cure of hernia, 768 Richerand, fracture of sacrum, 244 Richet, hypodermic use of caustic, 494 primary hydrarthrosis, 582 Rickets, 419 in bone, 575 predisposing to fracture, 214 Ricord, amputation of penis, 951 phagedaenic chancroid, 436 phimosis, 947 syphilis, 439 et seq. varicocele, 960 Rigal, India-rubber suture, 144 Rigidity of membrana tympani, 692 Ring for fracture of patella, 265 strangulation by, 139, 948 Ring-forceps for piles, 828 Ringer, temperature in pyaemia, 411 Ripley, dislocation of hyoid bone, 278 Risus sardonicus, 517 Rivington, anatomy of sternum, 242 dislocation of hip, 292 Rizet, massage in diagnosis of fracture, 221 Rizzioli, median lithotomy, 881 Rizzoli, anchylosis of jaws, 303, 737 Robert, fracture of skull, 317 Roberts, J. B., paracentesis pericardii, 365 Roberts, W., urinary calculi, 849 et seq. Robertson, rupture of trachea, 345 Robin, induration of chancre, 441 Robinson, insufflator for tracheotomy, 354 Rodent ulcer, 502 Rodgers, anchylosis of hip, 599 ligation of left subclavian artery, 199 ununited fracture, 236, 237 Rofeta, cephalic chancroid, 432 Rogers, D. L., excision of both upper jaws, 734 Rogers, S., excision of scapula, 608 Rognetta, fracture of astragalus, 269 Rohe, ether inhaler, 77 Rokitansky, bony union of fractured ver- tebrae, 333 tubercle, 416 Roller bandages, 80 Rollet, mediate contagion of syphilis, 439 Roosa, affections of ear, 341, 446, 703 et seq. ophthalmia tarsi, 681 Rope windlass for dislocations, 273, 293 Rose, hallux valgus, 512 urachal fistula, 938 Roser, discharge of cerebro-spinal fluid, 318 INDEX. 1025 Rossi, amputation at knee, 125 Rotation of vertebrae in lateral curvature of spine, 626, 628 Rotatory displacement in fractures, 218 Rouge, necrosis of nasal bones, 704 Rouse, gonorrhoeal epididymitis, 428 Roussel, transfusion, 88 Roux, J., disarticulation for osteo-myelitis, 568 Roux, P. J., staphyloraphy, 738 ununited fracture, 236 Rubefacients, 83 Run-around. See Onychia. Rupia, syphilitic, 447 Rupture. -See Hernia. of abdominal muscles, 367 aneurism, 539, 543 arteries, 172, 368 bladder, 375, 933 gall-bladder, 368 heart, 357, 518 intestine, 368, 780 kidneys, 327, 367 liver, 367 lungs, 357 muscles and tendons, 207, 518 oesophagus, 354 perineum, 379 peritoneum, 367 sphincter ani, 824, 828 vaginae, 973 stomach, 368 stricture of urethra, 924 ureter, 368 urethra, 377, 933 uterus, 844 vena cava, 368 SABINE, normal ovariotomy, 843 subclavian aneurism, 555 Sac of hernia. See Hernia. Sacciform disease of anus, 833 Sacculated aneurism, 532 bladder, 895 oesophagus, 744 Sacro-iliac disease, 593 Sacrum, fracture of, 244 Salivary fistula, 342, 711 Salivation, mercurial, 458 Salleron, hernia of testis, 427 tuberculous sarcocele, 962 Salter, cradle for fractured leg, 267 Salts of blood in inflammation, 36 Sand-bags for fractured thigh, 260, 261 Sands, laryngeal growths, 749 Sanguineous cysts, 464 Sanious pus, 38 Sanson, catoptric test for cataract, 662 recto-vesical lithotomy, 883 Santorio, lithotrity, 859 Sapolini, neurotomy, 515 Saponaceous matter in calculi, 851 Sappey, blisters for ulcers, 387 Sarcocele, 961 cystic, 963 65 Sarcocele— malignant, 964 simple, 962 syphilitic, 449, 963 tuberculous, 962 Sarcoma, 481 of breast, 757 sero-cystic, 465, 756 Sarsaparilla in inflammation, 61 Satterthwaite, enlarged prostate, 906 Sattler, diseases of eye, 648 et seq. Saussier, rupture of lung, 357 Savory, pyaemia, 411 shock, 135 thrill of aneurism, 536 Savreux-Lachappelle, idiopathic pyaemia, 411 Saw, amputating, 96 Butcher's, 121, 124, 607 chain, 607 Hey's, 320 Sayre, anchylosis of hip, 599 club-foot, 636 dislocation of elbow, 286 excisions, 611, 614 et. seq. fracture of clavicle, 248 hip disease, 591 et seq. jointed probe, 570 oakum seton, 571 spinal affections, 628, 629, 644, 645 Scabbing, healing by, 142 Scalds. -See Burns. Scalp, aneurism by anastomosis of, 525 contusions of, 305 erysipelas of, 404 naevus of, 527 tumors of, 637 sebaceous, 466 wounds of, 306 Scalpel, 95 Scaphoid bone, dislocation of, 298 Scapula, dislocation of, 280 excision of, 608 fracture of, 248 Scarification, 86 Scarlet fever after operations, 68 Scarpa, galactocele, 751 shoe for club-foot, 633 staphyloma, 655 Schell, arrow wounds, 152 Schiff, origin of pus cells, 40 Schmakhalden, fecal fistula, 374 Schneiderian membrane, inflammation and thickening of, 702 Schonborn, staphyloplasty, 740 Schuller, chloroform poisoning, 75 Schuppert, urinary vaginal fistula, 942 Schwanda, phagedaenic chancroid, 436 Sciatic artery. See Artery. hernia, 803 pain in cancer, 494 Scirrhous cancer. See Scirrhus. Scirrhus, 483 acute, 487, 757 atrophic, 495, 757 of breast, 757 1026 INDEX, Scirrhus— cachexia in, 485 capsulated, 758 cuirass-like, 487, 757 infiltration of, 483 lardaceous, 484, 757 microscopic appearances of, 486 morbid anatomy of, 485 natural history of, 483 treatment of. See Cancer, treatment of. ulceration of, 484 Scissors, canula, 668 for cutting uvula, 741 Sclerema. See Scleroderma. Scleroderma, 469, 505 Sclerosis of bone, 565 Sclerotic, staphyloma of, 653 tumors of, 656 Sclerotitis, 655 Sclerotomy, 677 Scoop, lithotomy, 871, 874 Screw extractor, 163 Scrofula or scrofulosis, 416 in bone, 417, 577 joints, 417 lymphatic glands, 418 mucous membranes, 417 operations in, 419 in skin, 417 treatment of, 418 Scrofulous diathesis, 417 osteitis, 577 sarcocele. See Sarcocele, tuberculous. synovitis, 583 temperament, 417 ulcer, 417, 418 Scrotal fistula, 913 hernia, 788, 790 diagnosis of, 793 Scrotum, contusions of, 378 diffuse inflammation of, 948 epithelioma of, 951 erysipelas of, 404 excision of, 949 for varicocele, 960 fissure or cleft of, 944 gangrene of, 390 hypertrophy or elephantiasis of, 949 wounds of, 378 Scultetus, bandage of, 81 Seabrook, shock, 132 Sealing gunshot Avounds of chest, 360 Searcher for lithotomy, 871 Sebaceous tumor, 466 Second intention, union by, 142 Secondary abscesses. See Pyaemia. adhesion, 142 amputation, 109 aneurism, 543 cataract, 667 deposits of encephaloid, 488 epithelioma, 495 scirrhus, 485 fever, 50 hemorrhage. See Hemorrhage. Secondary— syphilis, 443. See Syphilis. Secretion in inflammation, 34, 45 Section of bone in amputation, 99 excision, 607 Caesarean, 843 of nerves for tetanus, 520 perineal, 928. See Urethrotomy, ex- ternal. of tendons. See Tenotomy. veins for phlebitis, 523 varicocele, 961 varix, 524 Sedatives in inflammation, 60 Sedillot, amputation of leg, 123 evidement, 571 gastrostomy, 746, 747 pyaemia, 406 staphyloraphy, 738 Sediments from urine, 848 Semeleder, galvano-puneture for ovarian cysts, 839 Semilunar bone, dislocation of, 287 cartilages, dislocation of, 296 Semi-malignant or recurrent tumors, 463, 479 Seminal cysts, 465, 958 emissions, 966 vesicle, hydrocele of, 958 Semple, cystitis, 893 hemorrhoids, 828 spider bite, 153 Senile gangrene, 390 amputation for, 91 Sensory paralysis in spinal injuries, 326 Separation, line of, 49 Septhaemia and septicaemia. See Pyaemia. Septum of nose, diseases of, 707 Sequestra, classification of, 163 extraction of, 574 in fractures, compound, 231 gunshot, 163 in necrosis, 572 syphilitic, 451 Sero-cystic sarcoma, 465, 756 Sero-pus, 39 Serous cysts, 463 iritis, 657 membranes, erysipelas of, 400 in pyaemia, 409 Serpiginous chancroid, 433 Serre-fines, 146 for hemorrhage after lithotomy, 878 urinary vaginal fistulae, 939 Serres, cheiloplasty, 714 Serum, artificial, 840 effusion of, in lung wounds, 359, 363 of hernial sac, 764, 773 Seton, 84 in cold abscess, 384 fistulae, 385 of breast, 754 perineal, 936 oakum. See Oakum. in staphyloma, 655 ununited fracture, 236 INDEX. 1027 Setting fractures, 224 Seutin, pliers for starched bandage, 83 taxis, 777 Severinus, ununited fracture, 236 Sex, mode of determining, in cleft scrotum, 944 Sexton, condensed and rarefied air in ear diseases, 697 Shakespeare, ophthalmoscope, 669 Shapleigh, rattlesnake-bite, 153 Shaw, spine, curvature of, lateral, 627 injuries of, 323, et seq. Shell wounds, 158 Shinkwin, hydrophobia, 155 Shock,132 amputation during, 136 in burns, 299 causes of, 133 death from, 66, 134 effect of anaesthetics on, 136 in gunshot wounds, 160 injuries of abdomen, 368 lung wounds, 359 reaction from, 134 secondary or insidious, 67, 137 temperature in, 134, 136 treatment of, 66, 135 in wounds of testis, 133 Short-cut ligatures, 97, 182 Short-sight. See Myopia. Shortening in fracture, 218 of thigh, 258, 261 consecutive, 263 Shortt, snake-poisoning, 153 Shot, round, wounds by, 157 small, wounds by, 157 Shoulder, amputation above, 118 at, 116 anchylosis of, 600 contraction of, 629 diseases and injuries of. See under Joints. dislocations of, 280 et seq. excision of, 164, 609 Shoulder girdle, 246 Shrady, ligation of lingual artery, 727 Siegel, pneumatic aural speculum, 698 Sigmoid catheter, 842 Sigmund, induration of chancre, 441 Signoroni's tourniquet, 94 Silica in calculi, 851 Silicate of potassium bandage, 82 Silver-fork deformity in fractured radius, 256, 257 Silvester, artificial respiration, 350 Silvestri, bloodless operations, 93 Simmons, phagedaenic chancroid, 436 Simon, G., exploration of rectum, 816 extirpation of kidney, 845 transverse obliteration of vagina, 942 urinary vaginal fistulae, 938 et seq. Simon, J., extroversion of bladder, 890 inflammation, 35, 43 Simons, abscess in bone, 569 Simpson, acupressure, 186 anaesthetics, 72, 73 Simpson— coccygodynia, 244 hypodermic use of caustic, 494 metallic ligatures, 182 mode of dressing stumps, 103 vaginal suppositories in gonorrhoea, 429 vaginismus, 973 ■wire seton for hydrocele, 957 Simrock, perforation of membrana tym- pani, 693 rhinoscope, 703 Sims, amputation of cervix uteri, 977 chloroform poisoning, 75 cholecystotomy, 848 harelip, 718 ovariotomy, 842 et seq. porte-chaine, 974 ruptured perineum, 379 sigmoid catheter, 842 tetanus nascentium, 516 urinary vaginal fistulae, 937 et seq. uterine probe, 836 vaginismus. 973 Sinus, 385 frontal, affections of, 688, 711 Siphon aspirator, 89 trocar, 838 Skae, gunshot wound, 158 Skene, affections of urinary organs, 916, 936 laparo-elytrotomy, 844 Skey, ligation of arteries, 185, 200 opium for ulcers, 388 reduction of dislocations, 283, 286 tourniquet, 94 Skin, diseases of, 499 malignant, 505 syphilitic, 444, 447, 452 in pyaemia, 410 scrofula in, 417 Skull, contusions of, 314 extravasation within, 308, 312, 318 fracture of, 315 at base, 316 hernia cerebri in, 318 trephining for, 319 fungus of, 637 inflammation within, 313 necrosis of, 573 in rickets, 419 suppuration within, 313, 320 syphilitic diseases of, 451 trephining the, 318 et seq. tumors of, 637 Sliding tubes for stricture, 924 Sling for fractures of upper extremity, 257 Slough, 40, 48 separation of, 49 Sloughing of aneurisms, 539 et seq. of bursa patellae, 510 cancer, 484, 488 hernial sac, 773, 783 phagedaena. See Gangrene, hospital. in spinal injuries, 329 ulcer, 386 1028 INDEX. Smith, A. H., administration of ether, 76 uterine fibroids, 974 vaginal speculum, 971 Smith, E. N., penile fistula, 936 Smith, H., diseases of rectum, 819 et seq. puncture of testis, 427, 953 Smith, H. H., dislocation of shoulder, 284 ununited fracture, 236, 237 Smith, I., Jr., elephantiasis Arabum, 505 Smith, N., reduction of dislocations, 275, 291 lithotomy, 876 osteo-myelitis, 568 Smith, N. R., dislocation of shoulder, 284 fractures, 237, 240, 263, 267 hydrocele of seminal ATesicle, 958 intra-cranial abscess, 320 lithotomy staff, 875 Smith, R. W., dislocations, 279, 297 fractures, 244, 255 multiple neuromata, 513 rheumatoid arthritis, 594, 596 Smith, S., aneurism, 538 fracture of cervical spine, 333 ligation of common iliac artery, 560 Pirogoff's and Syme's amputations, 121, 123 rupture of bladder, 375 Smith, T., bunion, 512 congenital cyst of back, 640 tumor of sterno-mastoid, 207 dislocation of shoulder, 284 nephrotomy, 844 pernio, 304 puncture of bowel. 369 staphyloraphy, 739 toe-nail ulcer, 501 Smith, T. B., fracture of humerus, 253 Smith, T. C, fracture of patella, 264 Smith, Tyler, ovariotomy, 842 Smyth, ligation of innominate artery, 556 old dislocations, 275 Snake-bites, 153 Snare for aural polypi, 691 laryngeal growths, 749 Snellen's forceps, 682 Snow-blindness, 675 Soden, displacement of biceps tendon, 282, 595 Soft cancer. See Encephaloid. chancre. See Chancroid. Softening of bone. See Osteomalacia. brain in head injuries, 310, 313 in inflammation, 45 of spinal cord, 325 Solar plexus, concussion of, 367 Solly, convulsions in head injuries, 313 Soluble glass, 82 Solution of cataract, 667 Solvent treatment of calculus, 852, 859 Sonde a dart, 884 Soot cancer, 951 Sound, Bellocq's 702 for bladder, 855, 858 resection, 607 Sound— urethral, 911 uterine, 836 Sounding for calculus, 855 in women, 858 South, fracture of spine, 326 phlegmonous erysipelas, 404 Southam, forceps for removal of tongue, 726 Southey, intra-thoracic hydatid, 847 Spanish windlass, 94 Spasm of bladder, 900 of intestines, 804 muscles after amputation, 104 in dislocation, 272 fracture, 220, 225 spinal injuries, 326 tetanus, 517 of oesophagus, 744 sphincter ani, 824 vaginae, 973 urethra, 917 Spasmodic retention of urine, 899 stricture. -See Spasm. Speculum, aural, 689, 698 nasal, 703 rectal, 820 vaginal, 937, 939, 971 Speir, aneurism, 540 artery constrictor, 181 Spence, excision of elbow, 611 hip-joint amputation, 130 subclavian aneurism, 558 Sperino, glaucoma, 667 Spermatic cord. See Cord. Spermatocele, 957 Spermatorrhoea, 966 Sphacelus, 48. See Gangrene, Mortifica- tion, and Sloughing. Sphincter ani, rupture of, 824, 828 spasm of, 824 vaginae, spasm of, 973 Spica bandage, 80 Spider bite, 153 Spillman, statistics of excisions, 211 Spina bifida, 639 false, 640 ventosa, 579 Spinal abscess, 641, 643, 645 canal and s. column. See Vertebral. cord, compression of, 324, 336 concussion of, 323 from indirect causes, 329 state of, after amputation, 104 in hydrophobia, 155 inflammation of, 324 injuries of, 323 laceration of, 324 progressive disorganization of, 325 syphilitic affections of, 449 wounds of, 325 membranes, inflammation and lacera- tion of, 324 Spine, caries of. See Antero-posterior curvature. INDEX, 1029 Spine— concussion of. See Spinal cord. curvature of, antero-posterior, 641 lateral, 626. See Lateral curva- ture. • in rickets, 420 diseases of, 639 dislocations and fractures of, 331. See Vertebrae. injuries of, 323 cerebral complications of, 329 color of blood in, 169 trephining for, 336 et seq. necrosis of, 645 Pott's disease of. See Antero-poste- rior curvature. railway, 329 sprains of, 330 trephining the, 336, et seq. Spiral bandage, 80 spring for extension, 587 Splay-foot. See Talipes valgus. Spleen, abscess in, 846 excision of, 371, 845 lesions of, in pyaemia, 409 rupture of, 367 Splenotomy. See Spleen, excision of. Splints, 224 Bond's, 256 bracketed, 263, 620 Dupuytren's, 268, 297 for excision of knee, 620 interdental, 240 suspension, 263, 267 for vesico-vaginal fistula, 942 Splinters. See Sequestra. Spontaneous cure of aneurism, 538 dislocation, 269, 277 gangrene, 390 haematocele, 958 hemorrhage, 175 Spoons for cataract, 665, 666 Sprains, 209 of muscles, 207 vertebral column, 330 Sprain-fracture, 209 Spurious cataract, 661 Squibb, anaesthesia, 73 et seq. Squint. See Strabismus. Squire, B., port-wine stain, 526 Squire, T. H., vertebrated catheter, 904 Staff for lithotomy, 870, 872 in female, 887 hollow, 874 rectangular, 874, 882 straight, 874 Syme's, for division of strictures, " 927 Stafford, lancetted catheter, 928 spinal injuries, 325 Stammering with urinary organs, 899 Stanley, orbital exostoses, 476 spontaneous cure of aneurism, 538 Stapes, anchylosis of, to fenestra ovalis, 699 Stapin, flexion for aneurism, 549 Staphyloma, 653 ciliary, 655 of cornea, 654 iris, 654 sclerotic, 653 Staphyloplasty, 740 Staphyloraphy, 737 Staples, fracture of clavicle, 247 Starched bandage, 82 Steam, death from inhaling, 300 Steaming in inflammation, 57 Steatoma. See Tumor, fatty. Steel, flexible wire probe, 570 Steffen, tubercles of choroid, 672 Stellwag, keratocele, 652 Stercoraceous abscess, 847 vomiting in intestinal obstruction, 806 strangulated hernia, 774 Sterility in male, 967 from undescended testes, 952 Sterno-cleido mastoid muscle, congenital tumor of, 207, 451, 722 division of, 625 Sternum, dislocation or diastasis of, 242, 278 fracture of, 242 trephining the, 243, 358 Stertorous breathing from anaesthetics, 75 in compression of brain, 311 Stethoscope in diagnosis of fracture, 219 Steurer, stricture of urethra, 925 Stevens, hypermetropia, 676 Stewart, live fish in oesophagus, 356 Stillicidium lacrymarum, 686 Stimson, ruptured perineum, 380 Stimulants in inflammation, 54, 58 Stings of insects, 153 Stirrup, adhesive plaster, for extension, 260, 261 Stoffel, oesophagotomy, 746 Stokes, granular lids, 649 supra-condyloid amputation of thigh, 126 Stomach, foreign bodies in, 374 hernia of, 766 opening the. See Gastrostomy, and Gastrotomy. resection of, 845 rupture of, 368 wounds of, 372 Stomach-tube, introduction of, 747 Stomatitis, gangrenous, 391 syphilitic, 452 Stone, metallic ligatures, 182 paracentesis thorasis, 364 Stone in bladder or kidney. See Cal- culus. fit of, 851 Storer, ovariotomy, 841 Storrs, wounds of abdomen, 371 Strabismometer, 679 Strabismus, 679 Strangulated hernia, 771. See Hernia. Strangulation, 139 of aneurism, 550 epithelioma, 498 1030 IND EX. Strangulation of— hemorrhoids, 827, 830 internal, 804 diagnosis of, 806 statistics of, 805, 809 in strangulated hernia, 780 treatment of, 808 of naevus, 527 penis, 139, 947, 948 prolapsus of rectum, 832 by ring, 139, 948 of staphyloma, 655 by tight bandaging, 226 Strangury, 893 in gonorrhoea, 426 Strapping the breast, 753 testis, 953 for epididymitis, 427 ulcers, 387 Streatfeild, operations on eye and eyelids, 661 et seq. Strieker, origin of pus corpuscle, 39 Stricture fever, 922 of intestine, 805, 806 oesophagus, 344, 744 rectum, 815 seat of, in strangulated hernia, 772 of trachea, 750 urethra, 918 catheterization in, 931 classification of forms of, 920 Cock's operation for, 930 congestive, 918 contractile, 920, 924, 926 diagnosis of, 922 dilatation of, 923, 924 external urethrotomy for, 927, 929, 933 false passages in, 923 in female, 933 forced catheterization for, 928 impermeable, 920, 928 internal urethrotomy for, 926 irritable, 920, 921, 924, 926 lancetted catheter for, 928 locality of, 919 morbid anatomy of, 919 permanent or organic, 918 permeable, 920, 923 puncture of bladder for, 933 recurrent. See Contractile. retention of urine from, 921, 931 rupture for, 924 of bladder or urethra in, 933 spasmodic. See Urethra, spasm of. Syme's operation for, 927 symptoms of, 920 syphilitic, 448 tapping urethra for, .930, 933 traumatic, 918 treatment of, 922 et seq. urethral fever following, 921 urethrotomy for, external, with guide, 927 without guide, 929, 933 internal, 926 Stromeyer, anchylosis, 597 club-foot, 632 parenchymatous hemorrhage, 410 Struma, 415 Strumous synovitis, 583 Stumps, affections of, 104 dressing of, 103 fractures in, 229 secondary hemorrhage from, 192 structure of, 104 Sturgis, syphilitic disease of ear, 446 Stye. See Hordeolum. Stylet-pince, 162 Styptic colloid, 146 cotton, 690 Styptics in hemorrhage, 179 Sub-astragaloid amputation, 120 Subclavian artery. See Artery. Subclavicular dislocation, 282 Sub-conjunctival operation tor strabismus, 680 Subcoracoid dislocation, 282 Subcrustaceous cicatrization, 142 Subcutaneous division of urethral stric- ture, 928 injection. See Hypodermic. osteotomy, 598, 600 wounds, 139 Subglenoid dislocation, 280 Subglossitis, 723 Sub-hyoidean laryngotomy or pharyngoto- my, 349, 354, 743, 749 Subluxation of knee, 296 lower jaw, 278 Submammary inflammation, 752 Submaxillary gland, tumors of, 721 Subperiosteal abscess, 564 Sub-retinal effusion, 673 Subscapular friction, 597 Sub-spinous dislocation, 282 Suction operation for cataract, 667 trocar, 88, 364. Sugar-loaf stump, 105 Super-laryngeal encysted tumor, 722 Supination in fractures of forearm, 255, 257 Suppositories, vaginal, in gonorrhoea, 429 Suppuration. See Abscess, Inflammation, and Pus. in aneurismal sac, 539, 543 blue, 39 in bone, 566, 568 diffused, 385 in hemorrhoids, 826 intra-cranial, 313, 320 in joints. See Pyarthrosis. retro-peritoneal, 370 subperiosteal, diffuse, 564 in stumps, 107 Suppurative fever. See Pyaemia. stage of inflammation, 38, 46 Supra-mammary inflammation, 752 Supra-pubic cystotomy for enlarged pros- tate, 909 lithotomy, 883, 887 INDEX. 1031 Surgeon, demeanor of, during operations, 70 qualifications necessary for, 62 Surgery, 33 military. See Gunshot wounds. minor, 79 orthopaedic, 624 plastic. See Plastic operations. Surgical fever and s. typhus. See Pyaemia. kidney, 921 Surmay, enterostomy, 747 Suspension for fractures, 267 in spinal affections, 628, 629, 644 Sutton, dislocation of hip, 291 Suture, 71, 98, 143 et seq. in amputation, 98 bone, 236, 237, 601, 620 button, 942 in cataract operation, 664 continued or glover's, 144 Gely's, 372 harelip, 144 India-rubber, 144 interrupted, 143 lace, 936 Lembert's, 372 materials used for, 71 quilled, 144 for radical cure of hernia, 768 in strabismus, 680 tongue and groove, 709 tAvisted, 144 in wounds of chest, gunshot, 360 lacerated, 148 of intestine, 372 neck, penetrating, 344 nerves, 206, 513 scalp, 306 scrotum, 378 tendons, 208 Swain, excision of knee, 621 gelatiniform degeneration, 583, 584 Swelling in inflammation, 36, 42 white. See Arthritis. Switzer, badly united fracture, 233 Symblepharon, 685 Syme, amputation at ankle, 122 aneurisms, 194, 541 et seq. blisters for ulcers, 387 cheiloplasty, 714 excision of breast, 760 scapula, 608 tongue, 726 hernia of testis, 954 hydrocele, 957 of neck, 722 radical cure of hernia, 794 rhinoplasty, 710 stricture of urethra, 920 et seq. torsion, 180 Sympathetic ophthalmia and s. neurosis, K78 Symphysis pubis, diastasis at, 243 puncture of bladder through, 908 Synchisis, 671 Synchronous ampuation, 102 Syndectomy, 649 Synechia, anterior, 653, 654 posterior, 657, 661 Synostosis, 596 Synovial cysts, 464 Synovitis, 580 scrofulous or strumous. See Arthritis, gelatinous. Syphilides, 444 Syphilis, 437 alopecia in, 446, 448 of areolar tissue, 450 arteries, 450 bone and periosteum, 451, 577 bubo in, 442, 454, 456 causes of, 438 chancre in, 440 et seq. chorea from, 449 confrontation in, 453 congenital, 451 contagion in, 438, 439 course, or natural history of, 439 dementia from, 449 diagnosis of, 452 of ear, 446 of eye, 446, 449, 452, 657 gummy tumors in, 450 of hands and feet, 447, 451, 454 hereditary, 451, 460 history of, 437 incubation of, 439, 443 inheritance of, 438 inoculation in, 453 iodide of potassium for, 458, 459 of intestines, 448 lips, 445, 454 lymphatic enlargement in, 445 mercury for, 455 et seq. morbid anatomy of, 439 of mucous membranes, 445, 448 mucons patches in, 444, 458 origin of, from chancres, 442 of muscular and fibroid tissues, 450 nervous system, 446, 449, 454 nodes in, 451 onychia in, 448, 501 osteocopic pain in, 451 panaris in, 451 primary, 439 prognosis of, 455 pseudo-paralysis in, 452 rhagades in, 445 secondary, 443 of skin, 444, 447, 452 solid viscera, 449 stages of, 438 stricture from, 448, 922 tertiary, 447 of testis, 449, 963 throat, 444 et seq. tongue, 445, 447, 454 treatment of, 455 et seq. urethral, vaginal and uterine dis- charges in, 423, 445 Syphilodermata, 444 DEX, 1032 in Syphilization, 460 Syringe, ear, 341 lithotomy, 871 penis, 424 posterior nasal, 703 prostatic, 902 Syringotome, 823 T-BANDAGES, 81 Tait, fungus of dura mater, 637 staphyloraphy, 738 suppurating cervical glands, 419 Taliacotius, rhinoplasty, 708 Talipes, 632 calcaneo-valgus, 636 calcaneo-varus, 635 calcaneus, 635 equino-valgus, 636 equino-varus, 634 equinus, 633 treatment of, without cutting tendons, 636 valgus, 635 varus, 634 Tamplin, club-foot, 632, 634 Tanjore pill, 153 Tansley, foreign bodies in nostrils, 341 Tapping. See Paracentesis. hydrocele, 956 ovarian cysts, 838 Taranget, oesophagotomy, 746 Tarbell, paralysis of bladder, 898 Tarsal cartilage, grooving the, 683 tumor. See Chalazion. Tarsus, amputations through, 120, 123 dislocations of, 297 excisions of, 623 fractures of, 268, 269 Tattooing the cornea, 653 syphilis transmitted by, 439 Tatum, puncture of bowel, 371, 783 Taxil, phimosis, 946 Taxis, 777 abdominal, 807 adjuvants to, 778 for femoral hernia, 800 incarcerated hernia, 771 inguinal hernia, 797 strangulated hernia, 777 Taylor, A. S., suicidal wounds of neck, 342 Taylor, C. F., apparatus for hip disease, 593 refracture of bone, 233 Taylor, H. M., detection of calculi by mi- crophone, 856 Taylor, I. E., recto-vaginal fistula, 820 Taylor, M., enlarged prostate, 906 Taylor, R. W., cephalic chancroid, 432 hypertrophy of lips, 712 ichthyosis of tongue, 478, 724 rachitis, 419 syphilis, 439 et seq. of eye, 446, 449, 687 Teale, amputation, 101,103, 127 Teale— cheiloplastic operations, 302, 303 enucleation of naevus, 527 loose cartilages in joints, 602 suction operation for cataract, 667 symblepharon, 685 Teeth in hereditary syphilis, 452 Teevan, fracture of skull, 315 lithotomy, 875 Telescopic speculum, 971 Temperament, influence of, on result of operations, 64 scrofulous, 417 Temperature, extreme, recovery from, 304, 328 in inflammation, 43 inflammatory fever, 50 pyaemia, 411 shock, 134, 136 spinal injuries, 328 tetanus, 517 Temporal artery. See Artery. Tenaculum, 97 Tendinous tumor, 472 Tendo Achillis, division of, 633 rupture of, 207 suture of, 208 Tendons, contraction of. See Orthopaedic surgery. after amputation, 106 diseases of, 506 division of. See Tenotomy. injuries of, 207 luxation of, 208 repair in, 207, 633 Tenosynovitis, 507 Tenotome, 625 Tenotomy for club-foot, 632 et seq. club-hand, 630 contracted joints, 629 et seq. dislocation of astragalus, 298 congenital, 277 old, 275 hip disease, 592 knock-knee, 631 lateral curvature of spine, 629 repair after, 207, 633 for strabismus, 680 wry-neck, 625 Tertiary syphilis, 447 Testis, abscess of, 953 absence of, 952 cancer of, 964 dentigerous cyst of, 467 disappearance of, 952 excision of, 964. See Castration. hernia of, 953 hydatid, 963 inflammation of, 952. See Orchitis. inversion of, 952 lesions of, in pyaemia, 409 malformations and malpositions of 952 neuralgia of, 954 position of, in hydrocele, 955, 958 inguinal hernia, 791 INDEX. Testis— puncture of, 427. 953 sarcocele of. Sec Sarcocele. strapping the, 427. 953 swelled. See Epididymitis. syphilitic affections of, 449 tumors of, 961 et seq. undescended. 952 wounds of, 378 shock in, 133 Tetanus, 516 amputation for, 92 diagnosis of, 519 nascentium, 516 after operation for piles, 830 pathology of, 517 prognosis of, 519 in spinal injuries. 329 symptoms of, 517 treatment of, 519 Textor, excision of knee, 616 Thecae, inflammation of. See Tenosyno- vitis. Theobald, crotchet hook for strabismus, 680 cupping, 87 Thermal hammer, 83 Thilenius, club-foot, 632 Thigh, amputations of, 126 Thigh-bone. See Femur. Third intention, union by, 142 Thomas, intravenous use of milk, 88 elytrorraphy, 973 laparo-elytrotomy. 844 ovarian tumors. 835 et seq. scoop for uterine fibroids, 974 urinary vaginal fistulae, 938, 943 vaginal speculum, 971 Thompson, B., artificial membrana tym- pani, 694 Thompson, Sir H., bladder, affections of, 894 et seq. lithotomy and lithotrity, 854 et seq. prostate, affections of, 902 et seq. recto-vesical fistula, 819 stricture of urethra, 910 et seq. Thomson, C, siphon trocar, 838 Thomson, Va\, ametropia, 676 counter-irritation by bromine vapor, 431 hospital gangrene, 394 Thoracic viscera, ruptures of, 357 Thorax. See Chest. Thornton, ovarian fluids, 836 Thrill in aneurism, 536 Throat, diseases of, 722 syphilitic, 444, 448, 459 injuries of. See Air-passages, Larynx, Neck, and Trachea. Thrombosis, 172 arterial, 172. 410 connection of, with pyaemia, 407 of penis, 949 Thrombus, 138, 139 Thudichum's douche for ozaena, 703 foreign bodies in nose and ear, 341 Thumb, amputation of, 114 dislocations of, 288 excision and fracture of. See Fingers. Thyroid artery. -See Artery. foramen, dislocation into, 292 gland. See Gland. Thyroideal laryngotomy, 749 Thyrotomy, 351 Tibia, dislocations of, 297 epipyseal separations of, 265, 266 excision of, 167, 622 fractures of, 265, 268 section of, in amputation, 124 Tibial artery. -See Artery. Tic douloureux, 514 Tillmans, dislocation of wrist, 287 Tinea tarsi, 681 Tinnitus aurium, 692, 700 Tirefond, 163 Tobacco enemata, 778, 808 Toe-nail, avulsion of, 501 hypertrophy of, 502 ingroAving, 501 ulcer, 501 Toes, amputation of, 118, 119 contraction of, 636 dislocations of. 298 excision of, 624 fractures of, 269 Tongue, abscess of, 723 aneurism by anastomosis of, 525 atrophy of, 723 cancer of, 726 chancre of, 454 corns on, 500 cysts of, 724 diseases of, 722 syphilitic, 445, 447, 454 epithelioma of. 726 excision of, 726 foreign bodies in, 342 hypertrophy or prolapsus of, 723 ichthyosis of, 478, 724 malignant tumor of, 726 naevus of, 527 operations on, 725 et seq. papiloma of, 478 removal of, 726 tumors of, 724 ulcers of, 723 wounds of, 342 Tongue and groove suture, 709 Tongue-tie, 724 Tonics in inflammation, 61 Tonsillitis, 741 Tonsillotome or tonsil guillotine, 742 Tonsils, diseases of, 741 syphilitic, 444, 448 excision of, 742 foreign bodies in, 355 hypertrophy of, 741 Tooth wounds. See Wounds. Torsion, 180 compared with acupressure and liga- tion, 189 for hemorrhoids, 830 1034 INDEX, Torticollis. See Wry-neck. Tour de maitre, 913 Tourniquet, 90, 92 et seq. abdominal, 130 for dislocations, 273, 294 Esmarch's, 93 provisional, 164 Toynbee, affections of ear, 689 et seq. Trachea, diseases of, 748 syphilitic, 448 fracture or rupture of, 345 Tracheal canula or tube, 353 Tracheocele, 748 Tracheotomy, 351 compared with laryngotomy, 354 in excision of upper jaw, 734 for foreign bodies in air-passages, 348 glossitis, 723 hemorrhage in, 352 for injuries of larynx and trachea, 345 malignant nasal tumor, 707 stricture of oesophagus, 746 oedema of glottis, 346 stricture of larynx or trachea, 344 in tetanus, 520 Trachoma, 648 Traction operation for cataract, 665 Transfusion of blood, 88, 178, 414 Transplantation of cuticle, 388 bone, 236 hairs, 388 Transportation of patients with fracture, 223 Transverse fracture, 216 obliteration of vagina, 942 Traumatic aneurism, t. arthritis, etc. See Aneurism, Arthritis, etc. fever. See Fever, inflammatory. typhus. See Gangrene, hospital. Travers, lateral ligature, 170 prostration with excitement, 134 sanguineous cyst of clavicle, 578 Trelat, tuberculous ulcer of tongue, 724 Trenholine, normal ovariotomy, 843 Trephine, 320, 321 Trephining for abscess of bone, 569 cornea, 677 in epilepsy, 320 injuries of head, 318 mastoid process, 699 for osteo-myelitis, 568 spine, 336 sternum, 243, 358 Trichiasis, 681 Trismus, 516 Trocar for hydrocele, 956 ovariotomy, 840 siphon, 838 suction, 88, 364 Trochanter, amputation through, 127 caries of, 591 Tromatopnea, 359, 362, 366 Trousseau, perinephritic abscess, 846 Truss for hernia, 766 femoral, 800 inguinal, 794 Truss for hernia— irreducible, 769 umbilical, 787 prolapsus of rectum, 833 varicocele, 960 Tube, Eustachian. See Eustachian. perineal, 871, 875, 878, 928 rectal, 807 stomach, introduction of, 747 tracheal, 353 Tubercle or tuberculosis, 415 analogy of, to pyaemia, 416 of bladder, 896 bone, 577 choroid, 672 mucous. -See Syphilis, mucous patch. painful subcutaneous, 478, 513 of breast, 757 of prostate, 909 syphilitic, 447 of testis, 962 tongue, 724 urethra, 934 Tubercular disease of foot, 503 syphilitic sarcocele, 449 Tuberculous cases, operations in, 416 sarcocele, 962 ulcer of anus, 825 conjunctiva, 648 tongue, 724 Tubes of Galli, 206 Tubular aneurism, 532 Tuckey, acute lateral curvature of spine, 627 Tufnell, aneurism, 540, 546 Tumors, 460 adenoid, 476 amputation for, 92 bony, 475 cartilaginous, 473 causes of, 461 classification of, 461, 462 chondroid, 472 cystic. See Cysts. desmoid, 472 erectile, 477, 525 excision of, 498 fatty, 468 fibro-calcareous, 471 fibro-cartilaginous, 473 fibro-cellular, 469 fibro-cystic, 471 fibro-muscular, 471 fibro-nucleated, 480 fibro-plastic, 480 fibrous or fibroid, 471 malignant, 473, 492 recurrent, 479 floating, 479 glandular, 476 lymphoid, 477 malignant, 462, 483. See Cancer and Epithelioma. mixed, 473 mucous, 471 muscular, 472 INDEX. 1035 Tumors— myeloid, 480 neuralgic, 478 non-malignant, 462 osseous, 475 painful subcutaneous, 478, 513 papillary, 477 phantom, 479 pulsating, 479 recurrent, 463, 479 sebaceous. -See Cysts. semi-malignant, 463, 479 tendinous, 472 vascular, 477, 525 villous. See Papillary. Tumors of antrum, 730 auditory meatus, 691 auricle, 689 bladder, 895 bone, 578 breast, 755. See Breast. bursae, 511 cheeks, 711 choroid, 672 cicatrices, 502 eyelids, 685 gums, 728 intestine, 805, 806 jaw, loAver, 735 upper, 730 labia majora, 971 larynx, 748 superlaryngeal encysted, 722 lips, 712 malar bone, 730 mouth, 724 muscle, 507 neck, 722 nerves. See Neuroma. nostrils, 707 optic nerve, 674 orbit, 687 ovary, 835. See Ovarian tumors. palate, 741 parotid region, 720 penis, 950, 951 pharynx, 743 prostate, 877, 902 rectum, 818 retina, 673 scalp, 637 sclerotic, 656 scrotum, 949 skin, 499 etseq. skull, 637 spermatic cord, 964 sterno-mastoid, congenital, 207, 451, 722 submaxillary gland, 721 testis. See Sarcocele, and Testis. thyroid gland, 719 tongue, 724 urethra, 934 uterus, 973. See Uterus. vagina, 972 Tunica albuginea, puncture of, 427, 953 Tunica— vaginalis, excision of, 957 haematocele of, 958 hydrocele of. See Hydrocele. Tuning-fork in aural surgery, 696 Tunnelling the prostate, 907 Turnbull, section of tensor tympani, 692 Turner, lymphoid tumors, 477 Turpentine, oil of, in hospital gangrene, 394 syphilitic iritis, 459 Twisted suture, 144 Twisting of vertebrae in lateral curvature of spine, 626, 627 Tympanum, diseases of cavity of, 696 inflamed mucous membrane of, 697 inflation of, 694 medullary cancer of, 700 membrane of. See Membrana tympani. syphilitic inflammation of, 446 membranous bands in, 698 mucus in, 697 paralysis of muscles of, 700 rigidity of mucous lining of, 698 Typhus, surgical. See Pyaemia. traumatic. See Gangrene, hospital. Tyre, excision of elbow, 611 Tyrrell, iris hook, 660 needle-guard, 144 ophthalmic gonorrhoea, 430 UHLER, gunshot wounds, 163 Ulceration, 40, 46 arrest of, 46, 47 of bone. See Caries. cartilage, 585 phagedaenic, in chancre, 440, 456 in chancroid, 433, 436 serpiginous, in chancroid, 433, 437 Ulcers, 385 amputation for, 389 of anus, painful, 823 atheromatous, 530 cancerous, 484 of cheeks, 711 cicatrization of, 47 classification of, 385 of cornea, 652 duodenum, in burns, 299 eczematous, 387, 388 epitheliomatous, 496 of foot, perforating, 503 granulation of, 46 of gums, 728 hemorrhagic, 389 indolent or callous, 387 transplantation of cuticle for, 388 inflamed or phlegmonous, 386 irritable, 387 of lips, 712 lupous, 504 mechanical, of stumps, 105 of mucous membranes, 389 neuralgic, 387 of nose, 707 1036 INDEX. Ulcers of— penis, 924 perforating, 304, 503 of rectum, 824 repair of, 46 rodent, 502 of vulva, 971 scrofulous, 417 et seq. simple or healthy, 386 venereal. See Chancroid. sloughing, 386 syphilitic, 440, 447, 450, 459 toe-nail, 501 of tongue, 723 treatment of, after cicatrization, 389 tuberculous, 648, 724, 825 of vagina, painful, 972 varicose, 389 venereal. See Chancroid, and Syphilis. warty, of cicatrices, 502 weak or oedematous, 386 Ulna, dislocations of, 285, 286 excision of, 167, 612 fractures of, 254, 257 Ulnar artery. See Artery. Ulrich, urinary vaginal fistulae, 938, 941 Umbilical hernia, 786 Umbilicus, gonorrhoea of, 422, 430 Uncipressure, 189 Union by adhesion, 141 by first intention, 140 of fractures, 221 delayed, 234 by granulation, 142 immediate, 140 of nerves, 205 by second intention, 142 of tendons, 207 by third intention, 142 Upper jaw. See Jaw, upper. Urachal calculus, 888 fistula, 937 Urachus, cyst of, 847 Uranoplasty, 740 Urates in calculi, 849 Ureter, catheterization of, 851, 887 dilatation of, 851, 921 impaction of calculus in, 851 occlusion of, in operation for vesico- vaginal fistula, 942 rupture of, 368 Uretero-vaginal fistula, 942 Urethra, abscess of, 426 bougies for, 910 calculus in, 866, 885 cancer of, 934 catheters for, 910 changes in, in enlarged prostate, 902 deficiency in floor of. See Hypospa- dias. in roof of. See Epispadias. diseases of, 909 endoscope for, 914 exploration of, 909 false passages in, 923 female, dilatation of, 886, 895, 935 Urethra— fissure of, 933 fistulae of. See Fistula. foreign bodies in, 377 hemorrhage from, 897 in catheterization, 924 gonorrhoea, 426 inflammation of, 916. See also Gonor- rhoea. inflation of, 913 laceration of, 377, 924 malformations of, 914 obliteration of, 920 occlusion of, 915 prolapsus of, 916 rupture of, 377, 933 sounds for, 910 spasm of, 917 stricture of, 918. See Stricture. complicating lithotrity, 868 congestive, 918 tapping the, 930 tubercle of, 934 tumors of, 934 vermicular movement of, 932 wounds of, 377 Urethral calculus, 885 discharge in syphilis, 423, 445 fever, 921 analogy of, to pyaemia and gonor- rhoeal rheumatism, 412, 430 complicating lithotrity, 868 fistula, 935 lithotomy, 887 Urethritis, 916. See also Gonorrhoea. Urethrocele, 916 Urethroplasty, 937 Urethro-rectal fistula, 819, 938 Urethrotomes, 926 Urethrotomy, external, with guide, 927 without guide, 929 for retention of urine, 933 internal, 926 Urethro-vaginal fistula, 938 Uric acid calculus, 848 Urinary calculus. See Calculus. deposits, 848 diatheses, 848 fistula. See Fistula. organs, condition of, influencing result of operations, 64 effect of calculus on, 858 enlarged prostate on, 903 stricture of urethra on, 921 Urine, albuminous, in calculus, 868 bloody. See Haematuria. changes in, after spinal injuries, 327 extravasation of, 370, 377," 932, 933 flow of, stopped by calculus, 855 incontinence of, in adults, 900 in children, 899 after lithotomy, 877 from enlarged prostate, 903 in spinal injuries, 327 infiltration of, after lithotomy, 878 retention of, 898 INDEX, 1037 Urine, retention of— from abscess of prostate, 901 in cystitis, 893 gonorrhoea, 426 hysterical, 899 after lithotrity, 866 with overflow, 898 from paralysis of bladder, 898 prostatic enlargement, 903 prostatitis, 901 spasm of urethra, 917 in spinal injuries, 327 from stricture of urethra, 921, 931 congestive, 918 secretion of, in intestinal obstruction, 806 suppression of, from renal calculus, 851 in spinal injuries, 327 Uriseptic suppuration, 921 Urostealith in calculi, 851 Uterine discharge in syphilis, 445 fibroids, 973 probe or sound, 836 Uterus, absence of, 969 amputation of neck of, 977 cancer of, 976 epithelioma of, 976 excision of, 975 with both ovaries, 843 injuries of, 378 polypi of, 975 procidentia of, 976 prolapsus of, 972, 976 rupture of, 844 tumors of, 973 diagnosis of, from ovarian tumors, 835 fibro-cellular. See Polypi. fibrous or fibro-muscular, 973 malignant, 976 myeloid and recurrent fibroid, 976 Uvula, bifid, 737 elongation of, 740 scissors for, 741 VACCINATION, 65 transmission of syphilis by, 438 Vacher, fracture of clavicle, 247 Vagina, absence of, 968 diseases of, 971 double, 970 fistulae of. See Fistulae. foreign bodies in, 379 gonorrhoea of, 428 hemorrhage from wounds of, 379 imperforate, 968 injuries of, 378 obliteration of, 970 transverse, 942 painful ulcer or fissure of, 972 polypi of, 972 prolapsus of, 972 spasm of, 973 tapping abdomen through, 838 Vagina— tumors of, 972 Vaginal discharge in syphilis, 445 hernia, 803 lithotomy, 887 ovariotomy, 843 poultices, 429 speculum, 938, 939, 971 Vaginismus, 973 Vagino-rectal fistula, 819 Valentin, haemothorax, 362 Valsalva, aneurism, 540 Valvular stricture of urethra, 920 Van Bidder, ptosis, 684 Van Buren, aneurism, 550 compression of iliac artery through rectum, 130 dermoid cyst of testis, 963 forcible dilatation of sphincter ani, 824 septhaemia, 405 stricture of urethra, 926 et seq. Van Buren and Keyes, diseases of male genitals, 949 et seq. foreign bodies in urethra, 377 ophthalmic gonorrhoea, 430 Vance, inversion of bladder, 892 Van Wattman, anchylosis of elbow, 600 Vanzetti, digital compression for aneur- ism, 547 Varicocele, 959 diagnosis of, from hernia, 793 operations for, 960 Varicose aneurism, 196 lymphatics, 506 ulcer, 389 veins, 523 of spermatic cord. See Varico- cele. Varix. See Varicose veins. aneurismal, 195 non-traumatic, 551 in stumps, 105 arterial, 525 Varus shoe, 635 Vas deferens, rupture of, 378 Vascular tumors, 477, 525 of penis, 950 Vegetations. See Warts. adenoid, 704 Vein or veins, air in, 170 condition of, in pyaemia, 410 diseases of, 521 hemorrhage from, 169 inflammation of, 521. See Phlebitis. injuries of, 169 remote consequences of, 172 internal jugular, wounds of, 169 ligation of, 170 pressure of aneurism on, 536, 544 repair in wounds of, 170 rupture of, 169 in reducing dislocations, 275, 276 saphena, dilated, diagnosis of from femoral hernia, 800 spermatic, valves in, 959 1038 IND EX. Veins- superficial, enlarged in cancer of breast, 758 varicose, 523 wounds of, 169 communicating with arteries, 195 Vein-stones, 172, 827 Velpeau, dextrine bandage, 82 fractures, 220, 239, 246 et seq. gonorrhoeal epididymitis, 427 spinal injuries, 326 torsion, 180 Vena cava, rupture of, 368 wounds of, 365 Venereal diseases, 421. See Chancroid, Gonorrhoea, and Syphilis. warts. See Warts. Venesection, 87. See Bloodletting. in shock, 135 Venning, duration of syphilis, 443 Venous aneurism, 169 naevi, 526 pulse in chloroform anaesthesia, 75 Ventilation, influence of, on result of ope- rations, 64, 65 Ventral hernia. See Hernia. Veratrum viride in aneurism, 540 inflammation, 60 Vermale, amputation of thigh, 126 Vermicular movement of urethra, 932 Vernet, compression in aneurism, 546 Verneuil, diseases of rectum, 813 et seq. gastrostomy, 747 pyaemia, 405, 409 Verrucae. See Warts. Vertebrae, caries of. See Spine, antero- posterior curvature of. necrosis of, 645 rotation of, in lateral curvature of spine, 626, 627 Vertebral artery. See Artery. canal, hemorrhage into, 324 column, dislocations of, 331, 334 fractures of, 331, 333, 334 trephining for, 336 sprains of, 330 Vertebrated catheter, 904 Vesical calculus. See Calculus. catarrh, 894 irritation in gonorrhoea, 426 Vesicants, 83. See also Blisters. Vesication in fracture, 226 Vesico-rectal fistula, 819, 938 Vesico-uterine fistula, 938, 942 Vesico-utero-vaginal fistula, 938, 942 Vesico-vaginal fistula, 938 et seq. Vesicular granulations, 648 Vezien's suture, 372 Vidal (de Cassis), puncture of testis, 427, 953 varicocele, 960 Vignes, wound of spinal cord, 325 Villate, liqueur de, 107, 571 Villous cancer, 491 epithelioma, 496 tumors, 478 Villous tumors— of bladder, 895 Vincent, excision of calcaneum, 624 Virchow, amyaline neuromata, 513 arteries, structural changes in, 531 pathology of inflammation, 36 et seq. pyaemia, 405 et seq. tubercle, 416 tumors, 461 et seq. syphilis, 439, 451 Viscera, abdominal, diseases of, 834 et seq. injuries of, 367 et seq. pelvic, injuries of, 376 thoracic, injuries of, 357 et seq. Visceral syphilis, 449 Vision, field of, in amaurosis, 674 Vitreous humor, diseases of, 671 Voice, impairment of, in throat wounds, ■ 344 Voillemier, cautery in arthritis, 587 fracture of radius, 255 Volkmann, excision of rectum, 818 Volvulus, 8(4 et seq. Vomiting of blood, in fractured skull, 316 in injuries of head, 309, 313 spine, 327 intestinal obstruction, 806 shock, 134 strangulated hernia, 774 Von Bruns's pliers, 83 Von Graefe, diseases of and operations on the eye, 653 et seq. Von Luschka, nature of Pacchionian bodies, 478 Vosburgh, urachal calculus, 888 Voss, separation of lower epiphysis of tibia, 266 Vulpian, spinal changes after amputation, 104 Vulva, adhesion of, 968 diseases of, 970 imperforate, 968 inflammation of, 971 gonorrhoeal, 428 injuries of, 378 ulcer of, rodent, 971 venereal. See Chancroid, and Syphilis. warts of, 971 WACHSMUTH, hemorrhagic diathesis, 175 Wagstaffe, mammary cancer in male, 760 temperature in shock, 134 Wainman, excision of elbow, 611 Wakley, stricture of urethra, 924 Waldenburg, tubercle and scrofula, 418 Wales, clasp for fractured jaw, 240 stricture of rectum, 817 Walker, abscess of bone, 569 Walker, J. B., resection of spine, 336 rupture of bladder, 375 Waller, anaesthesia by compressing vagi to migration of white blood corpuscles 39 INDEX. 1039 Waller- repair of nerves, 206 Walsham, air in veins, 172 Walter, rupture of bladder, 375 Wandering cells, 37 Ward, dislocation of shoulder, 283 Ward carriage, 65 Wardrop, aneurism, 545, 555 Warm bath in retention of urine, 426, 906, 932 strangulated hernia, 778 Warmth in inflammation, 57 Warren, J. C, badly united fractures,233 complicated luxation, 276 eiloides, 505 epithelioma of scrotum, 951 first operation with ether, 73 staphyloraphy, 73S Warren, J. Collins, keloid, 502 rodent ulcer, 503 Warren, J. M., amputation at hip, 128 compression of nerve by callus, 206 sinus containing hair, 821 uranoplasty, 740 Warts, 499 of cheeks, 711 larynx, 748 penis, 950 venereal, 433, 435, 499 of vulva, 971 Warty tumors and ulcers of cicatrices, 502 Washington, reduction of hernia, 777 Water-dressing in gunshot wounds, 163 warm, in inflammation, 57 Waterman, dislocation of ulna, 285 Wathen's pliers, 83 Watson, B. A., aneurism, 541 hydrophobia, 155 Watson, E., tetanus, 520 Watson, P. H., amputation of penis, 951 excision of knee, 620 trephining, 320, 321 Watson, Spencer, diseases of eye, 664 et seq. Watson, T., convulsions in head injuries, 313 Wax in ear, 690 Weak ankles, 636 sight, 676 ulcer, 386 Webbed fingers, 630 Webber, spinal changes after amputation, 104 Weber, applications to tympanum, 699 corelysis, 661 Weber (of Ohio), ae'rteriversion, 189 Wecker, diseases of eye, 673 et seq. Weeds, intracranial abscess, 314 Weight for bubo, 456 extension in anchylosis, 597 arthritis, 587 fractured femur, 260, 262 hip disease, 592 for hemorrhage, 179 Weir, gag for operations on mouth, 738 Weir— ichthyosis of tongue, 724 incurvation of penis, 944 urethroplasty, 937 Welch, splints for fractured humerus, 251, 253 Wells, H., nitrous oxide, 73 Wells, Soelberg, affections of eye, 340, 648 et seq. Wells, Spencer, bichloride of methylene, 78 ovariotomy, 837 et seq. traumatic fever, 56 urinary vaginal fistulae, 938 et seq. Wens. See Tumors, fibro-cellular. Wertheim, duodenal ulcer in burns, 299 Wheelhouse, external urethrotomy, 929 White, A., excision of hip, 613 White C, dislocation of shoulder, 283 excision of hip, 613 ununited fracture, 236 White, J. W., bulbous-pointed bougies, 911 White corpuscles in inflammation, 35 in pyaemia, 410 gangrene, 398 swelling. See Arthritis. Whitehead, cystotomy, 909 gag for staphyloraphy, 738 harelip, 718 periosteal uranoplasty, 740 stricture of rectum, 816 et seq. Whitlow. See Panaris, and Paronychia. Wilde, aural polypus, 691 symblepharon, 685 Wilhite, tetanus nascentium, 516 Wilkerson, wound of profunda femoris, 184 Wilks, arterial pyaemia, 408, 410 Willett, fracture of femur, 263 Williams, H. W., diseases of eye, 651 etseq. Williams (of New York), rupture of blad- der, 375 Williamson, excision of elbow and ulna, 612 Willett, lateral curvature of spine, 627 Willis, lithectasy in male, 886 Wilms, tracheotomy for diphtheria, 748 Wilson, local anaesthesia by carbolic acid, 79 Wilson, E., intravenous use of milk, 88 Wind of ball, 158 Windlass, rope, for dislocations, 273, 293 Spanish, 94 Windpipe. See Larynx, and Trachea. Wing, vaginal ovariotomy, 843 Wire coil in aneurism, 550 for drainage, 211, 383 seton for hydrocele, 957 snare for laryngeal growths, 749 splint for excision of knee, 620 suture for radical cure of hernia, 768 Wiseman, external urethrotomy, 929 Wolf, hydrophobia, 154 Wood, J., epispadias, 915 excision of tonsils, 742 extroversion of bladder, 891 1040 INDEX. Wood, J.— gag for operations on tongue, 726 hypospadias, 916 radical cure of hernia, 768, 787, 795, 800 rhinoplasty, 710 truss for hernia, 766, 787, 794 undescended testis, 952 varicocele, 961 Wood, J. R., digital compression in aneu- rism, 547 open method of dressing stumps, 103 Woodbury, compression of iliac artery through rectum, 130 Woodward, hospital gangrene, 392 nature of cancer, 492 osteo-myelitis, 566 Wormald, varicocele, 960 Worster, urachal fistula, 938 Wounds, 139 antiseptic treatment of, 149 arrow, 152 arterio-venous, 195 bayonet, 151 condition of, in erysipelas, 400 hospital gangrene, 393, 394 pyaemia, 410 tetanus, 517 contused. See Wounds, lacerated. dissection, 155 gunshot, 156 amputation and excision in, 164 characters of, 157 contusion of bone in, 168 debridement in, 163 direction of ball in, 160 dressing of, 159 entrance and exit wounds in, 158 hemorrhage from, 160, 161 momentum of projectile in, 157 nature of, 158 pain of, 160 remote consequences of, 168 removal of foreign bodies from, 162 shock in, 160 sloughing in, 158 symptoms of, 160 treatment of, 161 hernia following, 762 incised, 139 dressing of, 143 Wounds, incised— gaping of, 140 glazing of, 143 healing of, 140 hemorrhage from, 140 pain of. 139 treatment of, 142 lacerated, 147 amputation for, 92, 148 gangrene following, 147 treatment of, 148 open, 139 of particular tissues and organs. See the parts themselves. poisoned, 153 punctured, 151 treatment of, 153 repair of, 140 subcutaneous, 139 tooth, 153 Wreden, excision of malleus, 693 Wrist, amputation at, 114 diseases and injuries of. See under Joints. dislocations of, 287 excision of, 165, 612 fractures involving, 255 Wry-neck, 624 with painful spasm, 626 Wunderlich, temperature in tetanus, 517 Wutzer, radical cure of hernia, 794 vesico-vaginal fistula, 941 Wyeth, femoral hernia, 801 Syme's amputation, 122 Wyman, suction-trocar, 89, 364 XANTHIC oxide or Xanthine calculus, 851 Xerophthalmia, 686 Y-LIGAMENT, 288 YelloAV spot. See Macula lutea. Youatt, hydrophobia, 155 Young, hemorrhoids, 827 ZINC plate for ulcers, 388 Zone, genital, 379 Zonular cataract, 661 et seq. Zygoma, fracture of, 239 THE END. HENRY C. LEA'S (late lea & blanchard's) CLASSIFIED OATAX-iOG XJE] OF MEDICAL AND SUEGIGAL PUBLICATIONS. In asking the attention of the profession to the works advertised in the following pages, the publisher would state that no pains are spared to secure a continuance of the confidence earned for the publications of the house by their careful selection and accuracy and finish of execution. The printed prices are those at which books can generally be supplied by booksellers throughout the United States, who can readily procure for their customers any works not kept in stock. AVhere access to bookstores is not convenient, books will ho sent by mail post-paid on receipt of the price, but no risks are assumed either on the money or the books, and no publications but my own are supplied. . Gentlemen will therefore in most cases find it more convenient to deal with the nearest bookseller. An Illustrated Catalogue, of 64 octavo pages, handsomely printed, will be for- warded by mail, post-paid, on receipt uf ten cents. J HENRY 0. LEA. Noe. 706 and 708 Sansom St., Philadelphia, October, 1878. ADDITIONAL INDUCEMENT FOR SUBSCRIBERS TO THE AMERICAN J0UUNAL_0F_T11E MEDICAL SCIENCES. TEEEE MEDICAL JOURNALS, containing over 2000 LARGE PAGES, Free of Postage, for SIX DOLLABS Per Annum, TEEMS FOR 1878: The American Journal of the Medical Sciences and \ Five Dollars per annum, The Medical News and Library, both free of postage, j in advance. OJR Tue American Journal of the Medical Sciences, published qnar-") gix T)0uars terly (1150 pages per annum), with The Medical News and Library, monthly (384 pp. per annum), and J- per annum, The Monthly Abstract of Medical Science (592 pages per j -n advancfc# annum). J * * Advance-paying subscribers can obtain at tbe close of the year cloth covers giltdettered, for each volume of the Journal (two annually), and of the Abstract (one annually), free by mail, by remitting ten cents for each cover. • SEPARATE SI JiSCRIi'TlOKS Tit The American Journal of the Medical Sciences, when not paid for in advance, Five Dollars. The Medical Neavs and Library, free of postage, in advance, One Dollar. The Monthly Abstract of Medical Science, free of postage, in advance, Two Dollars and a Half. __________ In commencing a new half century in the career of the "American Journal of the Medical Sciences," the publisher has much pleasure in assuring its wide circle of readers that, at no former period has it had the prospect of a more extended sphere of usefulness. Sustained as it is by the profession of the whole United States, and with a circulation extending to every country in which the English language is read, the efforts of the editors will be directed, as heretofore, to render it in every way worthy of its reputation, and of the universal favor with which it is received. With its attendant periodicals, the "Medical News and Library" and the "Monthly Ab- stract of Medical Science," it combines the advantages of the elaborate preparation which can be given to a quarterly, and the prompt conveyance of intelligence by tbe monthly, while the whole, being under a single editorial supervision, the subscriber is secured against the duplication of matter inevitable under other circumstances. These efforts the publisher seeks to second by offering these periodicals at a price unnrecedentedly low—a price which places them within the reach of every practitioner, and "ives the equivalent of three large octavo volumes for the comparatively trifling (For "The Obstetrical Jouunal," see p. 23.) 2 Henry C. Lea's Publications—(Am. Journ.. Med. Sciences). cost of Six Dollars per annum. The three periodicals thus offered are universally known for their high professional standing in their several spheres. I. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by ISAAC DAYS, M.D., and I. MINIS HAYS, M.D., is published Quarterly, on the first of January, April, July, and October. Each num- ber contains nearly three hundred large octavo pages, appropriately illustrated wher- ever necessary. It has now been issued regularly for over fifty years, during the whole of which time it has been under the control of the present senior editor. Through- out this long period, it has maintained its position in the highest rank of medical peri- odicals both at home and abroad, and has received the, cordial support of the entire profession in this country. Among its Collaborators will be found a large number of the most distinguished names of the profession in every section of the United States, rendering its original department a truly national exponent of American medicine.* Following this is the "Review Department," containing extended and impartial reviews of important new works, together with numerous elaborate "Analytical and Bibliographical Notices" giving a complete survey of medical literature. This is followed by the "Quarterly Summary of Improvements and Discoveries in the Medical Sciences," classified and arranged under different heads, presenting a very complete digest of medical progress abroad as well as at home. Thus, during the year 1877, the "Journal" furnished to its subscribers 101 Original Communications, 135 Reviews and Bibliographical Notices, and 227 articles in the Quarterly Summaries, making a total of Four Hundred and Sixty-three articles illustrated with 64 maps and wood engravings, emanating from the best professional minds in America and Europe. That the efforts thus made to maintain the high reputation of the "Journal" are successful, is shown by the position accorded to it in both America and Europe as a leading organ of medical progress:— The Philadelphia Medical and Physical Journal issued its first number in 1820, and. after a brilliant career, -was succeeded in 1827 by the American Journal of the Medical Sciences, a periodical of world-wide reputation ; the ablest and one of the oldest periodicals in the world—a journal which has an unsullied record.—Gross's History of American Med. Literature, 1876. It is universally acknowledged to be the leading American medical journal, and, in onr opinion, is second to none in the language—Boston Med. and Surg. Jovrnal, Oct. 1S77. This is the medical journal of onr country to which the American physiciaa abroad will pQint with the greatest sati-faction, as reflecting the state of medical culture iu his country. For a great many years it ha-i been the medium through which our ablest writ- ers have made knowu their discoveries and observa- tions —Address of L. P Tandell, M.D., be fore Inter- national Med. Congress, Sept. 1876. And that it was specifically included in the award of a medal of merit to the Publisher in the Vienna Exhibition in liS73. The subscription price of the "American Journal of the Medical Sciences" has never been raised during its long career. It is still Five Dollars per annum ; and when paid for in advance, the subscriber receives in addition the " Medical News and Library," making in all about 1500 large octavo pages per annum, free of postage. II. THE MEDICAL NEWS ANI) LIBRARY is a monthly periodical of Thirty-two large octavo pages, making 384 pages per annum. Its '-Library Department" is devoted to publishing standard works on the various branches of medical science, paged separately, so that they can be detached for binding, when complete. In this manner subscribers have received, without ex- pense, such works as "Watson's Practice," "West on Children," "Malgaigne's Surgery," "Stokes on Fever," and many other volumes of the highest reputation and usefulness. Gosselin'* ■• Clinical Lectures on Surgery," having been com- pleted in the number for June, 18'.8. with July will be commenced the publication of "Lectures on the I) seases of the Nervous Ststem," by J. M. Charcot, Professor to the Faculty of Medicine of Paris, translated from the French by (jrokue Sigkrson * Communications are invited from j;entlemen in all parts of the country. Elaborate articles ius by the Editor are paid for by tue Puolioher. This is universally acknowledged as the leading American Journal, and has been conducted by Dr. Hays alone until 1869, when his son was associated with him. We quite agree with the critic, that this journal is second to none in the language, and cheer- fully accord to it the first place, for nowhere shall we find more able and more impartial criticism, and nowhere such a repertory of able original articles Indeed, now that the ''Brilish and Foreign Medic- Chirurgical Review" has terminated its career, the American Journal stands without a rival.—London Med. Times and Gazette, Nov. 21, 1877. The present number of the American Journal is an exceedingly good one, and gives every promise of maintaining the well-earned reputation ef the review Our venerable contemporary has our best wishes, and we can only express the hope that it may con- tinue its work with asmuch vigor and excellence for the next fif.y years as it has exhibited in the past. —London Lancet, Nov. 21, 1S77. Henry C. Lea's Publications—(Am. Journ. Med. Sciences). 3 M.D.. M.Ch., Lecturer on Biology, etc., Catholic Univ. of Ireland (see p. 16), thus rendering this date a valuable and convenient time to comm< nee subscriptions. The "News Department" of the "Medical News and Library" presents the current information of the month, with Clinical Lectures and Hospital Gleanings. A new and attractive feature of this will be found in an elaborate series of Original American Clinical Lectures, specially contributed to the News by gentlemen of the highest reputation in the profession throughout the United States. The arrange- ments for this are not as yet completed, but already the co-operation has been secured of the following:— S. D. Gross, M.D., Prof, of Surgerv. Jefferson Med Coll , Philadi. Austin Flint. M.D., Prof. Prin. and'Prae. of Med., Bellevue Hosp. Med. Coll.. N. Y. S. Weir Mitchell. M.D.. Phys. to the Infirmary for Nervous Diseases, Philada. T. Gaillard Thomas, M.D., Prof. Obstetrics. &c. Coll. Phvs. and Surg., X. Y. J. M. DaCosta. M.D., Prof. Prin. and Prac. of Med.. Jeff Med. Coll.. Philada. Roberts Bartholow. M.D., Prof. Theory and Practice of Med., Med. Coll. of Ohio. T. G. Richardson, M D., Prof. Genl. and Clin. Surg., Univ. of La., New Orleans. William Goodell. M.D.. Prof. Clin. Gynaecology, Univ. of Penna. Fordyce Barker.M.D., Prof. Clin. Midwiferv. &c. Bellevue Hosp. Med. Coll , N Y N. S. Davis, M.D., Prof. Prin. and Prac. of Med., Chicago Med. Coll. L. A. Duhring, M.D.. Clin. Prof, of Diseases of the Skin, Univ. of Penna. TheophilusParvin.M.D., Prof Obstetrics. &c. Coll. Phys.and Surg.. Indianapolis. Lewis A. Sayre, M.D.. Prof. Orthopaedic Surg.. &c. Bellevue Hosp. Med Coll., NY. W. H. Van Buren, M.D., Prof. Surgery, Bellevue Hosp. Med. Coll., X. Y. J. P. White, M D., Prof, of Obstetrics. &c, Univ. of Buffalo. John Ashhurst, Jr., M D., Prof, of Clin. Surg., Univ. of Penna. D. Warren Brickell, M.D., Prof. Obstetrics, &c, Charity Hosp. Med. Coll., X\ 0. William Pepper, M.D., Prof. Clin. Medicine, Univ. of Penna. J. Lewis Smith, M.D., Clin. Lee. on Dis. of Chil., Bellevue Hosp. Med. Coll., XT. Y. William F. Xorris, M.D., Clin. Prof, of Diseases of the Eye, Univ. of Penna. P. S. Conner, M.D.. Prof, of Anat. and Clin. Surgery, Med. Coll. of Ohio, Cin. Thomas G. Morton, M.D., Surgeon to Penna. Hospital, Philadi. F. J. Bumstead, M.D.. late Prof, of Venereal Dis., Coll. Phys. and Surg., X. Y. J. H. Hutchinson, M.D., Physician to Penna. Hospital. F. Peyre Porcher, M.D . Prof, of Mat. Med. and Chu. Medicine, Med. Coll. of S.C. Christopher Johnson, M.D., Prof, of Surgery, Univ. of Md., Baltimore. S AV. Gross. M.D., Surg, to Philada. Hospital.* William Thomson, M.D., Lecturer on Ophthalmology, Jeff. Med. Coll., Philada. With contributors such as these, representing every portion of the United States, the publisher feels safe in promising to the subscriber a series of practical lectures unsurpassed in variety, interest, and value. As stated above, the subscription urice of the "Medical News and Library" is One Dollar per annum in advance; and it is furnished without charge to all advance- paying subscribers to the "American Journal of the Medical Sciences." III. THE MONTHLY ABSTRACT OF MEDICAL SCIENCE is issued on the first of every mouth, each number containing forty-eight large octavo pages, thus furnishing in the course of the year about six hundred pages. The aim of the " Abstract" is to present—without duplicating the matter in the "Journal" and '• News"—a careful condensation of all that is new and important in the medical journalism of the world, and all the prominent professional periodicals of both hemi- spheres are at the disposal of the Editors. To show the manner in which this plan has been carried out it is sufficient to state that during the year 1877 it contained— !i'i Articles on Anntonuf it nil Fht/siolor/i/. ~>'i " " Jfntt-rin M'-dica and Therapeutics. UKi " " Mnlicinr. I4!t " «• Suri/rii/. SO ' " Miitirifiru and Oinia'colorft/. 9 " " ULnliciil .1tirisprudencr and Toxicology— making in all 527 articles in a single year. The subscription to the " Monthlv Abstract," free of postage, is Two Dollars and a Half a year, in advance. As stated above, however, it will be supplied in conjunction with the "American Journal of the Medical Sciences" and the "Medical Xews and Library," making in all about Twenty-one Hundred pages per annum, the whole free of postage, for Six Dollars a year, in advance. In this effort to bring so large an amount of practical information within the reach of every member of the profession, the publisher coniv'ently anticipates the hieudly 4 Henry C. Lea's Publications—(Dictionaries). aid of all who are interested in the dissemination of sound medical literature. He trusts, especially, that the subscribers to the "American Medical Journal" will call the attention of their acquaintances to the advantages thus ottered, and that he will be sustained in the endeavor to permanently establish medical periodical literature on a footing of cheapness never heretofore attempted. PREMIUM FOR OBTAINING NEW SUBSCRIBERS TO THE "JOURNAL." Any gentleman who will remit the amount for two subscriptions for 1878, one of which must be for a new subscriber, will receive as a premium, free by mail, a copy of "Browne on the Use of the Ophthalmoscope" (for advertisement of which see p. 29), or of "Flint's Essays on Conservative Medicine" (see p. 15J, or of "Sturges's Clinical Medicine" (see p. 14), or of the new edition of "Swayne's Obstetric Aphorisms" (see p. 22), or of "Tanner's Clinical Manual" (see p. f>), or of "Chambers's Restorative Medicine" (see p. 18), or of " West on Nervous Dis- orders of Children" (see p. 21). %* Gentlemen desiring to avail themselves of the advantages thus offered will do well to forward their subscriptions at an early day, in order to insure the receipt of complete sets for the year 1»78. Igg* The safest mode of remittance is by bank check or postal money order, drawn to the order of the undersigned. Where these are not accessible, remittances for the "Journal" may be made at the risk of the publisher, by forwarding in registered letters. Address, HENRY C. LEA, Nos. 706 and 708 Sansom St., Philadelphia, Pa. J\UNGLISON (ROBLEY), M.D., Late Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. MEDICAL LEXICON; A Dictionary op Medical Science: Con- taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae ftr Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of the Terms, and the French and other Synonymes; so as to constitute a French as well as English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- ified and Augmented. By Richard J. Dunglison, M.D. In one very large and hand- some royal octavo volume of over 1100 pages. Cloth, $6 50; leather, raised bands, $7 50. {Just Issued.) The object of the author from the outset has not been to make the work a mere lexicon or dictionary of terms, but to afford, under each, a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the positicn of a recognized and standard authority wherever the language is spoken. Special pains have been taken in the preparation of the present edition to maintain this en- viable reputation. Duringthe ten years which have elapsed since the last revision, the additiors to the nomenclature of the medical sciences have been greater than perhaps in any similar period of the past, and up to the time of his death the author labored assiduously to incorporate every- thing requiring the attention of the student or practitioner. Since then, the editor has been equally industrious, so that the additions to the vocabulary are more numerous than in any pre- vious revision. Especial attention has been bestowed on the accentuation, which will be found marked on every word. The typographical arrangement has been much improved, rendering reference much more easy, and every care has been taken with the mechanical execution. The work has been printed on new type, small but exceedingly clear, with an enlarged page, so that the additions have been incorporated with an increase of but little over a hundred pages, and the volume now contains the matter of at least four ordinary octavos. A book well known to our readers, and of which every American ought to he proud. When the learned author of the work passed away, probably all of us feared lest the book should -not maintain its place in the advancing science whose terms it defines. For- tunately, Dr. Richard J. Dunglison, having assisted his father in the revision of several editions of the work, and having been, therefore, trained in th e methods and imbued with the spirit of the book, has been able to edit it, not in the patchwork manner so dear to the heart of book editors, so repulsive to the taste of intel- ligent book readers, but to edit it as a work of the kind should be edited—to carry it on steadily, without jar or interruption, along the grooves of thought it has travelled during its lifetime. To show the magnitude of the task which Dr. Dunglison has assumed and car- ried through, it is only necessary to state that more than ^ix thousand new subjects have been added in the present edition.—Phila. Med. Tares, Jan. 3, 1874. About the first book purchased by the medical stu- dent is the Medical Dictionary. The lexicon explana- tory of technical terms is simply a tine qua nun. In a science so extensive, and with such collaterals as medi- cine, it is as much a necessity also to the practising physician. To meet the wants of students and most physHans, the dictionary must be condensed while comprehensive, and practical while perspicacious 11 was because Dunglison's met these indications that it became at ouce the dictionary of general use wherever medicine was studied in the English language In no former revision have the alterations and additions been so great. More than six thousand new subjects and terms have been added. Tbe chief terms have been set in black letter, while the derivatives follow in small caps- an arrangement which greatly facilitates reference ' We may safely confirm the hope ventured by the editor '• that the work, which possesses for him a filial as well as an individual interest, will be found worthy ticuance of the position so long accorded to it as a ftandard authority."— Cincinnati Clinic, Jan. 10 1874 It has the rare merit that It certainly hap no rival In the English language for accuracy and extant t references.— London Medical Gazette. Henry C. Lea's Publications—(Manuals). 5 A CENTURY OF AMERICAN MEDICINE. 1776-1870. By Doctors E. H. -Z-L Clarke, H. J. Bigelow, S. D. Gross, T. G. Thomas, and J. S. Billings. In one very hand- some 12mo. volume of about 350 pages : cloth, $2 25. (Just Ready.) This work has appeared in the pages of the American Journal of Medical Sciences during the year 1876. As a detailed account of the development of medical science in America, by gentle- men of the highest authority in their respective departments, the profession will no doubt wel- come it in a form adapted for preservation and reference. TJOBLYN (RICHARD D.), M.D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND TIIE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hats, M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume of over 600 double-columned pages; cloth, $1 50 ; leather, $2 00. It le the best bonk of definitions we have, and ought always to be apon the student'* table.—Bovtl em !ifW. and Surg. Journal. T>OD WELL (G. F), F.R.A.S., §v. A DICTIONARY OF SCIENCE: Comprising Astronomy, Cliem- istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an Essay on the History of the Physical Sciences. In one handsome octavo volume of 694 pages, and many illustrations : cloth, $5. jyEILL (JOHN), M.D., and UmItH (FRANCIS G.), M.D., "^ Prof, of the Institutes of Medicine in the Univ. of Penna. AN" ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of about one thousand pages, with 374 wood cuts, cloth, $4 ; strongly bounc in leather, with raised bands, $4 75. E ARTSHORNE (HENRY), M. D., Professor of Hygiene in the University of Pennsylvania. A CONSPECTUS OF THE MEDICAL SCIENCES; containing Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large royal 12tno. volume of more than 1000 closely printed pages, with 477 illustrations on wood. Cloth, $4 25 ; leather, $5 00. (Lately Issued.) We can say with the strictest truth that it is the I dents, but to many others who may desire to refresh best work of the kind with which we are acquainted, their memories with the smallest possible expendi- It embodies iua condensed form all recent contribu- ture of time.—N. Y. Med. Journal, Sept. 1874. tions to practical medicine, and is therefore useful j TIie student will find this the most convenient and . useful book of the kind on which he can lay his baud.—Pacific Med. and Surg. Journ., Aug. 1S74. This is the best book of its kind that we have ever examined. It is an honest, accurate, and concise compend of medical sciences, as fairly as possible representing their present condition. The changes aud the additions havebeensojudiciousand thorough as to render it, so far as it goes, entirely trustworthy. If students must have a conspectus, they will be wise to procure that of Dr. Hartshorne.—Detroit Rev. of Med. and Pkarm., Aug. 1874. to every busy practitioner throughout our country besides being admirably adapted to the u»e of stu- dents of medicine. The book is faithfully and ably executed.—Charleston Med. Journ., April, 1S75. The work is intended as an aid to the medical stu- dent, and as such appears to admirably fulfil its ob- ject by its excellent arrangement, thefullcompilation of facts, the perspicuity and terseness of language, and the clear and instructive illustrations in some parts of the work.—American Journ. of Pharmacy, Philadelphia, July, 1S74. The volume will be found useful, not only to stu- T UDLOW (J.L.), M.D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, ano Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. With 370 illustrations. In one handsome royal 12mo. volume of 816 large pages, cloth, $3 25 ; leather, $3 75. The arrangement of this volume in the form of question and answer renders it especially suit. able for the office examination of students, and for those preparing»for graduation. T BANNER (THOMAS HA WKES), M. D., Sec. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- NOSIS. Third American from the Second London Edition. Revised and Enlarged by Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, 4c. In one neat volume small 12mo., of about 375 pages, cloth, $1 50. *#* On page 4, it will be seen that this work is offered as a premium for procuring new subscribers to the "American Journal of the Medical Sciences." 6 Henry C. Lea's Publications—(Anatomy). QRAY (HENRY), F.R.S., Lecturer on Anatomy at St. George's Hospital, London. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings bv H. V. Carter, M.D.,and Dr. Westmacott. The Dissectionsjointly by the Author and Dr. Carter. With an Introduction on General Anatomy and Development by T. Holmes, MA., Surgeon to St. George's Hospital. A new American, from the eighth enlargec and improved London edition. To which is added " Landmarks, Medical and Surgical," by Luther Holden, F.R C.S., author of " Human Osteology," "A Manual of Dissections," etc. In one magnificent imperial octavo volume of 983 pages, with 522 large and elaborate engravings on wood. Cloth, $6 ; leather, raised bands, $7. [Just Ready.) The author has endeavored in this work to cover a more extended range of subjects than is ens' tomary in the ordinary text-books, by giving not only the details necessary for the student, bu" also the application of those details in the practice of medicine and surgery, thus rendering it both a guide for the learner, and an admirable work of reference for the active practitioner. The en- gravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference, with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Since the appearance of the last American Edition, the work has received three revisions at the hands of its accomplished editor, Mr. Holmes, who has sedulously introduced whatever has seemed requisite to maintain its reputation as a complete and authoritative standard text-book and work of reference. Still further to increase its usefulness, there has been appended to it the recent work byathe distinguished anatomist, Mr. Luther Holden—"Landmarks, Medical and Surgical" —which gives in a clear, condensed, and systematic way, all the information by which the prac- titioner can determine from the external surface of the body the position of internal parts. Thus complete, the work, it is believed, will furnish all the assistance that can be rendered by type and illustration in anatomical study. No pains have been spared in the typographical execution of the volume, which will be found in all respects superior to former issues. Notwithstanding tbe increase of size, amounting to over 100 pages and 57 illustrations, it will be kept, as heretofore, at a price rendering it one of the cheapest works ever offered to the American profession. The recent work of Mr Holden, which was no- ticed by us on p. 53 of this volume, has been added as an appendix, so that, altogether, this is the mott practical and complete anatomical treatise available to American students and physicians. The former finds in it the necessary guide in making dissec- tions ; a very comprehensive chapter on minute anatomy; and about all that can be taught him on general and special anatomy; while the latter, in its treatment of each region from a burgical point of view, and in tbe valuable edition of Mr Holden, will find all that will be essential to him in his practice.—New Remedies, Aug. 1S78. This work is as near perfection as one could pos- sibly or reasonably expect any book intended as a text-book or a general reference book on anatomy to be. The American publisher deserves the thanks of the profession for appending the recent work of Mr. Holden, " Landmarks, Medical ano Surgical," which has already been commended as a separate book. The latter work—treating of topographical anatomy—has become an essential to the library of every intelligent practitioner. We know of no book that can take its place, written as it is by a most distinguished anatomist. It would he simply a waste of words to say anything further in praise of Gray's Anatomy, the text-book in almost every medical college in this country, and the daily refer to consult his books on anatomy. The work is simply indispensable, especially this present Amer- ican edition.—Fa. Med. Monthly, Sept. 187P. The addition of the recent work of Mr. Holden, as an appendix, renders this the most practical and complete treatise available to American students, who find in it a comprehensive chapter on minute anatomy, about all that can be taught on general and special anatomy, while its treatment of each region, from a surgical point of vie*, in the valu- able section by Mr Holden, iR all that will be essen- tial to them in practice.—Ohio Medical Recorder, Aug 1678. It is difficult to speak in moderate terms of this new edition of "Gray." It seems to be as nearly perfect as it is possible to make a book devoted to any branch of medical science The labors of the eminent men who have successively revised the eight editions through which it has passed, would seem to leave nothing for future editors to do. The addition of Holden's " Landmarks" will make it as indispensable to the practitioner of medicine and surgery as it has been heretofjre to the student. As regards completeness, ease of reference, utility, beauty, and cheapness, it has no rival. No stu- dent should enter a medical school without it ; no physician can afford to have it absent from his ence book of every practitioner who has occasion | library.—St. Louis Clin. Record, Sept. 1878 Also for sale separate— TTOLDEN (LUTHER); F.R.C.S., Surgeon to St. Bartholomew's and the Foundling Hospitals. LANDMARKS, MEDICAL AND SURGICAL. From the 2d London Ed. In one handsome volume, royal 12mo., of 128 pages : cloth, 88 cents. (Now Ready.) The title of this book is very suggestive of its transparent before him, is incalculable. The man. practical value, while the perusal ot ihe work itself i ping out of the human body is one which is most in verifies the most extravagant expectations. The j structive to the practical man, and he is enabled object of the author has been to collect in compact ' after considerable experience, to have landmarks form the landmarks, or surface-marks of the different j of his own; but in the little work before us this parts of the body, and indicate iheir relation to the | knowledge is systematized in such an intelligible teeper-seated parts. The value of thissoitof know- manner as to place it within the reach of all u ,a l<-dge to the physician, bin especially to tbe surgeon one of the most interesting little works we have seen who, with anatomical eye, can make the tissues for a long time.—N. Y. Med. Record, May 11 jgyg Hbnry C. Lba's Publications— (Anatomy). 7 A LLEN (HARRISON), M.D. -*-*- Professor of Compa'ative A natomy and Physiology in the Univ. of Pa. A SYSTEM OF HUMAN ANATOMY: INCLUDING ITS MEDICAL and Surgical Relations. For the Use of Practitioners and Students of Medicine. With an Introductory Chapter on Histology. By E. 0. Shakespeare, M D , Ophthalmologist to the Pliila. Hosp. In one large and handsome quarto volume, with several hundred original illustrations on lithographic plates, and numerous wood-cuts in the text. (Preparing.) In this elaborate work, which has been in active preparation for several years, the author has sought to give, not only the details of descriptive anatomy in a clear and condensed form, but also the practical applications of the science to medicine and surgery. The work thus has claims upon the attention of the general practitioner, as well as of the student, enabling him not only to re- fresh his recollections of the dissecting room, but also to recognize the significance of all varia- tions from normal conditions. The marked utility of the object thus sought by the author is self-evident, and his long experience and assiduous devotion to its thorough development are a sufficient guarantee of the manner in which his aims have been carried out. No pains have been spared with the illustrations. Those of normal anatomy are from original dissections, drawn on stone by Mr. Hermann Faber, with the name of every part clearly engraved upon the figure, after the manner of "Holden" and "Gray" and in every typographical detail it will be the effort of the publisher to reuder the volume worthy of the very distinguished position which is anticipated for it. WILSON (ERASMUS), F.R.S. A SYSTEM OF HUMAN ANATOMY, General and Special. Edited by W. H. Gobrbcht, M. D., Professor of General and Surgical Anatomy in the Medical Col- lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In one large and handsome octavo volume, of over 600 large pages ; cloth, $4 ; leather, $5 H EA TH (CHRISTOPHER), F. R. C. S., Teacher of Operative Surgery in University College, London. PRACTICAL ANATOMY: A Manual of Dissections. From tbe Second revised and improved London edition. Edited, with additions, by W. W. Keen, M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. In one handsome royal 12mo. volume of 578 pages, with 247 illustrations. Cloth $3 50; leather, $4 00. VMITH (HENRY H.), M.D., and JJORNER ( WILLIAM E.), M.D., Prof, of Surgery in the Univ. of Penna., Ac. Late Prof, of Anatomy in the Univ. of Penna., <*e AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, cloth, with about six hundred and fifty beautiful figures. $4 50. The plan of tW',' Atlas, which renders it so pecu- I the kind that has yet appeared; and we must add, liarly convenient'for the student, and its superb ar- | the very beautiful manner in which it is "got up," ti> ical execution, have been already pointed out. We j is so creditable to the country as to be flattering to must congratulate the student upon the completion onr national pride.—American Medical Journal. of this Atlas, as it is the most convenient work of I IJELLAMY(E.), F.R.C.S. THE STUDENT'S GUIDE TO SURGICAL ANATOMY: A Text- Book for Students preparing for their Pass Examination. With engravings on wood. In one handsome royal 12mo. volume. Cloth. $2 25. (Lately Published.) rtLELAND (JOHS), M.D., ^y Professor of Anatomy andPhysiology in Queen's College, Galvoay. A DIRECTORV FOR THE DISSECTION OF THE HUMAN RODY. In one small volume, royal 12mo. of 182 pages : cloth, $125. (Just Issued.) QCHAFER (ED WARD ALBERT), M.D., O Assistant Profetsor of Physiology in C'niversity College, London. A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to the Use of the Microscope. In one handsome royal 12mo. volume of 304 pages, with numerous illustrations: cloth, $2 00. (Just Issued.) We are very much pleased with the book, which teaches the student eiinply how to use his instruments and conduct his studies without «oing further into the microscopic anatomy of the tissue? and organs than is absolutely necessary. What we particularly praise in it is the way in which it takes the student by the hand, as it were, showing him what to do, and explaining simply, but thoroughly, how to do it.—Bust n Med. and Surg. Journ., April, lb77. UOR.NER'SSPECIAL ANATOMY AND HISTOLOGY. SHARPEY AND QUAIN'S HUMAN ANATOMY. Re- Eixhtb edition, extensively revised and modified., vised, with Notes and Additions, by Joseph Leidt, In 2 vols bvo of over 1000 pages, wlih 320 wood- M D., Professor of Anatomy in the University of rnts • cloth *R OO Pennsylvania Complete in two large octavo Vol- HODGES' PRACTICAL DISSECTIONS. Second' umes of about 1300 pages, with 511 illustrations; Edition, thoroughly revised, in one ueat royal j cioin, »o u . l>uio volume, half bound, $2 00. 8 Henry C. Lea's Publications—(Physiology). flARPENTER ( WILLIAM B.), M.D., F.R.S., F.G.S., F.L.S., ^ Registrar to University of London, etc. PRINCIPLES OF HUMAN PHYSIOLOGY; Edited by Henry Power, M.B. Lond., F.R.C.S., Examiner in Natural Sciences, University of Oxford. Anew American from the Eighth Revised and Enlarged English Edition, with Notes and Addi- tions, by Francis G. Smith, M. D., Professor of the Institutes of Medicine in the Univer- sity of Pennsylvania, etc. In one very large and handsome octavo volume, of 1083 pages, with two plates and 373 engravings on wood; cloth, $5 50; leather, $6 60. (Just Issued.) The great work, the crowning labor of the distinguished author, and through which so many generations of students have acquired their knowledge of Physiology, has been almost metamor- phosed in the effort to adapt it thoroughly to the requirements of modern science. Since the appearance of the last American edition, it has had several revisions at the experienced hand of Mr. Power, who has modified and enlarged it so as to introduce all that is important in the investigations and discoveries of England, France, and Germany, resulting in an enlargement of about one-fourth in the text. The series of illustrations has undergone a like revision, a large proportion of the former ones having been rejected, and the total number increased to nearly four hundred. The thorough revision which the work has so recently received in England, has rendered unnecessary any elaborate additions in this country but the American Editor, Pro- fessor Smith, has introduced such matters as his long experience has shown him to be requisite for the student. Every care has been taken with the typographical execution, and the work is presented, with its thousand closely, but clearly printed pages, as emphatically the text-book for the student and practitioner of medicine—the one in which, as heretofore, especial care is directed to show the applications of physiology in the various practical branches of medical science. Notwithstanding its very great enlargement, the price has not been increased, rendering this one of the cheapest works now before the profession. We have been agreeably surprised to find the vol- ume so complete in regard to the structure and func- tions of the nervous system in all its relations, a subject that, in many respects, is one of the most diffi- cult of all, in the whole range of physiology, npon which to produce a full and satisfactory treatise of the class to which the one before us belongs. The additions by the American editor give to the work as it is a considerable value beyond that of the last English edition. In conclusion, we can give our cor- dial recommendation to the work as it now appears. The editors have, with their additions to the only work on physiology in our language that, in the full- est sense of the word, is the production of a philoso- pher as well as a physiologist, brought it up as fully as could be expected, if not desired, to the standard of our knowledge of its subject at the present day. It will deservedly maintain the place it has always had in the favor of the medical profession.—Journ. of Nervous and Mental Ditease, April, 1877. " Good wine needs no bush" says the proverb, and an old and faithful servant like the " big" Carpenter, as carefully brought down as this edition has been by Mr. Henry Power, needs little or no commendation by us. Such enormous advances have recently been made in our physiological knowledge, that what was perfectly new a year or two ago. looks now as if it had been a received and established fact for years. In this encyclopaedic way it is unrivalled. Here, as it seems to us, is the great value of the book; one is safe in sending a student to it for information on almost any given subject, per- I fectly certain of the fulness of information it will con- vey, and well satisfied of the accuracy with which it will I there be found stated.—London Med. Times and Gazette, Feb. 17,1877. Thus fully are treated the structure and functions of all the important organs of the body, while there are chap- ters on sleep and somnambulism; chaptcrson ethnology; a full section on generation, and abundant references to the curiosities of physiology, as the evolution of light, heat, electricity, etc. In short, this new edition of Car- penter is, as we have said at the start, a very encyclo- pedia of modern physiology.—The Clinic, Feb. 24,1877. The merits of " Carpenter's Physiology are so widely known and appreciated that we need only allude briefly to the fact that in the latest edition will befonnd a com- prehensive embodiment of the results of recent physio- logical investigation. Care has been taken to preserve the practical character of the original work. In fact the entire work has been brought up to date, and bears evidence of the amount of labor tha£ has been bestowed upon it by its distinguished cditor,^Mr Henry Power. The American editor has made the latest additions, in order fully to cover the time that has elapsed since the last English edition.—iV. Y. Med. Journal, Jan. 1877. A more thorough work on physiology could not be found. In this all the facts discovered by the late re- searches are noticed, and neither student nor practi- tioner should be without this exhaustive treatise on an important elementary branch of medicine.—Atlanta Med. and Surg. Journal, Dec. 1876. K IRKES ( WILLIAM SENHOUSE), M.D. A MA?Y^JJ 0F P1IYSIOLOGY. Edited by W. Morrant Raker, M.D O.C.S. A new American from the eighth and improved London edition. With about two hundred and fifty illustrations In one large and handsome royal 12mo. vol- ume. Cloth, $3 25; leather, $3 75. (Lately Issued ) Kirkes' Physiology has long been known as a concise and exceedingly convenient text-book presenting within a narrow compass all that is important for the student. The rapidity with which successive editions have followed each other in England has enabled the editor to kel it thoroughly on a level wrth the changes and new discoveries made in the science, and the eighth edition, of which he present is a reprint, has appeared so recently that it may be regarded as the latest accessible exposition of the subject. regnrueu as the hands of students.—Boston Med. and Sum Journ., April 10. 1S73. »urg. subj On the whole, there is very little in the book which eitherthe student or practitioner will notfind of practical value and consistent with our present knowledge of this rapidly changing science ; and we have no hesitation in exprefsing our opinion that this eighth edition is one of the best handbooks on physiology which we have in our language.—N. Y. M'd. Record, April 15, 1873. The book is admirably adapted to be placed In In its enlarged form it is, in our opinion, still the best book on physiology, most useful to the stud«nf —Phila. Med. Times, Ang. 30, 1873. Btuuent. This is undoubtedly the best work for students of physiology extant.—Cincinnati Med. News, Sept. '73 H ARTSHORNE (HENRY), M.D., Professor of Hygiene,etc , in the Univ. of Penna. HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second Edi- tion, revised. In one royal 12mo. volume, with 220 wood-outs: cloth, $1 75. (JustIssued ) Henry C. Lea's Publications—(Physiology). 9 DALT^tof-)h\Ho-Zintne Collet A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use of Students and Practitioners of Medicine. Sixth edition thoroughly rKevls«^"'1ne"1J,orgeod' with three hundred and sixteen illustrations on wood. In one very beautiful octavo vol- ume, of over 800 pages. Cloth, $5 50 ; leather, $6 50. (Just Issued.) From the Preface, to the Sixth Edition. In the present edition of this book, while every part has received a careful revision, the ori- ginal plan of arrangement has been changed only so far as was necessary for the introduction of ^ThHddiSns and alterations in the text, requisite to present concisely the growth of positive ph^Soal knowledge, have resulted in spite of the author's earnest efforts at condensation, Fn an infreae of fully fifty per cent, in the matter of the work. A change, however, m the ty- pographicTarrangementhL accommodated these additions without undue enlargement in the ^^,^^1^1 notation and nomenclature are introduced into the present edition, as hav- j.ue new o.ieiuu, , , j fch t COnfusion need result from the change. KXr^d^ volume, and weight is also adopted, these i«.n™»^bSr«t Present almost universally employed in original #%^t&™£*£ tions and their published accounts. Temperatures are given »" 'legrees ofthe«Jntlgr;^ca,e. usually accompanied by the corresponding degrees of Fahrenheit b scale, inclosed in brackets. New York, September, 1S75. During the past few years several new works on phy- siology, and new editions of old works, have appeared, competing for the favor of the medical student, but none will rival this new edition of Dalton. As now enlarged, it will be found also to be. in general, a satisfactory work of ref-rence for the practitioner.—Chicago Med. Journ. and Examiner, Jan. 1876. Prof. Dalton has discussed conflicting theories and conclusions regarding physiological questions with a fairness, a fulness, and a conciseness which lend fresh- ness and vigor to the entire book. But his discussions have been so guarded by a refusal of admission to those speculative and theoretical explanations, which at best exist in the minds of observers themselves as only pro- babilities, that none of his readers need be led into grave errors while making them a Study.—The Medical Record, Feb. 19,1676. The revision of this great work has brought it forward with the physiological advances of the day, and renders it, as it has ever been, the finest work for students ex- tant— Nashville Journ. of Med. and Surg., Jan. 1876. For clearness and perspicuity, Dalton's Physiology tommended itself to the student years ago, and was a pleasant relief from the verbose productions which it supplanted. Physiology has, however, made many ad- vances since then-and while the style has been pre- served intact, the work in the present edition has been brought up fully abreast of the times. The new chemical notation and nomenclature have also been introduced into the present edition. Notwithstanding the multi- plicity of text-books on physiology, this wil lose none of its old-time popularity. The mechanical execution of the work is all that could be desired.—Peninsular Journal of Meilicine, Dec. 1875. ______ This popular text-book on physiology comes to us in its sixth edition with the addition of about fifty percent. of new matter, chiefly in the departments of patho- logical chemistry and the nervous system, where the principal advances have been realized. With so tho- rough revision and additions, that keep the work well up to the times its continued popularity may be confi dently predicted, notwithstanding the competition it may encounter. The publisher's work is admirably done.—St. Louis Med. and Surg. Journ , Dec. 1875. We heartily welcome this, the sixth edition of this admirable text book, than which there are none of equal brevity more valuable. It is cordially recommended by the Professor of Physiology in the University of Louisi- ana, as bv all competent teachers in the United States and wherever the English language is read, this book has been appreciated. The present edition, with its 316 admirably executed illustrations, has been carefully revised and very much enlarged, although its bulk does not seem perceptibly increased.—New Orleans Medical and Surgical Journal, March, 1876. The present edition is very much superior to every other, not only in that it brings the subject up to the times, but that it d<*» so more fully and satisfactorily than any previousedition. Takeit altogether.it remains in ourhuinbleopinion, the best text book on physiology in any land or language.—The Clinic. Nov. 6, 1875. As a whole, we cordially recommend the work as a text-book for the student, and as one of the best.— The Journal of Nervous and Mental Disease, Jan. 1876. Still holds its position as a masterpiece of lucid writ- ing and is, we believe, on the whole, the best book to place in the hands of the student.— London Students' Journal. D Professor of Institutes of Medicine in 'Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and extensively modified and enlarged, with five hundred n*™*?-*"0™^*™- In tw0 large and handsomely printed octavo volumes of about 1500 pages, cloth, $7 00. T EHMANN (C. O.). PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- tion by Geoege B. Day, M. D., F. R. S., Ao., edited by R. E. Rogers M. D Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustration* selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Com- plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two hundred illustrations, cloth, $6 00. T>Y THE SAME AUTHOR. MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, with Notes and Additions, by J Cheston Morris, M D., with an Introductory E.say on Vital Force, by Professor Samuel Jackson, M. D., of the University* oTPennsyl vania. With illustrations on wood. In one very handsome octavo volume of 336 pages, sloth, $2 25. 10 Henry C. Lba's Publications—(Chemistry). TPO WNES (GEORGE), Ph. D. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. Revised and corrected by Henry Watts, B.A., F U.S., author of ' A Diction- ary of Chemistry," etc. With a colored plate, and one hundred and seventy-seven illus trations. A new American, from th< twelfth nnd enlarged London edition. Edited by Robert Bridges, M.D. In one large royal 12mo. volume, of over 1000 pages; cloth, $2 75; leather, $3 25. (Just Ready.) Two careful revisions by Mr. Watts, since the appearance of the last American edition of " Fownes," have so enlarged the work that in England it has been divided into two volumes In reprinting it, by the use of a sma'l and exceedingly clear type, cast for the purpi se, it has been found possible to comprise the whole, without omission, in one volume, not unhandy for study and reference. The enlargement of the work has induced the American Editor to confine his additions to the narrowest compass, and he has accordingly inserted only such discoveries as have been an- nounced since the very recent appearance of the work in England, and has added the standards in popular use to the Decimal and Centigrade systems employed in the original. Among the additions to this edition will be found a very handsome colored plate, representing a number of spectra in the spectroscope. Every care has been taken in the typographical execu- tion to render the volume worthy in every respect of its high reputation and extended use, and though it has been enlarged by more than one hundred and fifty pages, its very moderate price will still maintain it as one of the cheapest volumes accessible to the chemical student. done, and that Professor Bridges has added some fresh and valuable matter, especially in the inor- ganic chemistry. The book has always been a fa When we state that, in our opinion, the present edition sustains in every respect tbe high reputation which its predecessors have acquired and eujoyed, we express therewith.our full belief in its intrinsic value as a text-book and work of reference.—Am. Journ. of Phnrm , Aug. 1878. The conscientious care which has been bestowed npon it by the American and English editors renders it still, perhaps, the best book for the student and the practitioner who would keep alive the acquisitions of his student days. It has, indeed, reached a some- what formidable magnitude with its more than a thousand pages, but with less than this no fair repre- sentation of chemistry as it now is can be given. The type is small but very clear, and the sections are very lucidly arranged to facilitate study and reference.— Med and Surg. Reporter, Aug 3, 1878. The work is too well known to American students to need any extended notice ; suffice it to say that the revision by the English editor has been faithfully vorite in this coun'ry, and in its new sbape bids fair to retain all its former prestige.—Boston Jour. of Chemistry, Aug 1878. It is almost superfluous to remark on a book so long and favorably known. In the present edition, organic chemistry is treated more fully than it has been done in the previous editions.—Philada. Chemist and Druggist, July, 1878. It will be entirely unnecessary for us to make any remarks relating to the general character of Fowne's Manual. For over twenty years it has held the fore- most place as a text-book, and the elaborate and thorough revisions which have been made from time to timeleavelittlecbance for any wide awake rival to Btep before it.—Canadian Pharm. Jour., Aug 1878. As a manual of chemistry it is without a superior in the language.—Md. Med. Jour., Aug. 1&7S. ATTFIELD (JOHN), Ph.D., Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, *c. CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL ; including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. Seventh American edi- tion, revised from the Sixth English edition by the author. In one handsome royal 12mo. volume of 668 pages, with 87 illustrations: cloth, $2 75; leather, $3 25. (Just Issued.) This work has received a very oareful revision atthe handsofthe author,resultingin a consider- able increase in size, together with the addition of a handsome series of illustrations Notwith- standing these improvements, the price has been maintained at the former very moderate rate. It is a valuable work for the busy practitioner, ex- | student. The more we have used it, the more we were eluding as it does everything that would be of inte rest only to the scientific chemist, and having a com- prehensive index which renders after consultation easy. That portion devoted to urinalysis and prac- tical toxicology, and the tests for impurities in medi- cinal preparations, is especially valuable to the practising physician. For the student it is desirable, for the reason that it is so arranged that he may, without an instructor, study the science experiment- ally.—Am. I'ractitioner, March, 1877. After having used it as a text-book in the laboratory of the PhiladelphiaCollegeof Pharmaeyduring the last five years, we can speak from our own experience, and testify to its intrinsic value in the instruction of the pleased with it, and on the appearanceof a new, revised, and enlarged edition, we take occasion to again cordi- ally recommend it, believing that for the practical in- struction of pharmaceutical students in chemistry it has no superior in the English language.—Am. Journ. of Pharm., Nov. 1876. As a compact manual of the general principles of the science nnd their applications in medicine and phar- macy it has no rival, and the frequent and thorough revision it receives keeps it in all respects up with the times Tbe American edition, which covers the United States Pharmacopoeia, is prepared under the authnr's upervision —Boston Journal of Chemistry, Nov. 1876. jRO WMAN (JOHN E.), M.D. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Sixth American, from the sixth and revised London edition. With numer- ous illustrations. In one neat vol., royal 12mo., cloth, $2 25. Df THE SAME AUTHOR. ---- PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. In one neat volume, royal 12mo., pp. 351, with numerous illustrations; cloth, $2 25. KNAPP'8 TECHNOLOGY ; or Chemistry Applied tc the Arts, and to Manufactures With American additions by Prof. Waltee R. Johnsok. In two very handsome octavo volumes, with 500 wood engravings, cloth, $6 00. Henry C. Lea's Publications—(Chemistry). 11 JfLOXAM (C. L.), Professor of Chemistry in King's College. London. CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illustra- tions. Cloth, $4 00 ; leather, $5 00. (Just Issued.) We have in this work a complete and most excel lent text-book for the use of schools, and can heart lly recommend it as such.—Boston Med. and Surg Journ.. May 28, 1S74 The above is the title of a work which we can most conscientiously recommend to students ot chemistry It is as easy as a work on chemistry could be made, at the same time that it preseuts a full account of th at icience as it now stands. We have spoken of the workasadmirably adapted to the wants of students ; it is quite as well suited to the requirements of prac- titioners who wish to review their chemistry, or ha ve occasion to refresh their memories on any point re- lating to it. In a word, it is a book to be read by all who wish to know what is the chemistry of the pre- lent day.—American PractUioner, Nov. 1873. (JLASSEN (ALEXANDER), v-y Professor in the Royal Pnluttchnic School, Aix ln-Chnpelle. ELEMENTARY AND QUANTITATIVE ANALYSIS. Translated with notes and additions by Edgar F. Smith, Ph.D., Assist Prof, of Chemistry in the iowne Scientific School, Univ. of Penna. In one handsome royal 12mo. volume, of 324 pages, with illustrations; cloth, $2 00. (Just Ready.) This little book will supply a want of a condensed and convenient laboratory guide for the student m quantitative analysis. Since its appearance in Germany, two or three years since, it has been received throughout the continent as a recognized authority, and its translation into trench and Russian shows that the author has succeeded in thoroughly fulfilling the object at which he aimed. The translator has added such processes and details as seemed requisite to adapt the volume more thoroughly to the wants of the American student. • The short treatise of Classen has met with much to say that it stands where Fresenius' work did popularity on the continent, on account of its clear \ tome years ago Tne translation, by Dr. Smith statements, brevity, and judicious selection of me- hds beeu accurately made, and the pages are illus- tnoas. *ur a handy book for quantitative datermi- trated with a number of engravings of apparatus — nations it hardly has its superior, and it is enough Medical and Surgical Reporter, Sept. H, ls7b. fjLO WES (FRANK), D.Sc, Loudon ^ Senior Science- Master at the High School, Ntwcastle-under Lyme, etc. AN ELEMENTARY TREATISE ON PRACTIC A L CHEMISTRY AND QUALITATIVE INORGANIC ANALYSIS. Specially adapted for Use in tbe Laboratories of Schools and Colleges and by Beginners. From the Second and Revised English Edition, with about fifty illustrations on wood. In one very handsome royal 12mo. volume of 372 pages : cloth $2 50. (Now Ready.) It is short, concise, and eminently practical. We are so simple, and yet concise, as to be interesting therefore heartily commendit to stnden s, aape- ! and intelligible. The work is unincumbered with dally to those who are obliged to dispense with a I theoretical deductions, dealing wholly with the master. Of course, a teacher is in every way desi- practical matter, which it is the aim ' f this coropre- rable, but a good degree of technicil skllland prac- : hensive text-book to impart. The accuracy of the tical knowledge can be attained with no other analytical methods are vouched for from the fact instructor than the very valuable handbook now that they have all been worked through bv the aider coasideration.— St Louis Clin. Record, Oct. j author and the members of his ciass, from the ls'«- j printed text. We can heartily recommend the work The work is so written and arranged that it can be I t0 tlle "tudent of chemistry as beiog a reliable and comprehended by the student without a teacher, and comorehensive one —Druggists' Advertiser, Oct. the descriptions and directions tor the various work I 15,1877. Q.ALLOWAY (ROBERT), F.C.S., Prf of Applied Chemistry in the Royal College of Science for Ireland, etc. A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lon- don Edition. In one neat royal 12mo. volume, with illustrations ; cloth, $2 75. ( Lately Issued.) _ The success which has carried this work through repeated editions in England, and its adop- tion as a text-book in several of the leading institutions in this country, show that the author has succeeded in the endeavor to produce a sound practical manual and book of reference for the ehemi-al student. We regard this volume aR a valuable addition to | acids, and of compounds and varions secretions and the chemical text-books, and as particularly calcu- | excretions of animal origin.— Am. Jour, of Pharm , lared to iustruct the *tude it in analytical re-earches I Sspt. 1.S72. of the inorganic compounds, the important vegetable | R EM-'-*- Prof, of Mat. Med. and Bot ir, i.D.. in Phila. and of Clinical Med. in Univ. of Pa. Coll. Pharmacy, Secy, to the American Pharmacentica I Association. THE NATIONAL DISPENSATORY: Embracing the Chemistry, Botany, Materia Medica, Pharmacy, Pharmacodynamics, and Therapeutics of the Pharmaco- poeias of the United States and Great Britain. For the Use of Physicians and Pharma- ceutists. In one handsome octavo volume, with numerous illustrations. (In Press.) The want has long been felt and expressed of a work which, within a moderate compass, should give to the physician and pharmaceutist an authoritative exposition of the Pharmaco- poeias from the existing standpoint of medical and pharmaceutical science. For several years the authors have been earnestly engaged in the preparation of the present volume, with the hope of satisfying this want, and their labors are now sufficiently advanced to enable the pub- lisher to promise its appearance during the coming season. Their distinguished reputation in their respective departments is a guarantee that the work will fulfil all reasonable expectation as a guide in the selection, compounding, dispensing, and medicinal uses of drugs, complete in all respects, while convenient in size, and carefully divested of all unnecessary and obsolete matter. TjlARQUHARSON (ROBERT). M.D., ■*■ Lecturer on Materia Medica at St. Mary's Hospital Medical School. A GUIDE TO THERAPEUTICS. Edited, with Additions, embracing the U. S. Pharmacopoeia. By Frank Woodbury, M.D. Iu one neat volume, rojal 12mo. volume of over 400 pages : cloth, $2. (Now Ready.) The object of the author has been to present in a compact and compendious form the the- rapeutics of the Materia Medica, unincumbered by botanical and pharmaceutical details. The volume is thus einphatijally a work for the medical student, to aid in his acquiring a clear and connected view of the subj'Ct in its most modern aspects; and for the busy practitioner who may wish to refresh his meinorv. Under each article, in parallel columns, are given its phy- siological and therapeutical actions, thus enabling the reailer to take in at a glance the essential facts with respect to each remedy, and numerous formulae are givtn as examples of their prac- tical use. Considerable additions have been introduced by Dr. Woodhury, who has made numerous changes to adapt the work to the wants of the American student, introducing all the preparations of the U. S. Pharmacopoeia, and many of the newer remedies. This little volume is an earnest effort to advance manner, that it deserves careful study by every stu- the interests of intelligent therapeutics. In a mode- ! dent and young practitiouer.— Cincinnati Clinic, rate compass we find the established facts concerning : Jan. 12, 1S7S. the physiological and therapeuticalI actions of reine- I Manv persons who learned therapeutics before dies. The corresponding effects of different remedies ,he penological action of remedies was taught to in health and disease are presented in parallel col- 8tudents fiud it difficuit to discover the bearing of umns. This arrangement impresses us very favor- ! physioloZical action on therapeutic employment ably, as both convenient and calculated to stamp ■ from ordi[1 ary text-books. Dr. Farquharson has most the tacts upon the memory. We do not know of an iDgeIlion,Ly shown it by printing the two in parallel equal number of pages in one work that con'ains for coinmus and corresponding paragraphs, so that,' by the needs of the student anything near as valuable , runnlng tlie eye down the left-hand side of a page we an account of these substances We can cordially et the physiological actions of a drug, and on the commend this work to the medical student as the best right-hand the therapeutical uses, while, bv running introduction to the study of larger and more elabo- : lt straignt across ,he pagei we at once per-ceive the rated treatises— Detroit Lancet, Jan. 1S78. j relations of the one to the other. On this account, the An excellent feature of Dr Farquharson's Guide, • work is likely to be useful, not only to students pre- and one which will commend it to all earnest stu- j p.cring for their examinations, but to those medical dents, is the arrangement, iu tabular form, of the va- men, also, who are well acquainted with larger rions officinal preparations and their dose, so that j books on the same subject, but experience the diffl- they may be readily committed to memory This , culty, already mentioned, of seeing the relations handbook is so well arranged, and presents the well , betwf-en the actions and use of remedies. — The established facts of therapeutics in so impressive a j London Practitioner, January, 1878. G RIFFITH (ROBERT E.), M.D. A UNIVERSAL FORMULARY, Containing the Methods of Pre par- ing and Administering Officinal and other Medicines. The whole adapted to Physiciaiis and Pharmaceutists. Third edition, thoroughly revised, with numerous additions, bj John M. Maisch, Professor of Materia Medica in the Philadelphia College of Pharmacy. Inonelarge and handsome octavo volume of about800pp., cl., $4 50 jleather, $5 50. (Lately Issued ) As a comparative view of the United States, the British, the German, and the French Pharmacopoeias, together with an immense amount of unofficinal formulas, it affords to the prac- titioner and pharmaceutist an aid in their daily avocations not to be found elsewhere, while three indexes, one of "Diseases and their Remedies," one of Pharmaceutical Names, and a General Index, afford an easy key to the alphabetical arrangement adopted in the text. • To the druggist a good formulary is simply indis- | A more complete forinularjathan it is in its pres- peusable, and perhaps no formulary has been more ent form the pharmacist or physician could hardly extensively used than the well-known work before desire. To the first some such work is indispeusa- us. Many physicians have to officiate, also, as drug- ble, and it is hardly less essential to the practitiouer gists. This is true especially of the country physi- j who compounds his own medicines. Much of what cian, and a work which shall teach him the means j is contained in the introduction ought to be com- by which to administer or combine his remedies in mitted to memory by every student of medicine. the most efficacious and pleasant manner, will al- As a help to physicians it will be foijnd invaluable. ways hold its place upon his shelf. A formulary of and doubtless will make its way into-libraries not this kind is of benefit also to the city physician in already supplied with a standard work of the kind . largest practice.—Cincinnati Jlinic, Feb. 21, 1874. I —The American Practitioner, Louisville, July, '74. 14 Henry C. Lea's Publications—(Pathology, &c). QORNIL (V.), AND TfANVIER (L.), Prof, in the Faculty of Med , Paris * Prof in the College of France. MANUAL OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by E. 0. Shakespeare, M.D , Pathologist and Ophthalmic Surgeon to Philada. Hospital, Lecturer on Refraction and Operative Ophthalmic Surgery in Univ. of Penna. In one very handsome octavo volume of about 600 pages, with over 300 illus- trations (Preparing.) So much has been done of late years in the elucidation of pathology by means of the micro- scope, and this subject now occupies so prominent a position as one of the most important branches of medical science, that the American profession cannot fail to welcome a translation of the pre- sent work, which, through its own merits and through the well-known reputation of its distin- guished authors, is regarded in Europe as the standard text-book and work of reference in its department. Such investigations and discoveries as have been made since its appearance will be introduced by the translator, and the work is confidently expected to assume in this country the same position which has been so universally accorded to it abroad. IfENWICK (SAMUEL), M.D., ■*- Assistant Physician to.the London Hospital. THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the Third Revised and Enlarged English Editioc. With eighty-four illustrations on wood. In one very handsome volume, royal 12mo., cloth, $2 25. (Just Issued ) Of the many guide-books on medical diagnosis, , are few books of this size on practical medicine that cluimed to be written for the special instruction of contain so much and convey it so well as cbe volume students, this is the best. Theauthor is evidently a i before us It is a book we can sincerely recommend well read and accomplished physician.and he knows I to the student for direct instruction, and to the prac- bow to teach practical medicine. Thecharm of sim- ' titioner as a ready and useful aid to his memory.— plicity is not the least int«Testingfeaturein theman- I Am. Journ. of Syphilography, Jan. 1874. nerin which Dr. Fenwickconveys instruction. There I Q.REEN (T. HENRY),M.D., ^-* Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School. PATHOLOGY AND MORBID ANATOMY. Second American,from the Third and Enlarged English Edition With numeronsillustrations on wood. In one very handsome octavo volume of over 300 pages, cloth $2 75 (Just Issued.) Those not acquainted with this text book ought to be. We have always thought that for the average doctor this work was much more useful than thelargf r treatises. In to it is condensed such knowledge to gain which, elsewhere, would require great labor and wide reading. For students and practitioners full of cares, it is particularly valuable. In this edition the general high character of the work is maintained, the new cuts are fully up to the standard of those used before, which were excellent, the execution of the work at. the hands of the publisher is faultless. - Chicago Med Journ. and Exam., Feb 1S77. Altogether, this is the best short manual of morbid anatomy in the English language, and we regret that our space and the character of onr contents forbids a more extended notice The ai rangeruent and choice of subjects, the clearness and comparative thorough- ness of its statements make it very satisfactory. We are especially pleased with th« appearance of the wood cuts, most of them made for this work after its author's own sections and drawings. We can only repeat what we have said before, that we know of nothing in the way of a brief manual, superior to it in the English language. It may be safely and heartily commended to students, especially of morbid ana- tomy.—Journ. of Nervous and Mental Disease, Oct. 1S76. D AVIS (NATHAN S.), Prof, of Principles and Practice of Medicine, etc., in Chicago Med. College. CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES ; being a collection of the Clinical Lectures delivered in the Medical Wards of Mercy Hos- pital, Chicago. Edited by Frank H. Davis, M.D. Second edition, enlarged. In one handsome royal 12mo. volume. Cloth, $1 75. (Lately Issued.) WHATTOOBSERVEATTHE BEDSIDE AND AFTER Death in Medical Cases. From the second Lou- don edition. 1 vol royal 12mo., cloth. #1 00. CHRISTISON'S DISPENSATORY. With copious ad- ditions. »nd 313 larare wnn(t-on«rravin«t» By R EolesfieldGriffith, M.D. One vol.8vo., pp. 100(i, cloth. $4 00. CARPENTER'S PRIZE ESSAY ON THE USE 01 Alcoholic Liquors in Health ano Diseask. Nev, edition, with a Preface by D. F. Condie. M.D., ant" explanations of scientific words. In one neatl2mc>. volume, pp. 178, cloth. 60.cents. GLUGE'S ATLAS OF f ATHOLOGICAL HISTOLOGY Translated, with Notes and Additions, by Joseph Leidt, M. D. In one volume, very large imperial quarto, with 320 copper-plate figures, plain and colored, cloth. 91 00. LA ROCHE ON YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeu tical Relations. In two large and handsome octavo volumes of nearly 1500 pages, cloth $7 00. HOLLAND'S MEDICAL NOTES AND REFLEC tions. 1 vol. 8vo., pp. 500, cloth. $3 50. BARLOW'S MANUAL OP THE PRACTICE OF MEDICINE. With Additions by D. F. Cokdib, M D 1 vol. 8vo„ pp. 600. cloth. *2 SO TODD'S CLINICAL LECTURES ON CERTAIN ACUTB Diseases. In one neat octavo volume, of 320 pages, cloth *2 fio STURGEs'S INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. Being a Guide to the In- vestigation of Disease. In one handsome 12mo. volume, cloth, $1 2">. (Lately Issued.) STOKES' LECTURES ON FEVER Fdited by John William Moork, M. 1)., A-si*taut Physician to the Cork Street Fever Hospital. In one neat 8vo. volume, cloth, #2 00. (Just Issued.) THE CYCLOPEDIA OF PRACTICAL MEDICINE- comprising Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics Dis- eases of Women and Childien. Medical Jurispru- dence, etc etc By Dunglison, Forbiib, Tweedie and Conoi.lv. In four larse super royal octavo volumes, of 325-t donble-columned p;ige>, strongly and handsomely bound in leather, $15; cloth $11. Henry C. Lea's Publications—(Practice of Medicine). 15 J?LINT (AUSTIN), M.D., ■*■ Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. Y. A TREATISE ON THE PRINCIPLES AXD PRACTICE OF MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth edition, revised and enlarged. In one large and closely printed octavo volume of about 1100 pp. ; cloth, $6 00 ; orstrongly bound in leather, with raised bands, $7 00. (Lately Issued.) By common consent of the English and American medical press, this work has been assigned O the highest position as a complete and compendious text-book on the most advanced condition of medical science. At the very moderate price at which it is offered it will be found one of the oheapest volumes now before the profession. This excellent treatii-e on medicine has acquired t dentsand abook of ready reference for practitioners. for itself in the rtnited States a reputation similar to j The force of its logic, its simple and practical teach- that enioyed in England by the admirable lectures i ings, have left it without a rival in the field —N. Y. of Sir Thomas Watson. It may not possess the same ! Med Record, Sept 15,1874 charm of style but it has like solidity, the fruit of | Flint sPracticeof Medicine basbecomeso fixed in long and patient observation, and presents kindred iUp0sitionasan American text book that little need moderation and eclecticism We have referred to nesaid beyoud the announcement of a new edition. many of the mostimportantchapters. and find there- It may. however, be proper to say that theauthor vision spoken ofin the preface is a genuine one, and 1 hft8 improved the occasion to introduce the latest hat theauthor•has very fairlybrought up hismatter i contributions of medical literature together with the totheleveloftheknowledgeofthepresentday. The j remits of his own contiuued clinical observations. work has thisgreatrecommendation, that it is in one , Not s0 extended as many of the standard works on volume, and therefore will not oe so terrifying to the | practice, it still is sufficiently complete for all ordi- student as the bulky volumes which several of our nary reference and we do not know of a more con- English text-books of medicine have developed into —British and Foreign Med.-Chir. Rev., Jan. lS7f- venient work for the busy general practitioner.— Cincinnati Lancet and Observer, June, 1873. Itis of course unnecessary tointroduce or eulogize Prof. Flint, in the fourth edition of his great work, this now standard treatise All the colleges recom- | has performed a labor reflecting much credit upon mend it as a text-book, and there are few libraries himself.andconferringalastingbeneflt upon the pro- in which one of its editions is not to be found. The | fessiou. The whole work showsevidence of thorough present edition has been enlarged and revised to bring it up to the author's present level of experience and reading. Hisown clinical studies and the latest con- tributions to medical literature both in this country and in Europe, have received careful attention, so that some portions have been entirely rewritten, and about seventy pages of new matter have been added. —Chicago Mi-d Journ., June, 1873. revision, so that it appears like a new book wi itten expressly for the times For thegeneral practitioner and student of medicine, we cannot recommend the book in too strong terms.—#. Y. Med. Jour . Sept. '73. It is given to very few men to tread in the steps of Austin Flint, whose sirgle volume on medicine, though here and there defective, is a masterpiece of lucid condensation and of general grasp of an enor- Has never been snrpassed as a text-book for stu- J mously wide subject—Lond. Practitioner, Dec. '73. DF THE SAME AUTHOR. ESSAYS OX CONSERVATIVE MEDICINE AXD KINDRED TOPICS. In one very handsome royal l2mo. volume. Cloth, $1 38. (Just Issued) LJARTSHORNE (HENRY), M.D., ■*■-*- Professor of Hygiene in the University of Pennsylvania. ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDj- CINE. A handy-book for Students and Practitioners. Fourth edition, revised and im- proved. With about one hundred illustrations. In one handsome royal 12mo volume, of nbout 550 pages, cloth, $2 63 ; half bound, $2 88. (Lately Issued.) As a ha ndbook, which clearly sets forth the essen- ' advances in medicine, is admirably condensed, and TlAl.sof the principles and practice op medicine, we j yet sufficiently explicit for all the purposes in tended, do not know of its equal — Va Med. Monthly. \ thus making it by far the best work of its character As a brief, condensed, but comprehensive hand- i evrer published.-Cmcin»u/« Clinic, Oct. 24, 1874. book, it cannot be improved upon.—Chicago Med. j Without doubt the best book of thekind published .Examiner, Nov. 15, 1874 in the English language.—St. Louis Med. and Surg The work is brought fully up with all the recent | Journ., Nov. 1874. W: A TSON (THOMAS), M. D., fi-c. LECTURES ON THE PRINCIPLES AND PRACTICE Ol PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- vised and enlarged English edition. Edited, with additions, and several hundred illustra- tions, by Henrt Hartshorne, M.D., Professor of Hygiene in the University of Pennsylva- nia. In two large and handsome 8vo. vols. Cloth, $9 00 j leather, $11 00. (Lately Published.) It Is a subject for congratulation and for thankful- ness that Sir Thomas Watson, during a period of com- parative leisure, after a long, laborious, and most honorable professional career, while retaining full possession of his high mental faculties, should have pmployed the opportunity to submit his Lectures to a more thorough revision than was possible during tbe earlier and busier period of his life. Carefully passingin review some of tbe most intricate and im- portant pathological and practical questions, the re- sults of hisclear insight and his calm judgment are now recorded for the bene fit of mankind, in language which, for precision, vigor, and classical elegance, has rarely been equalled, and never surpassed The re- vision has evidently been most carefully done, and the results appearin almost every page.—Brit. Med. Tourn , Oct. 14, 1871. The author's rare combination of great scientific attainments combined with wonderful forensic elo- quence has exerted extraordinary influence over the last two generations of physicians. His clinical de- scriptions of most diseaseshave never been equalled ; and on this score at least his work will live long in the future. The work will be sought by all who appreciate a great book.—Amer. Journ. of Syphil- i ography, July, 1872. 16 Henry C. Lea's Publications—(Practice of Medicine). 7DRISTO WE {JOHN SYER), M.D , F.R.C.P., J-J Physician and Joint Lecturer on Medicine, St. Thomas's Hospital. A MANUAL ON THE PRACTICE OF MEDICINE. Edited, with Additions, by James II. Hutchinson, M.D., Physician to the Penna. Hospital. In one handsome octavo volume of over 1100 pages: cloth, $5 50; leather, $6 50. (Just Ready.) In the effort of the author to render this volume a complete and trustworthy guide for the student and practitioner he has covered a wider field than is customary in text-books on the Practice of Medicine, and has sedulously endeavored to present each subject in the light of the most modern developments of observation and treatment. So much has been done of late years to enlarge our knowledge of disease by improved methods of diagnosis, and so many new agencies have been called into service in treatment, that a condensed and compendious work, thoroughly on a level with the advance of medical science, can hardly fail to prove of value to the profession. Dr. Bristowe ha= long been before the profession as an able thinker and writer on professioual sub- jects. His present work is second to uone of its kind, the part on diseases of the nervous system being, perhaps, the most deserving of praise. It is emineutly readable, both in matter aud print, and fully deserves the success it is sure to obtain.— Edin. Med. Journ., Oct. 1877. The treatment of the various diseases is admirably Mimrue* up, and we pronounce Dr. Bristiwe's book to be eminently practical on this subject. A fair space is given to the dietetics of disease, and we are giad that this subject is receiving more and more attention in the works on medicine We give the author our hearty congratulations, and his book our best commendations and wish it all success.—Lond. This portly volume is a model of condensation. In a style at once clear, interesting, and concise, Dr. Bristowe passes in review every conceivable subject connected with the practice of medicine. Those practitioners who purchase few books will find this a mott opportune publication, because so many top- ics not usually embraced in a work on practice are adequately baud led. The book is a thoroughly good one, and its usefulness to American readers has been increased by the judicious notes of the Editor.— Cincinnati Clinic, Jan. 7, 1877. Med. Times and Gaz., Sept. 15, 1877. Anyone who wants a good, clear, condensed work upon Practice, quite up with the most recent views in pathology, will find this a most valuable work The Upon 'the whole, we know of no work" which we could more confidently recommend to the student or the practitioner, intending a review of tbe field of theory and practice, than this book of Dr. Bris- towe's. We thus commend it, because the vast ar- ray of facts pertaining to the practice of medicine, as it is to.day, are here presented ably, and with that method, order, and perspicuity which, in all depart- ments of education, distinguish tbe lessons of an ac- additions made by Dr. Hutchinson are appropiiate i ceptable and profitable teacher —Chicago Med and useful, and so well done that we wish there were j Jnurn. and Examiner, Aug. 1877 more of them.—Am. Practitioner, Feb. 1877. i TJAMILTON (ALLAN McLANE), M.D., Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelV s Island, N. Y., and at the Out-Patients' Department of the New York Hospital. NERVOUS DISEASES; THEIR DESCRIPTION AND TREATMENT. In one handsome octavo volume of 512 pages, with 53 illus.; cloth, $3 50. (Just Ready.) The object of the author has been to furnish to the student and practitioner in a clear and concise form a guide to the diagnosis and treatment of affections of the nervous system, em- bodying the very great advances made during the last few years in our knowledge of these dis eases. Unusual opportunities in public and private practice have qualified him for this work, and his desire has been to render it strictly practical, adapting it to the wants not only of the spe- cialist, but of the general practitioner. Particular care has therefore been devoted to the manage- ment of nervous diseases, and in an appendix will be found a careful selection of well-tried formulae. The different nervous diseases are taken up sys- but, unlike most works of this class, it is very com- tematically and fully treated. The volume through- out is written in clear and practical language, and contains in brief the salient points of clinical his- tory, diagnosis, pathology, and treatment of nervous diseases recognized at the present day. The work has been prepared with a view of meeting the wants of the student and general practitioner. Whenever necessary, handsome illustrations are added to ex- plain the text. It is a volume which will supply a need long felt by the profession, and to Dr. Hamilton the profession is indebted for this clear and able clas- sification of nervous diseases and publication of un- common merit.—Md. Med. Journal, Aug 187S. As stated in the preface, the author's object has been to wri'e a concise and practical book, for which there is certainly a place, and we think he has succeeded admirably in fulfilling his object. The usual plan is adopted in the classification of the different diseases, the book not being greatly uulike Hammond's in this respect, although it is very noticeable throughout that the author's opin- ions vary widely from those of Dr Hammond.—Am. So,/ii>. Obstet. Journ. Great Britain and Ireland, July, 1S7S. From a very careful examination of the whole work, we can j ustly say that the author has not only clearly and fully treated of diagnosis and treatment, prehensive in regard to etiology, and exposes the pathology of nervous diseases in the light of the very latest experiments *ud discoveries. The drawings are excellent aud well selected. After this careful revision, we can heartily recommend this work to students and general practitioners in particular as being a full exposition of diseases of the nervous sys- tem,their pathology and treatment, to date. — N. Y. Med. Record, Aug. 3, 1878. The treatment is op to the requirements of the most advanced therapeutical and pathological know- ledge. The work is free from dogmatism, and as a whole may be accepted as containing about the best information on the subjects within its scope, com- pressible within so limited space. It is lucid and direct in style, and the author certainly has suc- ceeded in his purpose, as announced in the preface, of producing a '"concise and practical book."—Cin- cinnati Lancet and Clinic, July 20, 1878. A wide acquaintance with the recent literature of nervous disease is manifested throughout, and an attempt—and a successful one—is made, to do away with much of the obscurity and confusion arising from physiological themes, which cloud several of the more popular recent works on the same subject. —Med. and Surg. Reporter, July 6, 1878. /WARCOT (J. 31.), Professor to tlie Faculty of Med. Paris, Phys. to LaSalpetriire, etc. LECTURES ON DISEASES OF THE NERVOUS SYSTEM. Trans- lated from the Second Edition by George Sigerson, M.D., M.Ch., Lecturer on Biology, etc., Cath. Univ. of Ireland. With illustrations (Publishing in the Medical News and Library, commencing with the July No. 1878. See page 2.) Henry C. Lea's Publications—(Practice of Medicine). 17 fOTHERGlLL (J. MILNER). M.D. Edin., M.R.C.P. Loud., ■*■ Asst. Phys to the West hnnd Hosp. : As.it. Phys. to the City of Lond. Hosp., etc. THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, tbe Principles of Therapeutics. In one very neat octavo volume of about 550 pages : cloth, $4 00. (Now Ready.) It may be said that the scope of this work is not dissimilar to that of the well-known " Principles of Medicine," by Dr J. C. B. Williams, now long out of print, which in its day met with such unusual acceptance. More practical in its character, however, it seeks to bring to the aid and elucidation of positive therapeutics, the vast accumulation of scientific facts and theories made by the present generation, pointing out the measures to be adopted at the bedside and establishing them on firm rational grounds. Such a work, by a first-iate man, and fully up to the advanced condition of science, canuot fail to prove of the utmost service to both student and practitioner. Our frienus will find this a very readable book: and I I'rivate Hygiene. Food in Health and Ill-Health, and that it sheds light upon every theme it touches,causing ' the practitioi er to feel more certain of his dia^W'sis iu difficult cases. We confidently commend the work to our readers as one worthy of careful perusal. It lijzhis the way over obscure and difficult passes in niedicnl practice. The chapter on the circulation of the blood is the most exhaustive and instructive to be found. It is a book every practitioner needs, and would have, if he knew how su.-.vstive and helpful it would be to him.—St. Louis Mtd. and Surg. Jour".. A?ril, 1S77. It is our honest conviction, after a careful perusal of this goodly octavo, that it represents a great amount of earnest thought and painstaking work, and is therefore one of those books which both deserve and are likely to survive. This book, although writteu ostensibly for the young and inexperienced, may be very profitably studied by those who have been practising their profession more or less empirically for thirty or forty years. We particularly recommend the chapters on Public and the Conclusion—the Medical Man at the lledside. The last is hi^h-toned, and indicates much shrewdness of ob- servation. Our spare will not admit of further quotation. We content ourselves with again recommending the book very cordially.—Edin. Med. Journ., Jan. 1-77. We heartily commend his book to the medical student as an honest and intelligent guide through the mazes of therapeutics, and assure the practitioner who lias urown irray in the harness that he will derive pleasure and in- struction from its perusal The imperfections and errors which we have noticed are few and unimportant. On the other hnnd, the excellences are many and pateDt. Valuable suggestions and material for thought abound throughout. The chapters on body heat and fever, in- flammation, action and inaction, and the urinary sys- tem are particularly good. The descriptions of patho- logical conditions, and the character of the therapeutic measures advised irive evidence of sound clinical obser- vation.- BosUni Med. and Surg. Journal, Mar. S, 1877. J£Y THE SAME AUTHOR. THE ANTAGONISM OF THERAPEUTIC AGENTS, AND WHAT IT TEACHES. Being the Fothergilli.m Prize Essay for 1S78. In one neat volume, royal 12mo. of 156 pages; cloth, $ I 00. (Just Ready.) It would seem unnecessary to call the attention of the profess'on to a work on so suggestive a subject by a writer so brilliant as Dr. Fothergill. There is, perhaps, no one who has a better claim to be heard, and no topic more worthy the study and reflection of the practitioner. It will be found a highly interesting study and I certain drugs.— Medical and Surgical Reporter, practical application of the antagonistic action of | Sept. 14, 1878. &INLAYSON (JAMES), M.D., •*■ Physician a*d LeHurer on Clinical Medicine in the Glasgow Western Infirmary, etc. THE CLINICAL STUDY OF DISEASE; A Manual for* Students and Practitioners of Medicine. In one handsome octavo volume, with numerous illus- trations. (In Press.) So much has been done of late year? in increasing tbe accuracy of diagnosis by the application of the thermometer, the sphygtnograph, the laryngoscope, the stethoscope, and other instru- menfal aids to observation, and the study of disease has been so much facilitated by the com- parison of-results thus obtained, that a mass of indispensable information has accumulated, which has not yet been rendered accessible to the student. It has been the object of Dr. Fiulay- son to present all this in a form condensed but readily intelligible, and to render it available in the daily duties of the practitioner. The scope of the work being thus extensive, he has called in the aid of gentlemen well known in their special departments, for chapters on their special subjects. Thus the Physiognomy of Disease is treated by Prof. Gairdner ; the Disorders of the Female Organs by Prof Stephenson ; Insanity by Dr. Alexander Robertson ; Physical Diagnosis by Dr. Samson Gemmell, and Laryngoscopy and Post Mortem Examinations by Dr. Joseph Coats. Numerous illustrations have been introduced wherever they seemed desirable to eluci- date the text. OBERTS (WILLIAM), M.D.. Lecturer on Medicine in the Manchester School of Medicine, Ac. A PRACTICAL TREATISE OX URIXARY AND RENAL DIS- EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Seo- ond American, from the Second Revised and Enlarged London Edition. In one large and handsome octavo volume of 616 pages, with a colored plate ; cloth, $4 50. (Lately Published.) LINCOLN'S ELECTRO-THERAPEUTICS ; a Concise Manual of Medical Electricity. In one very neat royal 12mo. volume, cloth, with illustrations, §1 50. (Juft Issued.) CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS BvC. Handkikld Jones M.D., Physician to St. Mary's Hospital, &c. Sec ond American Edition. In one handsome octavo volume of 348 pages, oloth, $3 25. R BASIIAM ON RENAL DISEASES: a Clinical Guide to their Diagnosis and Treatment. With Illustra- tions. In one 12mo. vol. of 30t pages, cloth v". 00. LECTURES ON THE STUDY OF FEVER. By A. Hnrisoif, M.D., M.R.I.A., Physician to the Meath Hospital. In one vol. Svo., cloth, $2 50. A TREATISE ON FEVER. By Robert D. Lyons, K C C. Iu one octavo volume of 362 pages, cloth, $2 25. 18 Henry C. Lea's Publications—(Diseases of the Chest, drc). JgROWN (LENNOX), F.R.C.S. Ed., Senior Surgeon to the Central London Throat and Ear Hospital, etc., THE THROAT AXD ITS DISEASES. With one hundred Typical Illustrations in colors, and fifty wood engravings, designed and executed by the author. In one very handsome imperial octavo volume of 351 pages ; cloth, $5 00. (Now Ready.) EXTRACT FROM THE AUTHOR'S PREFACE "The followinc pages areoffered as a practical guide to the diagnosis and treatment of diseases of the throat. They are the result of eleven years of work, mainly devoted to those affections as met with in continuous hospital and private practice during that period. The book being written especially for the use of those engaged in the active practice of their profession, promi- nence is given to all matters tending to render diagnosis and treatment more successful, but no attempt has been made to discuss at length questions of purely pathological interest." There is much instruction to be gained from these excellent arrangement. We can heartily recommend pases, and the colored lithographs are very beauti- fully executed, and very trn'hful. — Canada Med. and Surgical Journal, Sept. 1878. Wood-cuts are freely interspersed throughout its pages, and lastly, wi would draw attention to the colored plates, 100 in number, the majority of which are excellent and most artistic; so arranged that the page on which they are arranged may be exposed to view while the reader is perusing the letter-press in the book referring to them—a most thin work to the medical reader; it is well printed in clear type, haudsomely got np, and does credit to both author and publisher.— Edinburgh Medical Jour., Aug. 1878. The plates are most excellent. Mr. Browne's well known dexterity with the brush and pencil makes us quite sure of the accuracy of tbe delineations here presented to us.—London Med. Times and Gazette, July 13, 187S. FLINT (AUSTIN), M.D., ■*■ Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. Y. PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- MENT, AND PHYSICAL DIAGNOSIS; in a series of Clinical Studies. By Austin Flint, M.D., Prof, of the Principles and Practice of Medicine in Bellevue H< spital Med. College, New York. In one handsome octavo volume : $3 50. (Lately Issued.) This book contains an analysis, in the author's lucid I mend the book to the perusal of all interested in the style, of the notes which he has made in several hun- study of this disease.—Boston Med. and Surg Journal, dred cases in hospital and private practice. We com | Feb 10, 1876. £Y THE SAME AUTHOR. (Just Issued ) A MANUAL OF PERCUSSION AND AUSCULTATION; of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. In one handsome royal 12mo. volume: cloth, $1 75. We can confidently recommend this treatise to all wh would learn auscultation and percussion, and rightly value these modes of exoloration of disease. —British and For. Med.-Chir Rev.,Ja\y, 1877. OF THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate, cloth $4 Dr. Flint chose a difficult subject for his researches lnd clearest practical treatise on those subjects, and t^ , a* B,?°Wn rem,a,rkable P?™8 of observation should be in the hands of all practitioners and stu- »nd reflection as we las great industry, in his treat-, ients. It is a credit to American medical literature. ment of it. His book musi be considered the fullest I -Amer. Journ. of the Med. Sciences, July, 1860. JDY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome ootavo volume of 595 pages, cloth, $4 50. WILLIAMS'S PULMONARY CONSUMPTION; its Nature, Varieties, and Treatment. Willi an An- alysis of One Thousand Cases to exemplify its duration. In one neat octavo volume of about 3.")0 pages ; cloth, $2 50. DIPHTHERIA; its Nature and Treat uent, with an account of the History of its Prevalence in vari- ous Countries. By D D. Slade, M.D. Second and revised edition. In one neat royal 12mo. volume cloth, $1 25. WALSHE ON THE DISEASES OF THE HEART ANI GREAT VESSELS. Third American edition. In I vol. 8vo.. 420 pi)., eloth *3 OO LECTURES ON THE DISEASES op THE STOMACH. With an Introduction on its Anatomy and Physio- logy. By William Brinton, M.D., F.R.S. From the second and enlarged Londonedition. With il- lustrations on wood. In one handsome octavo volume of about 300 pages; cloth, $3 26. LA ROCHE ON PNEUMONIA. 1 vol. 8vo., cloth. 600 pages. Price $3 00. KULLER ON DISEASES OF THE LUNGS AND AIR PASSAGES. Their Pathology, Physical Diaguoais, Symptoms, and Treatment. From the second and revised English edition. In one handsome ocatvo volume of about 500 pages : cloth, $3 50. CHAMBERS'S MANUAL OF DIET AND REGIMEN IN HEALTH AMU SICKNESS. In one haudsjine octavo volume. Cloth, $2 73 CHAMBERS'S RESTORATIVE MEDICINE An Har- veian Annual Oration. With Two Sequels. In one very handsome vol. small 12mo , cloth, $1 00. PAW'S TREATISE ON THE FUNCTION OF DI- GESTION; its Disorders and their Treatment. From the second London edition. In one hand- some volume, small octavo, cloth, $2 00. PAVY'S TREATISE ON FOOD AND DIETETICS Physiologically and Therapeutically Considered Iu one handsome octavo volume of nearly KOO pages, cloth, *4 75. MITH ON CONSUMPTION ; ITS EARLY AND BR HEDIABLE STAGES. 1 vol. 8vo., pp. 254* $2 26 Henry C. Lea's Publications—(Venereal Diseases, &c). 19 T>UMSTEAD (FREEMAN J.), M.D.. •*-* Professor of Venereal Diseases at the Col. of Phys*and Surg., New York. Ac. THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- EASES. Including the results of recent investigations upon the subject. Third edition, revised and enlarged, with illustrations. In one large and handsome octavo volume of over 700 pages, cloth, $5 00 ; leather, $6 00. In preparing this standard work again for the press, the author has subjected it to a very thorough revision. Many portions have been rewritten, and much new matter added, in order to bring it completely on a level with the most advanced condition of syphilography, but by careful compression of the text of previous editions, the work has been increased by only sixty-four pages. The labor thus bestowed upon it, it is hoped, will insure for it a continuance of its position as a complete and trustworthy guide for the practitioner. A. valuable work on Venereal Diseases, which not | venereal diseases, that it may seem almost superflu- only has a wide circulation in this country, and I ous to say more of it than that a new edition has-been been accepted as the standard, but appears tohsve j issued. But the author's industry has rendered this formed the basis, to a large extent, of many of the j nw edition virtually a new work, and so merits as books and articles which have been written on the ' much special commendation as if its predecessors had same subject and published in England.- The Glas- . nol been published. As a thoroughly practical book gow Med. Journ.. Oct. 1877. | on a cla8B of diseases which form a large share of It is the most complete book with which we are ac-' nearly every physician's practice, the volume before quainted in the langnage. The latest views of the I us is by far the best of which we have knowledge.— best authorities are put forward, and the information , N. Y. Medical Gazette, Jan. 28, 1871. Is well arranged—a great point for the student, and | It l8 rare in the history of medicine to find any one still more for the practitioner. The subjects of vis- book whjch contam8 all that a practitioner needs to eeral syphilis, syphilitic affections of the eyes, and know; while the possessor of "Bumstead on Vene- the treatment of syphilis by repeated inoculations, are | rear- has no occasion to look outside of its covers for very fully discussed.—London Lancet, Jan. 7, 1871. , anythin« practical connected with the diagnosis, hie- Dr. Bumstead's work is already so universally ; tory, or "treatment of these affections.—N. Y. Medical known as the best treatise in the English language on j Journal, March. 1871. ffULLERIER (A.), and JDUMSTEAD (FREEMAN J), ^ Burgeon to the Hopital du Midi. ■*-* Professor of Venereal Diseases in the College of Physicians and Surgeons, N. Y AN ATLAS OF VENEREAL DISEASES. Translated and Edited by Freeman J. Bdmstbao. In one large imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers, at $3 per part. Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- lars a Part, thus placing it within the reach of all who are interested in this department of prac- tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. We wish for once that our province was not restrict-1 to its end, we do not know a single medical work, •d to methods of treatment, that we might say some- thing of the exquisite colored plates in this volume. —London Practitioner, May, 1869. As a whole, it teaches all that can be taught by means of plates and print.—London Lancet, March 18: 186S. Superior to anything of the kind ever before issued which for its kind is more necessary for them to have. —California Med. Gazette, March. 1S69. The most splendidly illustrated work in the lan- guage, and in onr opinion far more useful than the French original— Am. Journ. Med. Sciences, Jan. 69. The fifth and concluding number of this magnificent work has reached us, and we have no hesitation in on this continent.—Canada Med. Journal, March, '69. i saying that its illustrations surpass those of previous The practitioner who desires to understand this! numbers.-Bo.st Med. and Surg, jr., Jan. 14 1869. branch of medicine thoroughly should obtain this, I Other writers besides M. Cullerier have given us a the most complete and best work ever published.— good account of the diseases of which he treats, but Dominion Med. Journal, May, 1869. no one has furnished us with such a complete series This is a work of master hands on both sides. M ] of illustrations of the venereal diseases. There is, Cullerier is scarcely second to, we think we may truly j however, an additional interest and value possessed say is a peer of the illustrious and venerable Ricord, by the volume before us; for it is an American reprint while in this country we do not hesitate to say that | and translation of M. Cnllerier's work, with inci- Dr. Bumstead, as an authority, is without a rival dental remarks by one of the most eminent American Assuring our readers that these illustrations tell the ! syphilographers, Mr. Bumstead.—Brit, and For. whole history of venereal disease, from its inception | Medico-Chir. Review, July, 1869. 7.EE (HENRY), "^ Prof, of Surgery at the Roya I College of Surgeons of England, etc. LECTURES ON SVPIIILTS AND ON SOME FORMS OF LOCAL DISEASE AFFECTING PRINCIPALLY THE ORGANS OF GENERATION. In one handsome octavo volume: cloth; $2 25. (Lately Published.) The work is valuable, as it treats quite fully of sub eets which are not dwelt upon in the systematic works of other English authors of the present day. as the inoc- ulability of syphilitic blood : theconditions under which the secretions of primary and secondary syphilitic man- ifestation^ maybe inoculated naturally or artificially; the morbid processes produced by such inoculation; the modifications of these processes in patientR previously syphilitic: primary and secondary syphilitic diseases of the mucous membranes and their liability to commu- nicate constitutional syphilis, etc. The h~->\-. N full of clinical material illustrating these t -vies, original or quoted.—Archives of Dermatology, April, 1876. H ILL'BERKELEY), Surgeon to the Lock Hospital, London. ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In one handsome octavo volume ; cloth, $3 25. 20 Henry C. Lea's Publications—(Diseases of the Skin, &c). TpOX (TILBURY), M.D.. F.R.C.P.. and T. C. FOX, B.A., M.R.C.S., -*- Physician to the Department for Skin Pineasix, University Colli ge Hnsjdtal. • EPITOME OF SKIN DISEASES. WITH FORMULAE. For Stu- dents and Practitioners. In one handsome 12mo. volume, of 120 pages: cloth, $1. (Jtist Issued.) TXTILSON (ERASMUS), F.R.S. ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- enth American, from the sixth and enlarged English edition. In one large octavo volume of over 800 pages, $5. A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- EASES OF THE SKIN," consisting of twenty beautifully executed plates, of which thir- teen are exquisitely colored, presenting the Normal Anatomy and'Pathology of the Skin. and embracing accurate representations of about one hundred varieties of disease, most t f them the size of nature. Price, in extra cloth, $5 50. Also, the Text and Plates bound in one handsome volume. Cloth, $10. j$Y THE SAME AUTHOR. ---- THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- eases of the skin. In one very handsome royal 12mo. volume. $3 50. ffELIGAN (J. MOORE),~M.D., M.R.I.A. ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, Piui»n as I Boston Med. and Surg. Journal. judicial, and have regarded him as one of the highest | 7^7 THE SAME AUTHOR. (Lately Issued ) ON SOM.E DISORDERS OF THE NERVOUS SYSTEM IN CHILD- HOOD,- being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- don, in March, 1871. In one volume, small 12mo., cloth, $1 00. T>Y THE SAME AUTHOR. LECTURES ON THE DISEASES OF WOMEN. Third American from the Third London edition. In one neat ootavo volume of about 550 pa^es alnrh' $3 75; leather, $4 75. n Henry C. Lea's Publications—(Diseases of Children). 21 &MITH (J. LE WIS). M. D., ^ '- Professor of Morbid Anatomy in the Bellevue Hospital Med. College, N. Y. A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Third Edition, revised and enlarged. In one handsome octavo volume of 726 pages. Cloth, $5 ; leather, $6. (Just Issued.) The eminent success which this work has achieved has encouraged the author, in preparing this third edition, to render it even more worthy than heretofore of the fnvor of the profession. It has been thoroughly revised, nnd very considerable additions have been made throughout. To accommodate these the volume has been printed in a smaller type, so as to prevent any notable incre.ise in its size, nnd it is presented in the hope that it may attain the position of the American text book on this important department of medical science. This work took a stand as an authority from its first i edition will confirm and add to its reputation. Having appearance, and every one interested in studying the [ been brought up to the present mark in the rapid ad- diseases of which it treats is desirous of knowing what ' vance of medical science, it is the best work in our improvements are apparent in the successive editions. I language, on its ranjre of topics, for the American prac- The principal additions to which we refer, and which will be the distinguishing features of the third edition, are chapters on diphtheria, cerebrospinal meningitis, and rotheln. The former disease is considered much more in detail than formerly, and a great amount of very practical information is added, and altogether it is one of the most comprehensive and one of the best writ- ten chapters of the subject we have thus far read, nis description of cerebro-spinal meningitis, founded also for the most part on personal experience, is admirably clear and exhaustive.— The Med. Record, Feb. 19,1876. In presenting this deservedly popular treatise for the third time to the profession, Dr. Smith has given it a careful preparation, which will make it of decided su- periority to eitherof the former editions. The position of the author, as'physician and consultant to several larire rhildren's hospitals in New York City, has fur- ni-h.'d him with constant occasions to put bis treatment to the test, and his work has at once that practical and thoughtful tone which is a marked characteristic ot the best productions of the American medical press.—Mtd. and Surg. Reporter, Feb. 1S76. titioner.—Pacific Med. and Surg. Journ., Feb. 1876. Dr. Smith's Diseases of Children is certainly the most valuable work on the subjects treated that the practi- tioner can provide himself with. It is fully abreast with every advance: it should be in the hands of prac- titioners generally, while, because of the conciseness and clearness of style of the writing of the author, every professor of diseases of children, if he has not already done so, should adopt this as his text-book.— Va. Medical Monthly, Feb. 1876. The third edition of this really valuable work is now before us, with a hundred pages of additional matter, an altered size of page, new illustrations, and new type. Of the diseases treated of for the first time, we notice rotheln and cerebro-spinal fever, wliich lately prevailed in epidemic form in some parts of the country. The article upon diphtheria, containing the latest develop- ments in the pathology and treatment of that dread dis- ease, which so lately ravaged our country, is peculiarly interesting to every practitioner. We gladly welcome this standard work, and cheerfully recommend it to our readers as the best on this subject iu the Knglish lan- The former editions of this book have given it the gua^e.—Nashville Journal of Med. and Surgery, March, highest rank among works of its class, and the present I 1876. fJONDIE (D. FRANCIS), M. D. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- printed pages, cloth, $5 25 ; leather, $6 25. The present edition, which is the sixth, is fully up 1 teachers. As a whole, however, the work is the best to the times in the discussion of all those points in the j imerican one that we have, and in its special adapta- pathology and treatment of infantile diseases which tion to American practitioners it certainly has no have been brought forward by the Germauand French I gqual. — New York Med. Record, March 2, 1868. gMITH(EUSTACE), M. D., Physician to the Northwest London Free Dispensary for Sick Children. A PRACTICAL TREATISE ON THE WASTING DISEASES OF INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged English edition. In one handsome octavo volume, cloth, $2 50. (Lately Issued.) scribed as a practical handbook of the common dis- eases of children, so numerous are the affections con- sidered either collaterally or directly. We are acquainted with no safer guide to the treatment of children's diseases, and few works give the insight into the physiological and other peculiarities of chil. dren that Dr. Smith's book does.—Brit. Med. Journ., April 8. 1871. This is in every way an admirable book. The modest title which the an thor h«s chosen for it scarce- ly conveys an adequate idea of the many subjects upon which it treats. Wasting is *o constant an at- tendant upon the maladies of childhood, that a trea- tise upon the wasting diseases of children must neces sirily embrace the consideration of many affections of which it is a symptom ; and this is excellently well done by Dr. Smith. Th« book might fairly he dn- s WAYNE (JOSEPH GRIFFITHS), M.D., Physician-Accoucheur to the British General Hospital, Ac. OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised London Edition with Additions by E. R. Hutchins, M. D. With Illustrations. In one neat 12mo volume. Cloth. $1 25. (Lately Issued.) *.t* See p. 4 of this Catalogue for the terms on which this work is offered as a premium to subscribers to the "American Journal op the Medical Scikncbs." CHURCHILL ON THE PUERPERAL FEVER AND OTHER DISEASES PECULIAR TO WOMEN. 1vol. «vo.,oo i/iO,cloth $2 50. DJWEES'R TREATISE ON THE DISEASES OF FE- MALES. With illustrations. Eleventh Edition, with the Author's last improvements and correc tlons. In one octavo volume of 536 pages, wit! plates, cloth. $3 00. MEIGS ON THE NATURE, SIGNS, AND TREAT- MENT OF CHILDBED FEVER. 1 vol. 8vo , pp. ISI cloth *•» OO. ASHWELL'S PRACTICAL TREATISE ON THE DIP- EASES PECULIAR TO WOMEN. Third American, from the Third and revised London edition. 1 vol. 8vo., pp. 528, cloth. $8 50. 22 Henry C. Lea's Publications—(Diseases oj f,u>ttt>uj. /THOMAS (T. GAILLARD),M.D., Professor of Obstetrics, Ac, in the College of Physicians and Surgeons, N. Y., Ac. A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 800 pages, with 191 illustrations. Cloth, $5 00; leather, $6 00. (Just Issued.) The author has taken advantage of the opportunity afforded by the call for another edition of this work to render it worthy a continuance of the very remarkable favor with which it has been received. Every portion has been subjected to a conscientious revision, and no labor has been spared to make it a complete treatise on the most advanced condition of its important subject. A work which has reached a fourth edition, and is classical without being pedantic, full In the details that. too. in the short space of five years, has achieved i of anatomy and pathology, without ponderous a reputation which places it almost beyond the reach translation of pages of German literature, describes of criticism, and the favorable opinions which we have , distinctly the details and difficulties of each opera- already expressed of the former editions seem to re-1 tion, without wearying and useless minutits, and is quire that we should do little more than announce , in all respects a work worthy of confidence, justify- this new issue. We cannot refrain from saying that, j ing the high regard in which its distinguished an- as a practical work, this is second to none in the Eng-, thor is held by the profession.—Am. Supplement, lish, or. indeed, in any other language. The arrange-J Obstet. Journ. Oct. 1874. ment of the contents, the admirably clear manner in j _ , _,, , . , . , ., ,, - „, IV. which the subject of the differential diagnosis of !„ Professor Thomas fairly-took the Profess on of the several of the diseases is handled, leave nothing to be | Unlted State» h7 8!tor,moyhe° hl8 bo?k farSt m*de V- desired by the practitioner who wants a thoroughly l appearance early in 1S68. Its reception was simply clinical work, one to which he can refer in difficult enthusiastic, notwithstanding a few adverse cntl- cases of doubtful diagnosis with the certainty of gain- C181»s fl0m our transatlantic brethren, the first large ing light and instruction. Dr. Thomas is a man with a edition was rapidly exhausted, and in six months a very clear head and decided views, and there seems to second one was issued, and in two years a third one be nothing which he so much dislikes as hazy notions was announced and published, and we are now pro- of diagnosis and blind routine and unreasonable thera-1 mised tbe fourth. The popularity of this work was peutics. The student who will thoroughly study this n°t ephemeral, and its success was unprecedented in theannalsof American medical literature. Six years is a long period in medical scientific research, but Thomas's work on " Diseases of Women" is still the leading native production of the United States. The order, tlie matter, the absence of theoretical disputa- tiveness, the fairness of statement, and the elegance - of diction, preserved throughout the entire range of both didacticand clinical, Prof. Thomashascertainly the book ;Dnicate that Professor Thomas did not taken the lead far ahead of his confreres and as an overestimate his powers when he conceived the idea author he certainly has met with unusual and mer- : and executed the work of producing a new treatise ited success.-^™ Journ. of Obstetrics, Nov. 1874 Qpon (Usease8 of WOmen.-PROF. Pallkn, in Louis- This volume of Prof. Thomas in its revised form ville Med. Journal, Sept. 1871. book and test its principles by clinical observation, will certainly not be guilty of these faults.—London Lancet, Feb. 13, I S75. Reluctantly we are obliged to close this unsatis- factory notice of so excellent a work, and in conclu- sion would remark that, as a teacher of gynaecology T>ARNES (ROBERT), M. D., F. R. C. P., *~* Obstetric Physician to St. Thomas's Hospital, *c. A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- CAL DISEASES OF WOMEN. Second American, from the Second Enlarged and Revised English Edition. In one handsome octavo volume, of 784 pages, with 131 illustrations. Cloth, $4 50 ; leather, $5 50. (Just Ready.) The call for a new edition of Dr. Barnes' work on the Diseases of Females has encouraged the author to make it even more worthy of the favor of the profession than before By a rear- rangement and careful pruning space has been found for a new chapter on the Gynaecological Relations of the Bladder ani Bowel Disorders, without increasing the size of the book, while many new illustrations have been introduced where experience has shown them to be needed. It is therefore hoped that the volume will be found to reflect thoroughly and accurately the present condition of gynaecological science. A new edition of Dr Barnes's admirable treatise | even seemed to be unnecessary, thus gaining space on the diseases of women can hardly fail to be most , for new matter, which materially enhances the acceptable to the republic of medicine By far the ' value of the work without increasing its size. In best of its kind published, it has for some time not j this new portion will be found a valuable chapter been obtainable, being out of print; but the space on the relations of bb.dder and bowel disorders to of time has been amply utilized by Dr. Barnes in j uterine affections Many of the illustrations are adding to or otherwise perfecting the volume now new aud well executed by the artist. Practitioners before us. Cue and industry are evinced in even j who do not possess a copy of the first edition of this page, and we think Dr. Barnes may be sincerely i work will flud it admirably adapted to meet their congratulated on the result.—Lond. Med. Times and wants as a book of reference in the multitudinous Gazate, July 13, 187S. I diseases that are peculiar to women.—Cincinnati In bringing out this new edition, the author in Lancet and Clinic, Sept. 14, 1878. his revision has carefully omitted all,-natter that i H ODGE (HUGH L.), M.D., Emeritus Professor of Obstetrics, Ac, in the University of Pennsylvania. ON DISEASES PECULIAR TO WOMEN; including Displacements of the Uterus. With original illustrations. Second edition, revised and enlarged. In one beautifully printed octavo volume of 531 pages, oloth, $4 50. Professor Hodge's work is trnly an original one I contribution to the study of women's diseases, it is 0J from beginning to end, consequently no one can pe- great value, and is abundantly able to stand' on its fuse its pages withoat learning something new. As.. | own merits.—N. Y. Medical Record, Sept. 15, 1868 Henry C. Lea's Publications—{Diseases of Women). 23 JjJMMET (THOMAS ADDIS), M.D. Surgeon to the Women's Hospital, New York. et". THE PRINCIPLES AXD PRACTICE OF GYNAECOLOGY, for the use of Students and Practitioners of Medicine. In one large and very handsome octavo volume of over 800 pages, with numerous illustrations. (In Press ) Dr Emmet is so widely known as among the most eminent of those who have made gynae- cology a peculiar American science that the profession cannot fail to welcome a work in which he has condensed the results of his long and extensive experience. He has sought to consider the whole subject of the diseases peculiar to females in a manner which will adapt the volume, not only to the wants of the student as a text-book, but to those of the practitioner as an aid in the emergencies of daily practice. A special feature of the work will be found in the numerous condensed tables, which convey at a glance and within the narrowest compass, the conclusions to be drawn from the many thousand cases which have passed under the care of the author. With trifling exceptions, the illustrations are all Original, and the volume will be found in every point of typographical execution worthy of the distinguished position which is confidently anti- cipated for it. QHADWICK (JAMES R.), A.M., M.D. A MANUAL OF THE DISEASES PECULIAR TO WOMEN. In one neat volume, royal 12mo , with illustrations. (Preparing.) America has contributed so largely to the advances which have made the treatment of Dis- eases of Women a distinctive department of medical science, that the student will naturally turn to American Books for the latest and most trustworthy instruction on the subject in its most modern aspect. Yet there has thus far been no attempt in this country to produce a handy manual, presenting in a condensed and convenient form the information requisite for the learner or for the general practitioner. This want it has been the effort of Dr. Chadwick to supply, and the special attention which he has devoted to the subject is a guarantee of the value of his labors. A distinguishing feature of the work will be a number of diagrammatic illustrations, facilitating greatly the comprehension of the text. \XTINCKEL (F.), ' ' Professor and Director of the Gynmcological Clinic in the University of Rostock. A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent of the author, from the Second German Edition, by James Read Chadwick, M.D. In one ^otavo volume. Cloth, $4 00. (Lately Issued.) This work was written, as the author tells us in his the field, and the present standpoint of science. The preface, to supply a want arising from the very briel work has reached a second edition, and bears evidence consideration given to puerperal diseases by writers on | throughout of careful study and practical experience Obstetrics, in which respect it seems the profession in As its title implies, it is a manual rather than a treatise. his country is not different from our«, and to fill a blank —American Journal of Med. Sciences, April, IfaTl. left between thetreatises upon tbe subject already in '. /THE OBSTETRICAL JOURNAL. (Free of postage for 1878.) THE OBSTETRICAL JOURNAL of Great Britain and Ireland; Including Midwifery, and the Diseases op Women and Infants. With an American Supplement, edited by J. V. Ingham, M.D. A monthly of about 96 octavo pages, very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 cents each. Commencing with April, 1873, the Obstetrical Journal consists of Original Papers by Brit- ish and Foreign Contributors ; Transactions of the Obstetrical Societies in England and abroad ; Reports of Hospital Practice ; Reviews and Bibliographical Notices ; Articles and Notes, Edito- rial, Historical, Forensic, and Miscellaneous; Selections from Journals; Correspondence, Ac. Collecting together the vast amount of ma terial daily accumulating in this important and ra- pidly improving department of medical science, the value of the information which it pre- sents to the subscriber may be estimated from the character of the gentlemen who have already promised their support, including such names as those of Drs. Atthill, Aveling, Robert Barnes, J. Henbt Betjnet, Nathan Bozeman, Thomas Chambers, Fleetwood Churchill, Charles Clay, Johv Clay, Matthews Duncan, Arthur Farrk, Robert Oreenhalgh, Graily Hew- itt, Braxton Hicks, Alfred Meadows, W. Lbishman. Alex. Simpson, Heywood Smith, Tyler Smith, Edward J. Tilt, Lawson Tait, Spencer Wells, Ao. Ac; in short, the repre- sentative men of British Obstetrics and Gynaacology. In order to render the Obstetrical Journal fully adequate to the wants of the American profession, each number contains a Supplement devoted to the advances made in Obstetrics and Gynaecology on this side of the Atlantic. This portion of the Journal is under the editorial charge of Dr J. V Ingham; to whom editorial communications, exchanges, books for re- view, Ac, may be addressed, to the care of the publisher. %* Complete set* from the beginning oan no longer be furnished, but subscriptions can com- mence with January, 1878, or Vol. VI., No 1, April, 1878. 21 Henry C. Lea's Publications—(Midwifery). pLAYFAIR ( W. S.), M.D., F.R.C.P., -*- Profebsor of Obstetric Medicine in King's College, etc. ftc. A TREATISE ON THE SCIENCE AND PU\CTIAMSBOTHAM (FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised bands;; with sixty-four beautiful plates, and numerous wood-outs in the text, containing in all nearly 200 large and beautiful figures. $7 00.' c HURCHILL (FLEETWOOD), M.D., M.R.I.A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With notes and additions by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Chil- dren," Ac. With one hundred and ninety-four illustrations. In one very handsome ootavo volume of nearly 700 large pages. Cloth, $4 00 ; leather, $5 00. MONTGOMERY'S EXPOSITION OP THE SIGNS I R'GBY'B SYSTEM OF MIDWIFERY. With Note* iND SYMPTOMS OF PREGNANCY. With two and Additional Illustrations. Second American exquisite colored plates, and numerous wood-cuts. >dltion. One volume octavo, cloth, 422 pages In 1 vol.8vo.,ofnearly600pp.,cloth. $3 75. | $260. Henry C. Lea's Publications—(Midwifery, Surgery). 25 JjEISHMAN (WILLIAM), M.D., Regius Professor of Midwifery in the University of Glasgow, Ac. A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF PREGNANCY AND THE PUERPERAL STATE. Second American, from the Second and Revised English Edition, with additions by John S. Parry, M.D., Obstetrician to tbe Philadelphia Hospital, Ac. In one large and very handsome octavo volume of over 700 pages, with about two hundred illustrations : cloth, $5 j leather, $6. (Just Issued.) That this book is recommended as a text-book by many of the leading scholars of medicine in this country, is sufficient evidence of the favor in which it is held. In a word, we know of no better book in our language, both for the student and practitioner. The value of the book is enhanced by this second edition, which contains many notes by our late Dr. Parry.—Chicago Med. Journ. and Examiner, March, 1877. But the most valuable additions to the volume are those made by the American editor, (.die of the best tests of a man's ability is for hiui to take a standard work in our profession, like this of Dr. Lefobnian. and materially improve it. Many a one, with more ambition than wis- dom, has attempted it with other books and failed. But Dr. Parry has succeeded most admirably. We know no obstetrical work that has anything better on the use of the forceps thau that which Dr. Parry has given in this, and no work that has the rational and intelligent views upon lactation with which he has enriched this. Having used "Leishman" for two years as a text-book for stu- dent 3. we can cordially coiinn endit. and are quite satisfied to continue such use now.—Am. Practitioner. Mar. 1876. This new edition decidedly confirms the opinion which we expressed of the first edition of the work, in the May, 1«74, number of this Journal, that this is "the best modern work on the subject in the English language." The excellent practical notes contributed by Dr. Parry refer principally to the use of the forceps, lactation, and the puerperal diseases, and are intended to increase the usefulness of the work in this country. An entirely new chapter on diphtheria of puerperal wounds has been added (Dr. I\ has had unusual experience in this form of puerperal fever), and also a number of illustrations of the principal obstetrical instruments in use in Ame- rica. We have no hesitation in saying that the work, in its present shape, is a great improvement on its prede- cessor, aud in recommending it as the one obstetrical textbook which we should advise every English speak- ing practitioner and student to buy.—American Jour- nal of Obstetrics, Feb. 1876. Perhaps the most useful one the student can procure. Some important additions have been made by the editor, in order to adapt the work to the professinu in tbis coun- try, and some new illustrations have been introduced, to represent the obstetrical instruments generally em- ployed in American practice. In its present form, it is an exceedingly valuable book for both the student atd practitioner.—New York Med. Journal, Jan. 187C. In about two years after the issue of this excellent treatise a seeoDd edition has been called for. We regard the treatise as thoroughly sound and practical, and one which may with confidence be consulted in any emer- gency.— The London Lancet, Dec. 11, lh76. Since the publication of Tyler Smith's lectnres on midwifery, no textbook which was in reality the exponent of British practice has appeared in the English language until Dr. Leishman supplied tie want by his system of midwifery, wliich was pub- lished about three years ago. The chief feature in this work is the exactness iu description of the me- chanism of labor ; it exhibits most accurate obser- vation, and is a perfect analysis of the subject, it is clear, precise and masterly. The work is in every way a valuable addition to the works already be- fore the profession on the science and practice of obstetrics, and will, we doubt not, be the favorite text-book used in onr schools.—Canada Med. and Surg. Journal, Nov. 1876. P ARRY (JOHN S.), M.D., Obstetrician to the Philadelphia Hospital, Vice-Prest. of the Obstet S ^ciety of Philadelphia. EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. Cloth, $i 50. (Lately Issued.) Itis with genuine satisfaction, therefore, that weread tne work before us, which is far in advance of any mo- nograph upon the subject in the English language, and exceeding very much, in the number of cases upon which it is based, we believe, any work of the kind ever published. The author has given great care and study to the work, and has handled his statistics with judg- ment; soihat, whatever was to be gained from them, he has gained and added to our knowledge on the sub- ject. We owe the author much for giving us a clear, readable book upon this topic. He has, so far as it is at present possible, removed the obscurity attending certain points of the subject. He has brought order out of something very like chaos.—Philadelphia Med. Times, Feb. 19,1876. In this work Dr. Parry has added a most valuable contribution to obstetric literature, and one which meets a want long felt by those of the profession who have ever been called upon to deal with this class of cases.— Boston Med. and Surg. Journ.. March 9,1876. This work, being as near as possible a collection of the experiences of many persons, will afford a most useful guide, both in diagnosis and treatment, for this most interesting and fatal malady. We think it should be in the hands of all physicians practising midwifery.—Cin- cinnati Clinic, Feb. 5, 1876. A SHHURST (JOHN, Jr.), M.D., "^^ Prof of Clinical Surgery, Univ. of Pa., Surgeon to the Episcopal Hospital, Philadelphia. THE PRINCIPLES AND PRACTICE OF SURGERY. Second and revised edition. In one very large and handsome octavo volume of about 1000 pages, with over 550 illustrations. (Preparing.) SKEY'S OPERATIVE SURGERY. In 1 ~"*-*™' cl., of 650 pages ; withabout lOOwood-cuts. $3 26 COOPER'S LECTURES ON THE PRINCIPLES AND Practice of Sitruery. In 1 vol. 8vo. cloth, 7o< i p. «2. GIBSON'S INSTITUTES AND PRACTICE OF SUR- qert. Eighth edition, improved and altered. With thirty-four plates. In two handsome octavo vol- nmes, about 1000 pp.,leather, raised bands. $6 «" THE PRINCIPLES AND PRACTICE OF SURGERY. By WilliamPirrie, F.R S.E., Professor of Surgery in the University of Aberdeen. Edited by John Neill, M.D., Professor of Surgery in the Penna. Med ical College, Surgeon to the Pennsylvania Hos- pital, &c. I none very handsome octavo volume of 7S0 pages, with 316 illustrations, cloth, $3 75. MILLKIl'SPKINOIPLES OF SURGERY. Fourth Ame- rican, from tbe Third Edinburgh Edition. In oi.e large 8vo. vol. of 700 pages, with 340 illustrations : cloth, $3 75. MILLER'S PRACTICE OF SURGERY. Fourth Ame- rican, from the last Edinburgh Edition Revised by the American editor. In onelargeSvo.vol.of nearly 700 pages, with 364 illustrations: cloth, $3 75. 2(5 Hbnry C. Lea's Publications—(Surgery). /1ROSS (SAMUEL D.), M.D., ^^ Professor of Surgery in the Jefferson Medical College of Philadelphia. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition, carefully revised, and improved. In two large and beautifully printed imperial octavo vol- umes of about 2300 pages, strongly bound in leather, with raised bands, $15. (Just Issued.) The continued favor, shown by the exhaustion of successive large editions of this great work, proves that it has successfully supplied a want felt by American practitioners and students. In the present revision no pains have been spared by the author to bring it in every respeot fully up to the day. To effect this a large part of the work has been rewritten, and the whole enlarged by nearly one-fourth, notwithstanding which the price has been kept at its former very moderate rate. By the use of a close, though very legible type, an unusually large amount of matter is condensed in its pages, the two volumes containing as much as four or five ordinary octavos. This, combined with the most careful mechanical execution, and its very durable binding, renders it one of the cheapest works accessible to the profession. Every subject properly belonging to the domain of surgery is treated in detail, so that the student who possesses this work may be said to have in it a surgical library. Primus inter Pares." It is learned, scholar-like, me- We have now brought our task to a conclusion, and have seldom read a work with the practical value of which we have been moreimpressed. Every chapter is bo concisely put together, that the busy practitioner, when in difficulty, can at once find the information he requires. His work, on the contrary, is cosmopolitan, the surgery of the world being fully represented in it. The work, in fact, is so historically unprejudiced, and so eminently practical, that it is almost a false compliment to say that we believe it to be destined to occupy afore- most place asawork ofrcference, while a system of sur- gery like the present system of surgery is the practice of surgeons. The printing and bindiug of the work is un- exceptionable; indeed, it contrasts, in the latter re- Bpc-t, remarkably with English medical and surgical cloth-bound publications, which are generally so wretch- edly stitched as to require re-binding before they are any time in use.—Dub. Journ. of Med. Sci., March, 1W4. Dr. Gross's Surgery, a great work, has become still greater, both in size and merit, in its most recent form. The difference in actual numberof pages is not more than 130. but. the size of the page having been increased to what we believe is technically termed ••elephant." there has been room for considerable additions, which, toge- ther with the alterations, are improvements.—Loud. Lancet, Nov. 16,1872. It combines, as perfectly as possible, the qualities of a text-book and work of reference. We think this last edition of Gross's " Surgery," will confirm his title of thodical, precise, and exhaustive. We scarcely think any living man could write so complete and faultless a treatise, or comprehend more solid, instructive matter, in the given number of pages. The labor must have been immense, and the work gives evidence of great powers of mind, and the highest order of intellectual discipline and methodical disposition, and arrangement of acquired knowledge and personal experience.—N. Y. Med Journ., Feb. 1873 As a whole, we regard the work as the representative "System of Surgery" in the English language.—St. Louis Medical and Surg. Journ., Oct. 1872. The two magnificent volumes before us afford a very complete view of the surgical knowledge of the day. Some years ago we had the pleasure of presenting the first edition of Gross's Surgery to the profession as a work of unrivalled excellence; and now we have the result of years of experience, labor, and study, all con- densed upon the great work before us. And to students or practitioners desirous of enriching their library with a treasure of reference, we can simply commend the purchase of these two volumes of immense research —- Cincinnati Lancet and Observer, Sept. 1V72. A complete system of surgery—not a mere text-book of operations, but a scientific accountof surgical theory and praeticeinall its departments.—Brit.and For.Med.- Chir. Rev., Jan. 1873. T> Y THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, and Malformations of the Urinary Bladder, the Prostate Gland, and the Urethra. Third Edition, thoroughly Revised and Condensed, by Samuel W. Gross, M.D., Surgeon to the Philadelphia Hospital. In one handsome octavo volume of 574 pages, with 170 illus- trations: cloth, $4 50. (Just Issued.) The book is fully up to the times, and we know of no monograph on the subject of urinary diseases that is fuller°and more complete than tbe one under notice.— Cincin. Lancet and Observer, Dec. lt?76. It is a valuable and exhaustive treatise on the surgery of the urinary organs, brought fully up to the existing state of our knowledge. A perusal of its 574 pages will auip'y repay the investigator.—Pac fie Med. and Sury. Journ , Nov. 1876. Nothing need be said to commend this «tandard work to the profession. It has long been considered one of the most valuable from the pen of the distinguished author The editor has done his work ably and faith- fully, and several of the chapters, by no means the least useful ones, are from his pen; as a monograph repre- senting all the surgery of the parts of which it treats, it has nosuperiorin our tongue—Med and Surg lie- porter, Oct. 21,1876. Kor reference and general information, the physician T)Y THE SAME AUTHOR A PRACTICAL or surgeon can find no work that meets their necessities more thoroughly than this, a revised edition of an ex- cellent treatise, and no medical library should be with- out it. Replete with handsome illustrations and good ideas, it has the unusual advantage of being easily comprehended, by the reasonable and practical manner in which the various subjects are syBtematized and arran.-ed We heartily recommend it to the profession as a valuable addition to the important literature of dis- eases of the uriuary organs— Atlanta Med Journ., Oct. 1876. ■ It is with pleasure we now again take up this old work in a decidedly new dress. Indeed, it must be regarded as a new book in very many of its parts. The chapters on "Diseases of the Bladder," -Prostate Body," and "Lithotomy," are splendid specimens of descriptive writing; while the chapter on ••Stricture" is one of the most concise and clear that we have ever read__V York Mtd. Journ., Nov. 1876. PRACTICAL TREATISE ON FOREIGN BODIES IN TT AIR-PASSAGES. In 1 vol. 8vo., with illustrations, pp. 468, cloth, $2 75. E BIGELO W (HENRY J.), M. />., Professor of Surgery in the Massachusetts Med. College. ON THE MECHANISM OF DISLOCATION AND FRACTURE OF THE HIP. With the Reduction of the Dislocation by the Flexion Method. W-th numerous original illustrations. In one very handsome octavo volume. Cloth, $2 do QTIMSON (LEWIS A ), A.M., M.D., *~> Surg"on to the Presbyterian Hospital. A MANUAL OF OPERATIVE SURGERY. In one very handsome royal 12mo. volume of about 500 pages, with 332 illustrations ; cloth, $2 50. (Just Ready ) ^ Many years having elapsed since the appearance in this country of any work devoted exclu- sively to the operations of surgery, and the ordinary surgical text-books being too large and unwieldy for ready consultation and reference, the author has thought that a compact manual devoted exclusively to practical operative details, thoroughly illustrated, would supply a want universally felt. ^ He has accordingly sought to embody in the work a concise account of all the operations practised at the present day, devoting special attention to the newer and less fami- liar ones, copiously illustrated with diagrams and figures, many of which are original. The work before us is a well printed, profusely illustrated manual of over four hundred aud seventy pages. Tne novice, by a perusal of the work, will does away with the necessity of pondering over larger works on surgery for descriptions of opeia- tious, as it presents in a nut-shell just what is wanted by the surgeon without an elaborate search to find it —Md. Med Journal, Aug. 1S78. The author's conciseness and the repleteness of the work with valuable illustrations entitle it to be classed with the text-books for students of operative surgery, and as one of reference to the prnctitioner. — Cincinnati Lancet and Clinic, July 27, 187b. We think he has succeeded very well in striking that happy and rarely trodden medium between the unsatisfying meagreness of an epitome, or cum- pend, and the wearying diffuseness of an elaborate the details of operations and the different modes of I trffUi>e. His language is lucid, and his wolds are performing them. The work is handsome y ill us- aided bv a free use of mirations, three hundred trated, and the descriptions are clear and well drawn. ' It is a clever and useful volume; every sludent should possess one. The preparation of this work gain a good idea of the general domain of operative surgery, while the practical surgeon has presented to him within a very concise and intelligible form the latest and most approved selections of operative procedure. Theprec'sion and concisenets with which the different operations are described enable the author to compress an immense amount of practical information in a very small compass —N. Y. Melical Record, Aug. 3, 1878 This volume is devoted entirely to operative sur- gery, and is iuteuded to familiarize the stndeut w th and thirty-two of which are inserted in the text.— M d. and Surg Reporter, June 29, 1878. JJOLMES (TIMOTHY), M.D., Surgeon to St George's Hospital, London. SURGERY, ITS PRINCIPLES some octavo volume of nearly 1000 pages, (Just Issued.) We believe it to be by far the best surgical text-book tfaat we have, insomuch as it is the completes!, aud the one most thoroughly brought up to the knowledge of the present day. All who will give this book the careful perusal that it deserves and requires, whe- ther student or practitioner, will agree with us, that, from the happy way in which justice is done, both to the principles and practice of surgery, from the care with which its pages are brought>up to modern date, from the respect which is paid all along to the opin- ions of others, it deserves to take the first place among the text-books on surgery. — British Med. Journ., Dec. 25,1S75. This is a work which has been lqoked for on both sides of the Atlantic with much interest. Mr. Holmes Is a surgeon of large and varied experience, and one of the best known, and perhaps the most brilliant writer npon surgical subjects in England. It is a book for students—and an admirable one—and for AND PRACTICE. In one hand- with 411 illustrations. Cloth, $6; leather, $7. the busy general practitioner. It will give a studen all the knowledge needed to pass a rigid examina- tion. The book fairly j ustifies the high expectations that were formed of it. its style is clear and forcible, even brilliant at times, and the conciseness needed to bring it within its proper limits has noi impaired its force and distinctness.—N. Y. Med. Record, April 14, 1876. It will be found a most excellent epitome of sur- gery by the general practitioner who has not the time to give attention to more minute and extended works, and to the medical student. In fact, we know of no one we can more cordially recommend. The author has succeeded well in giving a plain and practical account of each surgical injury and disease, and of the treatment which is most commonly advisable. It will no doubt become a popular work in the pro- fession, and especially as a text-book.—Cincinnati Med. News, April, 1876. fJAMILTON (FRANK H), M.D., Professdr of Fractures and Dislocations, 4c, in Bellevue Hosp. Med. College, New York. A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- TIONS. Fifth edition, revised and improved. In one large and handsome octavo volume of nearly 800 pages, with 344 illustrations. Cloth, $5 75; leather, $6 75. (Lately Issued.) This work is well known, abroad as well as at home, as the highest authority on its important subject—an authority recognized in the courts as well as in the schools and in practice—and again manifested, not only by the demand for a fifth edition, but by arrangements now in pro- gress for the speedy appearance of a translation in Germany. The repeated revisions which the author has thus had the opportunity of making have enabled him to give the most careful consid- eration to every portion of the volume, and he has sedulously endeavored in the present issue, to perfect the work by the aid of his own enlarged experience and to incorporate in it whatever of value has been added in this department since the issue of the fourth edition. It will there- fore be found considerably improved in matter, while the most careful attention has been paid to the typographical execution, and the volume is presented to the profession in the confident hope that it will more than maintain its very distinguished reputation. There is no better work on the subject in existence than that of Dr. Hamilton. It should be in the posses- sion of every general practitioner and surgeon.—The Am. Journ. of Obstetrics, Feb. 1876. The value of a work like this to the practical physi- cian ami surgeon can hardly be over-estimated, and the necessity of having such a book revised to the latest dates, not merely on accouut of the practical importance of* its teachings, but also by reason of the medicolegal bearings of the cases of which it treats, and which have recently beeu the subject of useful papers by Dr. Hamil- ton and others, is sufficiently obvious to every one The present volume seems to amply fill all the requisites. We can safely recommend it as the best of its kind in tbe English language, aud not excelled in any other.— Journ. of Ntrvous and Mental Disease,Jan. 1876. 28 Henry C. Lea's Publications—(Surgery''. &RICRSEN (JOHN E.), ■U Professor of Surgery in University College, London, etc. THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- gical Injuries, Diseases, and Operations. Carefully revised by the author from the Seventh ana enlarged English Edition. Illustrated by eight hundred and sixty two en- gravings on wood. Ii two large and beautiful octavo volumes of nearly 2000 pages: cloth, $8 50 ; leather, $10 50 (Now Ready.) In revising this standard work the author has spared no pains to render it worthy of a continu- ance of the very marked favor which it hns so long enjojed, by bringing it thoroughly on a level with the advance in the science and art of surgery made since the appearance of the last edition. To accomplish this has required the addition of about two hundred page' of text, while the illustrations have undergone a marked improvement. A hundred nnd fifty additional wood-cuts have been inserted, while about fifty other new ones have been substituted for figures which were not deemed satisfactory. In its enlarged.and improved form it is therefore pre- sented with the confident anticipation that it will maintain its position in the front rank of text-books for the student, and of works of reference for the practitioner, while its exceedingly moderate price places it within the reach of all. The seventh edition is before the world as the last word of surgical science. There may be monographs which excel it upon certain points, but as a con- spectus upon surgical principles and practice it is unrivalled. It will well reward practitioners to read it, for it has been a peculiar province of Mr. Erichsen to demonstrate the absolute interdepend- ence of medical and surgical science We need scarcely add, in conclusion, that we heartily com- mend the work to students that they may be grounded in a sound faith, and to practitioners as an invaluable guide at the bedside.— Am Practi- tioner, April, 1878. It is no ille compliment to say that this is the best edition Mr. Erichsen has ever produced of his well- kuowu book. Besides inheriting the virtues of is predecessors, it possesses excellences quite its own. Having stated that Mr. Erichsen h-s incorporated into this edition every recent improvement iu the science and art of surgerv, it would be a supereroga- tion to give a detailed criticism. In short, we un- hesitatingly aver that we know of no other single work where the student aud practitioner can gaiu at oncesoclear aniusigUtiuto the principles of surgery, and so complete a knowledge of the exigencies of surgical practice.— London Lancet, Feb. 14, 1S78 For the past twenty years Erichsen's Surgery has maintained its place as the leading text-book, not only in this country, but in Great Britain. That it is able to hold its ground, is abundantly proveu by the tho- roughness with wliich the present edition has beiin revised, and by the large amount of valuable mate- rial that has been added. Aside from this, c ne hun- dred and fifty new illustrations have been inserted, including quite a number of microscopical appear- ances of pathological processes, cio marked is this change for the better, that the work almost appears as an entirely new one.—Med. Record, Feb. 23, 1&7S. Of the many treatises on Surgery which it has been our task to study, or our pleasure to read, there is none which in all points has satisfied us so well as the classic treatise of Erichsen. His polished, clear style, his free- dom from prejudice and hobbies, bis unsurpassed grasp of his subject, and vast clinical experience, qualify him admirably to write a model text-book. When we wish, at the least cost of time, to learn the most of a topic iu surgery, we turn, by preference, to his work. It is a pleasure, therefore, to see that the appreciation of it is general, and lias led to the appearance of another edition. —Mid. ond Surg. Reporter. Feb. 2,1678. Notwithstanding the increase in size, we observe that much old matter has been omitted. The entire work has been thoroughly written up, and not merely amend- ed by a few extra chapters A great improvement has been made in the illustrations. One hundred and fifty new ones have been added, and many of the old ones have been redrawn. The author highly appreciates the favor wilh which bis work has been received by Ameri- can surgeons, and has endeavored to render his latest edition more than ever worthy of their approval. That he has succeeded admirably, must, we think, be the general opinion. We heartily recommend the book to both student and practitioner.—N. Y. Med. Journal, Feb.1S78. It is entirely unnecessary for us to attempt to add, by our praises, one jot to the established reputation of Erichsen's Science and Art of Surgery. It has long beeu a favorite text-book and authority in this country as well as in England aud on the Continent, and the present edition can but add to its popularity.— Ohio Med. Recorder, Jan. 1878. D RUITT (ROBERT), M.R.C.S., ice. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American, from the eighth enlarged and improved London edition. Illus- trated with four hundred and thirty-two wood engravings. In one very handsome octavo volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 00. practice of surgery are treated, and so clearly and perspicuously, as to elucidate every imporUni topic. We nave examined the book most thoroughly, and can say that this success is well merited. His book moreover, possesses the inestimable advantages of having the subjects perfectly well arranged and clas- sified, and of being written in a style at once clear ind succinct.—Am. Journal of Med. Sciences. All that the surgical student or practitioner could desire.—Dublin Quarterly Journal. It is a most admirable book. We do not know when we have examined one with more pleasure.— Boston Med. and Surg. Journal. In Mr. Druitt's book, though containing only some seven hundred pages, both the principles and the B RYANT (THOMAS), F.R.C.S., Surgeon to Guy's Hospital. THE PRACTICE OF SURGERY. Second American, from the Sec- ond and Revised English Edition. With over Five Hundred Engravings on Wood. In one large and very handsome octavo volume of nearly 1000 pages. (Shortly.) ASHTON ON THE DISEASES, INJURIES, AND MAL- FORMATIONS OF THE RECTUM AND ANUS ; with remarks on Habitual Constipation. Secoud Ameri- can, from tbe fourth and enlarged London Edition. With illustrations. In one 8vo. vol. of2S7 pages, cloth, $3 25. SARGENT ON BANDAGING AND OTHER OPFKa TIONS OF MINOR SURGERY. New edition, wi?h an additional chapter on Military Surgery.' On 12mo. vol. of 383 pag93, with 181 wood-cuts Cloth6 $175. ° Henry U. Lea's Publications—(Ophthalmology". 29 (GOSSELIN (L.), ^-" Professor of Clinical Surgery in the Faculty of Medicine, Paris, etc. CLINICAL LECTURES ON SURGERY. Delivered at the Hospital of La Charite. Translated from the French by Lewis A. Stimson, M.D., Surgeon to the Presbyterian Hospital, New York. With illustrations. In one neat octavo volume of 350 pages ; cloth, $2 50. (Now Ready.) From the Medical News and Library SUMMARY OF CONTENTS. PART IV. Traumatic Fever, Septicemia, AND Pv.liMlA. 4 LECT. PART V. DISEASES OP THE ARTICULATIONS. 7 " " VI. 1'hi.eomon, Abscess, and Fistula. 3 " It will be seen from this brief abstract of the contents that these Lectures treat of subjects which are of daily interest to the practitioner, while some of them hardly receive in the text- books the attention which their importance deserves. PARTI. Suroical Diseases op Youth. 8 Lect " II Fractures, of the Limbs. 18 " " III. Traumatic Osteitis and Necrosis 2 " B ROWNE (EDGAR A.), Surgeon to the Liverpool Eye and. Kw Infirmary, and to the Dispensary for Skin Diseases. HOW TO USE THE OPHTHALMOSCOPE. Being Elementary In- structions in Ophthalmoscopy, arranged for the Use of Students. With thirty-five illustra- tions. In one small volume royal 12mo. of 120 pages : cloth, $1. (Now Ready.) This capital little work should be in the hands of ev ry medical student, and we had almostsaid every general practitioner. Its explanation of the optical principles on which the ophthalmoscope is founded, is so clear and simple that the most stupid reader could scarcely fail of understanding them. Equally satisfactory are the directions for the use of the in- strument and the suggestions to aid in interpreting what is seen.—Ditroxt iled. Journ., Nov. 1877. The information is given in a very coi.cise, but we may also add, iu a very clear and forcible manner. Many uf the diagrams that illustrate the text are original and ingenious in tbeir construction, aud very instructive.— Edin. Med. Journ. /BARTER (R. BRUDENELL), F.R.CS, V-^ Ophthalmic Surgeon f« St George s Hospital, etc. A PRACTICAL TREATISE ON DISEASES OF THE EYE. Edit- ed, with test-types and Additions, by John Ureen, M.D. (of St. Louis, Mo.). In one handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $3 75. (Just Issued.) Dr. Green, whose reputation and experience in this department are well known, has given this work a very careful revision, and has introduced much matter which will be found of importance to the practitioner. As his system of test-types is the one recommended by the author, they have been inserted in the volume in a shape which will admit of their being detached and mounted for convenient office use. These test-types, on a sheet for mounting, can be had separate, price 25 cents. in view, and presents the subject in a clear and concise manner, easy of comprehension, and hence the more valuable. We would especially commend, however, as It would be difficult for Mr. Carter to write an uum- Btructive book, and impossible for him to write an un- interesting one. Even on subjects with which he is not bound to be familiar, lie can discourse with a rare degree of clearness and effect. Our readers will therefore not be surprised to learn that a work by him on the Diseases of the Eye makes a very valuable addition to ophthal- mic literature. . . . The book will remain one useful alike to the general aud the special practitioner. Not the least valuable result which we expectfrom it is that it will to some considerable extent despecializc this bril- liant department of medicine.—London Lancet, Oct. 30, 1875. It is with great pleasure that we can endorse the work as a most valuable contribution to practical ophthal- mology. Mr. Carter never deviates from the end he has worthy of high praise, the mauuer in which the thera- peutics of disease of the eje is elaborated, for here the author is particularly clear and practical, where other writers arc unfortunately too often deficient. The final chap' er is devoted to a discussion of the uses and selec- tion of spectacles, and is admirably compact, plain, and useful, especially the paragraphs on the treatment of presbyopia and myopia. In conclusion, our thanks are due the author for many useful hints iu the great sub- ject of ophthalmic surgery aud therapeutics, a held where of late years we glean but a few grains of sound wheat from a mass of chaff.—New York Medical Record, Oct. 23,1875. w ELLS (J. SOELBERG), Professor of Ophthalmology in King's College Hospital, Ac. A TREATISE ON DISEASES OF THE EYE. Third American, from the New and Revised London Edition, with additions ; illustrated with numerous engravings on wood, and six colored plates. Together with selections from the Test-types of Jaeger and Snellen. In one large and very handsome octavo volume. (Preparing.) T A URENCE (JOHN Z.), F. R. C. S., ■^ Editor of the Ophthalmic Review, Ac. A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of Practitioners. Second Edition, revised and enlarged. With numerous illustrations. In one very handsome octavo volume, cloth, $2 75. rAWSON (GEORGE), F. R. C. S., Engl., ■4 Assistant Surgeon to the Royal London Ophthalmic Hospital Moorfields, Ac. INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- diate and Remote Effects. With about one hundred illustrations. In one very hand some octavo volume, cloth, $3 50. 30 Henry C. Lea's Publications—(Medical Jurisprudence). JZ>URNETT (CHARLES H), M.A , M.D., ■*-* Aural Surg to the Presb. hosp., Surgeon-in-charge of the Infir for Dis. of the Ear, Phila. THK EAR, ITS ANATOMY, PHYSIOLOGY, AND DISEASES. A Practical Treatise for the Use of Medical Students and Practitioners. In one hand- some octavo volume of 615 pages, with eighty-seven illustrations : cloth, $4 50 ; leather, $5 50. (Just Ready.) Recent progress in the investigation of the structures of the ear, and advances made in the modes of treating its diseases, would seem to render desirable a new work in which nil the re- sources of the most advanced science should be placed at. the disposal of the practitioner. This it has been the aim of Dr. Burnett to accomplish, and the advantages which he has enjoyed in the special study of the subject are a guarantee that the result of his labors will prove of service to the profession at large, as well as to the specialist in this department. On account of the great advances which have been made of late years in otology, and of the increased interest manifested in it, the medical profession will welcome this new work, which presents, clearly and concisely its present aspect whilst clearly indi- cating the direction in which further researches can be most profitably carried on. Dr. Bnrnt-tt from his own matured experience, and availing himself of the observations and discoveries of others, has pro- duced a work, wliich as a text-book, stands facile princeps in our language. We had marked several passages as well worthy of quotation and the atten- tion of the general practitioner, but their number and the space at our command forbid. Perhaps it is bet- ter, as the book ought to be in the hands of every medical student, and its study will well repay the busy practitioner in the pleasure he will derive from the agreeable style in which many otherwise dry and mostly unknown subjects are treated. To the specialist the work is of the highest value, and his sense of gratitude to Dr. Burnett will, we hope, be proportionate to the amount of benefit he can obtain from the careful study of the book, and a constant reference to its trustworthy pages.—Edinbw gh Med. Jour., Aug. 1878. As the title of the work indicates, this volume treats of the auatomy and physiology of the ear, as well as of its diseases, and tbe author has taken special pains to make this difficult and complicated matter thoroughly clear and intelligible. The book is designed especially for the use of students and general practitioners, and places at their disposal much valuable material. Such a book as the pre- sent one, we think, has long been needed, and we may congratulate the author on his success in fill- ing the gap. Both student and practitioner can study the work with a great deal of benefit. It is profu-ely and beautifully illustrated.—N. Y. Hos- pital Gazette, Oct 15, 1877. The appearance of this book is another proof of the rapidly increasing amount of honest, valuable work that is now teing done in the various branches of medical scieucein this country. Dr. Burnett is to be commended for having written the best book on the subject in the English language, and especially for the care and attention he has given to the scientific side of the subject.—N. Y. Med. Journ., Dec. Ib77. T AYLOR (ALFRED S.), M.D., Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital. POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Third American, from the Third and Revised English Edition. In one large octavo volume of 850 pages; cloth, $5 50 ; leather, $6 50. (Just Issued.) being described which give rise to legal investiga- tions.—IVie Clinic, Suv. 6, 1875. Dr. Taylor hat brought to bear on the compilation of this volume, stores of learning, experience, and practical acquaintance with his subject, probably far beyond what any other living authority ou toxicol- ogy could have amassed or utilized. He has fully sustained his reputation by the consummate skill and legal acumen he has displayed in the arrange- ment of the subject-matter, aud the result is a work ou Poisons wbich will be indispensable to every stu- dent or practitioner in taw and medicine.—The Dub- lin Journ. of Med Sc>., Oct. 1S75. The present is based upon the two previous edi tions ; "but the complete revision rendered necessary by time has converted it into a new work." This statement from the preface contains all that it is de- sired to know in reference to the new edition The works of this author are already in the library of every physician who is liable to be called upon for medico-legal testimony (and what "nets not?), so that all that is required to be known about the present book is that the author has kept it abreast with the times. What makes it now, as always, especially valuable to the practitioner is its conciseness and practical character, only those poisonous substances B Y THE SAME AUTHOR. MEDICAL JURISPRUDENCE. Seventh American Edition. Edited by John J. Reese, M.D.; Prcf of Med. Jurisp. in the Univ. of Penn. In one large (Lately Issued.) octavo volume of nearly 900 pages. Cloth, $5 00; leather, $6 00. It is beyond question the most attractive as well as most reliable manual of medical jurisprudence published in the Englibh language.—Am. Journal of Syphilography, Oct. 1S73. This last edi tion of the Manual is probably the best of all, as it contains more material and is worked up to the latest viaws of the author as expressed in the last edition of the Principles. Dr. Reese theeriit..- It is altogether superfluous for us to offer anything of the Manual, has done everything to make h« in behalf of a work on medical jurisprudence by an work acceptable to bis medical countrymen -% y author who isalmost universally esteemed to be the , Mid. Record, Jan. 15, 1874. ' ""• r- B Y THE SAME AUTHOR. THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- DENCE. Second Edition, Revised, with numerous Illustrations. In two laree n~*n volumes, cloth, $10 00 ; leather, $12 00 ?V0 This great work is now recognized in England as the fullest and most authoritative treatise on every department of its important subject. In laying it, in its improved form, before the Ame * can profession, the publisher trusts that it will assume the same position in this country. "' Henry C. Lea's Publications—(Miscellaneous). 31 /THOMPSON (SIR HENRY), ■*• Surgeon and Professor of Clinical Surgery to University College Hospital. LECTURES ON DISEASES OF THE URINARY ORGANS. With illustrations on wood. Second American from the Third English Edition. In one neat octavo volume. Cloth, $2 25. (Just Issued.) J£Y THE SAME AUTHOR. ---- ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF THE URETHRA AND URINARY FISTULA. With plates and wood-cuts. From the third and revised English edition. In one very handsome octavo volume, cloth, $3 50. (Lately Published.) B Y THE SAME AUTHOR. B THE DISEASES OF THE PROSTATE, THEIR PATHOLOGY AND TREATMENT. Fourth Edition, Revised. In one handsome 8vo. vol. ol 355 pages, with 13 plates, plain and colored, and illustrations on wood. Cloth, $3 75. (Just Issued.) rTUKE (DANIEL HACK), H.dT •*■ Joint author of "The Manual of Psychological Medicine," Ac. ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. (Lately Issued.) LANDFORD (G. FIELDING), m7d7,FR. C.P.; Lecturer on Psychological Medicine at the School of St. George's Hospital, Ac. INSANITY AND ITS TREATMENT: Lectures on the Treatment, Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very handsome octavo volume of 471 pages; cloth, $3 25. It satisfies a want which must have been sorely actually seen in practice and the appropriate treal- fjltby the busy general practitioners of this country, j ment for them, we find in Dr. Blaudford s work a U takes the form of a manual of clinical description ' considerable advance over previous writings on the of the various forms of insanity, with a description , subject. His pictures of the various forms of mental of the mode of examining persons suspected of in- disease are so clear and good that no reader can fail sanity. We call particular attention to this feature to be struck with their superiority to those given in of the book, as giving it a unique value to the gene- irdinary manuals in the English language or (so far ral practitioner. If we pass from theoretical conside- as our own reading extends) in any other.__London rations to descriptions of the varieties of insanity as Practitioner, Feb. 1871. r EA (HENRY C). SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Third Revised and Enlarged Edition. In one handsome royal 12mo. volume of 552 pages. Cloth $2 50. (Just Ready.) The appearance of a new edition of Mr. Henry C. Lea's " Superstition and Force" is a s gn that our highest scholarship is not without honor in its ua- tl/e country. Mr. Lea has met every fresh demand for his work with a careful revision of it, and the present ecition is not only fuller and. if possible, more accurate than either of the preceding, but, from the thorough elaboration is more like a har- monious concert and less like a batch of otudies.— The Nation, Aug. I, 1878. Many will be tempted to say that this, like the 'Decline and Fa 11,''in one of tbe uucriticizable books Its facts are innumerable, its deductionssiraple and inevitable, and its chevaux-dtffise of references bristling and dense enough to make the keenest, stoutest, and best equipped assailant think twice before advancing. Nor is there anything contro- versial in it to provoke assault. The author is no polemic. Though he ooviously feels and thinks strongly, he succeeds in attaining impartiality. W he tier looked on as a picture or a minor, a work such as this has a lastiag valae. — Lippincott's Magazine, Oct. 187s. Of the curious learning and the profound philoso- phy which Mr Lea brings to the almost exhaustive exposition of these themes, anything but a simple recognition would be on our part impertinent. We have already noted the richness of his resources and bis ability and fidelity in the use of them —Boston Eveni-g Transcript, Aug. 28, lb7s T>Y THE SAME AUTHOR. (Late y Published.) STUDIES IN CHURCH HISTORY—THE RISE OF THE TEM- PORAL POWER—BENEFIT OF CLERGY—EXCOMMUNICATION. In one large royal 12mo. volume of 516 pp.; cloth, $2 75. The story was never told more calmly or with i literary phenomenon that the head of one of the first greater learning or wiser thought. We doubt, indeed, If any other study of this field can be compared with this for clearness, accuracy, and power. — Chicago Examiner, Dec. 1870. Mr. Lea's latest work, "Studies in Church History," fully sustains the promise of the first. It deals with three subjects—the Temporal Power, Benefit of Clergy, and Excommunication, the record of which American houses is also the writer of some of its most original books.—London Athenceum, Jan. 7, 1871 Mr. Lea has done great honor to himself aud thit country by the admirable works he b&» written on ecclesiologicaland cognate subjects. We have already had occasion to commend his "Superstition aud Force" and his "History of Sacerdotal Celibacy." The pre.-ent volume is fully as admirable in its me- has a peculiar importance for the English student, and i thodof dealing with topics and in the thorough uess— Is a chapter on Ancient Law likely to be regarded as a quality so frequently lackingin American aufhori— final. We can hardly pass from our mention of such | with which they are investigated—N. Y. Journal of works as these—with which that on "Sacerdotal Psychol Medicine, July, 1870. Celibacy" should be included—withont noting the' 32 Henry C. Lea's Publications. INDEX TO CATALOGUE. American Journal of the Medical Sciences Abstract, Monthly, of the Med. Sciences Allen's Anatomy..... Anatomical Atlas, by Smith and Horner Ashton on the Kectum and Anns . Attfield's Chemistry .... Ashwell on Diseases of Females . Ashhurst's Surgery .... Browne on Ophthalmoscope . brown on the Throat .... Burnett on the Ear..... Barnes on Diseases of Women Bellamy's Surgical Anatomy Bryant's Practical Surgery . Bloxam's Chemistry .... Blandford on Insanity .... Basham on Renal Diseases . Brinton on the Stomach Bigelow on the Hip .... Barlow's Practice of Medicine Bowman's (John E.) Practical Chemistry Bowman's (John E.) Medical Chemistry Bristowe's Practice .... Bumstead on Venereal .... Bumstead and Cullerier's Atlas of Venereal Carpenter's Human Physiology . Carpenter on the Use and Abuse of Alcohol Cornil and Kanvier .... Carter on the Eye..... Cleland's Dissector .... Classen's Chemistry .... Clowes' Chemistry..... Century of American Medicine Chadwick ou Diseases of Women . Charcot on the Nervous System Chambers ou Diet aud Regimen . Chambers's Restorative Medicine Cbristison and Griffith's Dispensatory C hurchill's Svstem of Midwifery . Churchill on Puerperal Fever Condie on Diseases of Children . Cooper's (B. B.) Lectures on Surgery . Cullerier's Atlas of Venereal Diseases Cyclopaedia of Practical Medicine Dalton's Human Physiology Davis's Clinical Lectures Dewees on Diseases of Females . Drnitt's Modern Surgery Dunglison's Medical Dictionary . Dnnglison's Human Physiology . Erichsen's System of Surgery Emmet ou Diseases of Womeu Farquharson's Therapeutics . Fenwick's Diagnosis .... Fiulayson's Clinical Study of Disease . Flint on Respiratory Organs . Flint on the Heart..... Flint's Practice of Medicine . Flint's Essays..... Flint on Phthisis..... Flint on Percussion .... Fothergill's Handbook ofTreatment . Fothergill's Antagonism of Therapeutic Agents Fownes's Elementary Chemistry . Fox on Diseases of the Skin . Fuller on the Lungs, &c. Green's Pathology and Morbid Anatomy Gibson's Surgery..... Gluge's Pathological Histology, by Leidy Gray's Anatomy..... Galloway's Analysis .... Griffith's (R. E.) Universal Formulary Gross on Urinary Organs Gross on Foreign Bodies in Air-Passages G ross's Principles and Practice of Snrgery Gosselin's Clinical Lectures ou Surgery Hamilton on Dislocations and Fractures Hartshorne's Essentials of Medicine . Hartshorne's Conspectus of the .Medical Sciences Hartshorne's Anatomy and Physiology Hamilton on Nervous Diseases . Heath's Practical Anatomy . Hoblyn's Medical Dictionary Hodge on Women .... Hodge'b Obstetrics .... vols Sci dy PAGE | 1 Hodge's Practical Dissections lolland's Medical Notes and Reflections Holmes's Surgery .... Holden's Landmarks Corner's Anatomy and Histology Hudson on Fever .... Kill on Venereal Diseases . Hillier's Handbook of Skin Diseases Jones (0. H, mlfitlil) on Nervous Disorde Kirkes' Physiology Knapp's Chemical Technology . Lea's Superstition and Force Lea's Studies in Church History . Lee on Syphilis .... Lincoln on Electro-Therapeutics , Leishman's Midwifery . La Roche on Yellow Fever . La Roche on Pneumonia, &c. Laurence and Moon's Ophthalmic Snrgery Lawson on the Eye Lehmann's Physiological Chemistry, Lehmann's Chemical Physiology . Ludlow's Manual of Examinations Lyons on Fever .... Medical News and Library . Meigs on Puerperal Fever Miller's Practice of Surgery . Miller's Principles of Surgery Montgomery on Pregnancy . Neill and Smith's Compendium of Med Neligan's Atlas of Diseases of the Skin Obstetrical Journal Parry on Extra-Uterine Pregnancy Pavy on Digestion Pavy on Food..... Parrish's Practical Pharmacy Pirrie's System of Surgery . Playfair's Midwifery Quain and Sharpey's Anatomy, by Lei Roberts on Urinary Diseases . Ramsbotham on Parturition . Remsen's Principles of Chemistry Rigby's Midwifery .... Rodwell's Dictionary of Science . Stimson's Operative Surgery Swayne's Obstetric Aphorisms Sargent's Minor Surgery Sharpey and Quain's Anatomy, by Leidy Skey's Operative Surgery Slade on Diphtheria Schiifer's Histology Smith (J. L.) on Children Smith (H. H.) and Horner's Anatomical Smith (Edward) on Consumption Smith on Wasting Diseases in Children Still6's Therapeutics Stille & Maisch's Dispensatory Sturges on Clinical Medicine Stokes on Fever .... Tanner's Manual of Clinical Medicine Tanner on Pregnancy Taylor's Medical Jurisprudence, . Taylor's Principles and Practice of Med Taylor on Poisons . Tuke on the Influence of the Mind Thomas on Diseases of Females . Thompson on Uriuary Organs Thompson on Stricture . Thompson on the Prostate Todd on Acute Diseases . Walshe on the Heart Watson's Practice of Physic . Wells on the Eye .... West on Diseases of Females West on Diseases of Children West on Nervous Disorders of Children What to Observe in Medical Case Williams on Consumption Wilson's Human Anatomy . Wilson on Diseases of the Skin Wilson's Plates on Diseases of the Skin Wilson's Handbook of Cutaneous Medicine Wohler'sOrganic Chemistry Winckel on Childbed PAGE 7 14 27 B 7 17 19 20 17 Jurisp. For "The Obstetrical Journal," Five Dollars a year, see p. 23. \ \ % ?»*-*£. _^H*-;*'a.?»*-i" ****** /L .^^ .._!*. s 'ff'!1,1!", . "\W*''- *rrr